A collaborative, computer-assisted, psychoeducational intervention for depressed patients with chronic disease at primary care: protocol for a cluster-randomized controlled trial

Introduction

Depression treatment recommendations seldom include chronic illness comorbidity.

Objectives

To describe the rationale and methods for a cluster-randomized trial (CRT) in primary care clinics (PCC) comparing a computer-assisted psychoeducational (CAPE) intervention to usual care (UC) for depressed patients with hypertension or diabetes.

Methods

Two-arm, single-blind CRT in Santiago, Chile. Eight PCC will be randomly assigned to the intervention or UC. A total of 360 depressed individuals aged 18 or older PHQ-9 scores ≥ 15 and hypertension or diabetes will be recruited. Patients with alcohol/substance abuse; current treatment for depression, bipolar disorder, or psychosis; illiteracy; severe impairment; and residents in long-term care facilities will be excluded. Patients in the intervention will receive eight CAPE sessions by trained therapists, structured telephone calls to track progress, and usual medical care for chronic diseases. Psychologists and psychiatrists will regularly supervise therapists. To ensure continuity of care, the PCC team will meet monthly with a research team member. Patients in UC will receive standard medical and depression treatment. Three, six, and twelve months after enrollment, outcomes will be assessed. The primary outcome will be a 50% reduction in baseline PHQ-9 scores at six months. Intention-to-treat analyses will be used.

Results

A previous, small-scale pilot study provided valuable insights for study design.

Conclusions

This study will provide first-hand evidence on the effectiveness of a CAPE for depressed patients with chronic diseases at PCC in a Latin American country.

Disclosure

No significant relationships.

Parásitos gastrointestinales en mamíferos silvestres cautivos en el Centro de Fauna de San Emigdio, Palmira (Colombia)

La parasitosis intestinal en mamíferos silvestres es una de las principales complicaciones debido a las condiciones exógenas del cautiverio. Predisponen al animal a complicaciones fisiológicas o infecciones secundarias que impiden su rehabilitación y reintroducción. El objetivo es determinar la presencia de parásitos gastrointestinales en mamíferos silvestres del Centro de Atención y Valoración de fauna silvestre del Centro de Educación Ambiental San Emigdio, San Emigdio, Palmira, Colombia. Se tomaron muestras fecales de 25 animales cautivos en el Centro de Atención y Valoración, analizándose mediante dos técnicas: a) montaje con solución salina al 0,85 % y solución de lugol al 1% y b) técnica de flotación por solución saturada (Sheather) con densidad de 1.28g/ml, encontrándose un 36% de positividad. Se encontró Enterobius vermicularis, Fasciola sp., Entamoeba sp. y Ancylostoma sp. El grupo de primates no humanos presentó cargas parasitarias más altas con respecto a felinos, caninos y demás mamíferos del estudio. Los microorganismos identificados, son reconocidos como parásitos causantes de complicaciones en animales cautivos y en vida libre; al igual, son catalogados como posibles riesgos zoonóticos.

Panniculitis caused by Mycobacterium monacense mimicking erythema induratum: a case in Ecuador

We report the first case of recently characterized species M. monacense associated with chronic nodular vasculitis, infecting a young woman. This case represents the first isolation of M. monacense from Ecuador. The isolate was identified by conventional and molecular techniques.

Winter is coming: hibernation reverses the outcome of sperm competition in a fly

Sperm commonly compete within females to fertilize ova, but research has focused on short‐term sperm storage: sperm that are maintained in a female for only a few days or weeks before use. In nature, females of many species store sperm for months or years, often during periods of environmental stress, such as cold winters. Here we examine the outcome of sperm competition in the fruit fly Drosophila pseudoobscura, simulating the conditions in which females survive winter. We mated females to two males and then stored the female for up to 120 days at 4°C. We found that the outcome of sperm competition was consistent when sperm from two males was stored for 0, 1 or 30 days, with the last male to mate fathering most of the offspring. However, when females were stored in the cold for 120 days, the last male to mate fathered less than 5% of the offspring. Moreover, when sperm were stored long term the first male fathered almost all offspring even when he carried a meiotic driving sex chromosome that drastically reduces sperm competitive success under short‐term storage conditions. This suggests that long‐term sperm storage can radically alter the outcome of sperm competition.

[Histopathological findings and biomarker analysis in cutaneous graft-versus-host disease ]

Graft-versus-host disease (GVHD) remains the greatest source of morbidity-mortality in allogenic transplant patients. Although in most cases the more easily obtainable clinical and laboratory test parameters suffice to confirm the diagnosis and establish the stage of the disease biopsies of the affected organ are sometimes needed. At present there is great Interest in the study of factors allowing a prognosis of the course and type of response to treatment in patients with CVHD. In this sense, It would be necessary to objectively Identify and validate biomarkers capable of predicting biological or pathological processes in patients with cVHD. To this effect we have performed serial analyses of skin tissue using peripheral blood and tissue biomarkers in a prospective observational study conducted in three transplant centers. The still preliminary results Indicate that certain histopathological findings classically attributed to CVHD ore also seen in patients not clinically affected by the disease--this probably being related to other physiopathological phenomena occurring during transplantation. The study of these findings, combined with biomarker analysis, will allow improved understanding of the underlying etiopathogenesis, as well as the definition of new diagnostic, prognostic and response-evaluating criteria.

Development of two multiplex mini-sequencing panels of ancestry informative SNPs for studies in Latin Americans: an application to populations of the State of Minas Gerais (Brazil)

Admixture occurs when individuals from parental populations that have been isolated for hundreds of generations form a new hybrid population. Currently, interest in measuring biogeographic ancestry has spread from anthropology to forensic sciences, direct-to-consumers personal genomics, and civil rights issues of minorities, and it is critical for genetic epidemiology studies of admixed populations. Markers with highly differentiated frequencies among human populations are informative of ancestry and are called ancestry informative markers (AIMs). For tri-hybrid Latin American populations, ancestry information is required for Africans, Europeans and Native Americans. We developed two multiplex panels of AIMs (for 14 SNPs) to be genotyped by two mini-sequencing reactions, suitable for investigators of medium-small laboratories to estimate admixture of Latin American populations. We tested the performance of these AIMs by comparing results obtained with our 14 AIMs with those obtained using 108 AIMs genotyped in the same individuals, for which DNA samples is available for other investigators. We emphasize that this type of comparison should be made when new admixture/population structure panels are developed. At the population level, our 14 AIMs were useful to estimate European admixture, though they overestimated African admixture and underestimated Native American admixture. Combined with more AIMs, our panel could be used to infer individual admixture. We used our panel to infer the pattern of admixture in two urban populations (Montes Claros and Manhuaçu) of the State of Minas Gerais (southeastern Brazil), obtaining a snapshot of their genetic structure in the context of their demographic history.

Effectiveness and cost of replacing a calcineurin inhibitor with sirolimus to slow the course of chronic kidney disease in renal allografts

Renal grafts suffer a progressive decrease in glomerular filtration rate (GFR) because of several factors including calcineurin inhibitor (CNI) nephrotoxicity. Switching CNIs to sirolimus may improve this adverse prognosis. We performed a prospective, open-label clinical trial among 18 kidney transplant patients with more than 12 months of evolution (range, 385-1826 days), showing progressive GFR decreases and biopsies with interstitial fibrosis and tubular atrophy (IFTA). Immunosuppressive treatment included cyclosporine, ketoconazole, and steroids associated with azathioprine or mycophenolate mofetil. After signing an Institutional Review Board-approved written consent, cyclosporine was switched to sirolimus seeking to achieve a trough blood sirolimus concentration of 6-15 ng/mL. Wilcoxon and Student's t-tests were used to compare the values in the annual periods before and after the switch. GFR was estimated by the Modification of Diet in Renal Disease formula. There were no acute rejection episodes. Estimated GFR on the day of the switch was 38.0 +/- 12.1 mL/min. After CNI switch, the slope of the estimated GFR significantly improved from -6.5 +/- 9.2 to 8.1 +/- 14.0 mL/min/year (P < .01). The estimated GFR 1 year after the switch was 47.2 +/- 16.9 mL/min (P = .003 vs baseline). Total expenditures increased. The ratio of post-switch versus baseline total expenditures was 1.93 (95% confidence interval, 1.54-2.31) and the ratio of sirolimus to CNI cost was 2.16 (95% confidence interval, 1.53-2.78). Switching from CNI to sirolimus for kidney transplants with decreasing GFR and a biopsy with IFTA changes, suggesting progressive graft nephropathy, almost doubled total expenses. It is necessary to conduct trials using clinical end points to definitively validate this therapeutic intervention.

Everolimus versus azathioprine in a cyclosporine and ketoconazole-based immunosuppressive therapy in kidney transplant: 3-year follow-up of an open-label, prospective, cohort, comparative clinical trial

In cyclosporine-based protocols, everolimus is more effective than azathioprine to reduce acute rejection. Ketoconazole may reduce cyclosporine and everolimus requirements. We compared kidney transplant patients treated with everolimus or azathioprine in a ketoconazole- and cyclosporine-based immunosuppressive regimen. This open-label, prospective trial of low immunologic risk patients. Included one group (n = 11) who received everolimus (target blood level, 3-8 ng/mL) and the other (n = 11) azathioprine (2.0-2.5 mg/kg/d). Both received steroids, ketoconazole, and cyclosporine with C(0) targets (ng/mL) in the everolimus group of 200-250, 100-125, and 50-65 for months 1 and 2 and thereafter and in the azathioprine group of 250-300 in month 1, 200-250 in month 2, 180-200 until month 6, and 100-125 thereafter. Their baseline characteristics were similar. Two biopsy-proven acute rejections occurred in each group. Three-year graft and patient survival in both groups was 100%. Creatinine clearances at months 6, 12, 24, and 36 were 63.7 +/- 25.4, 58.9 +/- 24.9, 56.0 +/- 22.9, and 57.0 +/- 27.6 in the everolimus group versus 72.6 +/- 20, 68.6 +/- 21.3, 71.4 +/- 23.2, and 68.4 +/- 19.2 in the azathioprine group (NS for every comparison). Major complications were rare and similar in both groups. Five patients in the everolimus group received simvastatin versus 4 in the azathioprine cohort (P = .53). The average cyclosporine doses to achieve targets were 0.8-1.2 mg/kg in the everolimus group and 1.6-2.2 mg/kg in the azathioprine group. The average everolimus dose after month 2 was 0.75-0.9 mg/d. We concluded that with cyclosporine, ketoconazole, and steroids, everolimus was as effective and safe as azathioprine. Cyclosporine reduction with everolimus did not influence graft survival or function at 3 years.

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]

OBJECTIVE

To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007.

METHODS

Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit.

RESULTS

The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%.

CONCLUSIONS

The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

In vitro fermentation response of laying hen cecal bacteria to combinations of fructooligosaccharide prebiotics with alfalfa or a layer ration

The objective of this in vitro study was to evaluate the effects of combining a prebiotic with alfalfa on fermentation by laying hen cecal bacteria. Cecal contents from laying hens were diluted to a 1:3,000 concentration with an anaerobic dilution solution and added to serum tubes filled with ground alfalfa or a layer ration with or without fructooligosaccharide (FOS) prebiotic. Samples were processed in an anaerobic hood, pressurized by using a pressure manifold, and incubated at 37 degrees C. Volatile fatty acid (VFA) and lactic acid concentrations were quantified at 6 and 24 h of substrate fermentation. In this study, fermentation of alfalfa resulted in greater production of acetate, VFA, and lactic acid compared with the layer ration. Although with a relative inconsistency in data between trials, the amendment of FOS to both alfalfa and the layer ration appeared to further increase fermentation as demonstrated by overall higher propionate, butyrate, VFA, and lactic acid concentrations. The effect was more pronounced after 24 h of fermentation, implying time constraints for the optimal production of fermentation products in the chicken gastrointestinal tract. These data indicate that in vitro cecal fermentation can be enhanced by the addition of FOS.

Organ weight and serum triglyceride responses of older (80 week) commercial laying hens fed an alfalfa meal molt diet

Since one of the costs in the commercial egg industry is that of replacement pullets, commercial egg layer managers have opted to induce molt older hens in order to extend their productive life for additional egg laying cycles. Conventional molt induction involves the complete removal of feed for several days. However, this management practice can lead to deleterious physiological responses by the hen and subsequent susceptibility to infection by pathogens. Consequently less stressful molting regimens involving the feeding of low energy diets such as alfalfa have been developed. In this study, 80 week old laying hens that were deprived of feed or fed alfalfa meal during a nine day induced molt. Full fed hens were used as the control. On day 8 serum triglycerides were quantified and on day 9 hens were euthanized and the liver, spleen, heart, intestine, pancreas, ovary, and kidney were collected and weighed. Intestinal weight were highest in the non-molted hens, lower in the hens fed alfalfa, and lower still in the hens deprived of feed. Molted hens exhibited reduced weights of liver, heart, ovary, and pancreas compared to the non-molted hens. Serum triglycerides were highest in the non-molted hens, less in feed deprived hens, and the lowest in alfalfa fed hens. These results suggest that a comparable molt could be achieved with feeding alfalfa meal to 80 week hens compared to feed deprivation.

Immunological cell and serum metabolite response of 60-week-old commercial laying hens to an alfalfa meal molt diet

The practice of induced molting involves the restriction of light, feed removal and optionally water for 5-14 days. However, there is growing concern regarding feed removal and animal welfare issues. With this in mind, alternative diets have been developed to produce similar molting effects as that of feed deprivation. Alfalfa, which largely consists of insoluble fiber, can be used as a molting diet. In this study, heterophil and lymphocyte counts, serum chemistry, and organ weight parameters were evaluated in hens that were deprived of feed or fed alfalfa during a nine day induced molt. Full-fed hens were used as the control. Blood serum parameters assessed included calcium, magnesium, glucose, total protein, ketone bodies, uric acid, and cholesterol. White blood cells were counted and categorized by cell type. On the ninth day of the trial, the hens were euthanized and the liver, spleen, heart, intestine, pancreas, ovary, oviduct, and kidney were collected and weighed. On day 8 birds molted with alfalfa or by feed deprivation had significantly higher (P<0.05) levels of ketone bodies and cholesterol and lower levels of calcium, and magnesium compared to the full-fed hens while birds molted by feed deprivation exhibited significantly lower levels of uric acid. Birds molted by both methods exhibited significant reductions in ovary, oviduct, liver and pancreas weights and increased spleen weights when compared to the non-molted hens. On days 0, 2, and 6 there were no significant differences (P>0.05) in either heterophil or lymphocyte percentages. However, heterophil percentages were higher in feed withdrawal birds than full-fed birds on day 4 but lymphocyte percentages were higher in full-fed birds compared to feed withdrawal birds. On day 8 of the induced molt lymphocyte percentages were higher from full-fed birds when compared to feed withdrawal birds but no significant differences were detectable for heterophil percentages. Based on reproductive organ weight loss and changes in serum and immunological responses of birds during molt, it appears that alfalfa meal can be an effective molt induction alternative.

The current state of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is an uncommon condition that has challenged pediatric surgeons for decades. Patients with CTS can present with a wide spectrum of symptoms and varying degrees of severity. In addition, a variety of techniques have been devised to repair this malformation. A review of these procedures and our suggestions for clinical standards and practice guidelines will be presented in this paper. A retrospective review of the literature on CTS from 1964 to 31 March, 2006. There is not one standard technique for the repair of CTS, as individualized approach to each patient and airway lesion is necessary to optimize patient management; nevertheless there is a consensus about segmental resection and anastomosis being best for short segment stenosis while slide tracheoplasty is most effective for the long-segment ones. Conservative management is also an option for select group of patients with careful and close follow up. Survival following surgery over the years has improved, but mortality remained high, particularly in a specific subset of patients presenting at the age less than 1 month with associated cardiac malformations. In conclusion, CTS remains a significant challenge for pediatric surgeons. Additional research is required to improve our understanding of the pathogenesis of CTS, and to develop evidence-based treatment protocols for the entire spectrum of presentation including conservative management.

Detection of methane and quantification of methanogenic archaea in faeces from young broiler chickens using real-time PCR

AIMS

To detect the presence of methanogens in the faeces of broiler chicks during the first 2 weeks of age.

METHODS AND RESULTS

Chicken faecal samples from 120 broiler chicks were incubated for methane gas formation and methanogenic archaea were analysed using real-time PCR. The copy number of the order Methanobacteriales 16S rDNA gene in chicken faeces when the broilers were 3-12 days of age, litter and house flies collected in the bird house ranged from 4.19 to 5.51 log(10) g(-1) wet weight. The number of positive methane culture tubes increased from 25% to 100% as the birds aged.

CONCLUSIONS

Methanogens were successfully detected in faecal samples from 3- to 12-day-old broilers, as well as litter and house flies using real-time PCR. The copy number of methanogenic 16S rDNA gene in these samples was also similar to the number observed in litter and house flies.

SIGNIFICANCE AND IMPACT OF THE STUDY

The same methanogens consistently appeared in chicken faeces a few days after birth. Detection of the methanogenic bacteria in litter and house flies implicated them as potential environmental sources for methanogen colonization in broiler chicks.

Pancreatic deletion of insulin receptor substrate 2 reduces beta and alpha cell mass and impairs glucose homeostasis in mice

AIMS/HYPOTHESIS

Insulin signalling pathways regulate pancreatic beta cell function. Conditional gene targeting using the Cre/loxP system has demonstrated that mice lacking insulin receptor substrate 2 (IRS2) in the beta cell have reduced beta cell mass. However, these studies have been complicated by hypothalamic deletion when the RIPCre (B6.Cg-tg(Ins2-cre)25Mgn/J) transgenic mouse (expressing Cre recombinase under the control of the rat insulin II promoter) is used to delete floxed alleles in insulin-expressing cells. These features have led to marked insulin resistance making the beta cell-autonomous role of IRS2 difficult to determine. To establish the effect of deleting Irs2 only in the pancreas, we generated PIrs2KO mice in which Cre recombinase expression was driven by the promoter of the pancreatic and duodenal homeobox factor 1 (Pdx1, also known as Ipf1) gene.

MATERIALS AND METHODS

In vivo glucose homeostasis was examined in PIrs2KO mice using glucose tolerance and glucose-stimulated insulin secretion tests. Endocrine cell mass was determined by morphometric analysis. Islet function was examined in static cultures and by performing calcium imaging in Fluo3am-loaded beta cells. Islet gene expression was determined by RT-PCR.

RESULTS

The PIrs2KO mice displayed glucose intolerance and impaired glucose-stimulated insulin secretion in vivo. Pancreatic insulin and glucagon content and beta and alpha cell mass were reduced. Glucose-stimulated insulin secretion and calcium mobilisation were attenuated in PIrs2KO islets. Expression of the Glut2 gene (also known as Slc2a2) was also reduced in PIrs2KO mice.

CONCLUSIONS/INTERPRETATION

These studies suggest that IRS2-dependent signalling in pancreatic islets is required not only for the maintenance of normal beta and alpha cell mass but is also involved in the regulation of insulin secretion.

In vitro anaerobic incubation of Salmonella enterica serotype Typhimurium and laying hen cecal bacteria in poultry feed substrates and a fructooligosaccharide prebiotic

The objective of this study was to investigate the effect of combining a prebiotic with poultry feeds on the growth of Salmonella enterica serotype Typhimurium (ST) in an in vitro cecal fermentation system. Cecal contents from three laying hens were pooled and diluted to a 1:3000 concentration in an anaerobic dilution solution. The cecal dilution was added to sterile test tubes filled with alfalfa and layer ration with and without fructooligosaccharide (FOS). Two controls containing cecal dilutions and anaerobic dilution solution were used. The samples were processed in the anaerobic hood and incubated at 37 degrees C. Samples were inoculated with Salmonella at 0 and 24h after in vitro cecal fermentation and plated at 0 and 24h after inoculation with ST. Plates were incubated for 24h and colony forming units (CFU) enumerated. The samples immediately inoculated with ST without prior cecal fermentation did not significantly lower ST counts 24h later. However, samples pre-incubated for 24h with cecal microflora prior to ST inoculation exhibited reduced ST CFU by approximately 2 logarithms, with the most dramatic decreases seen in alfalfa and layer ration combined with FOS. The addition of FOS to feed substrate diets in combination with cecal contents acted in a synergistic manner to decrease ST growth only after ST was introduced to 24h cecal incubations.

Increasing uncoupling protein-2 in pancreatic beta cells does not alter glucose-induced insulin secretion but decreases production of reactive oxygen species

AIMS/HYPOTHESIS

Levels of uncoupling protein-2 (UCP2) are regulated in the pancreatic beta cells and an increase in the protein level has been associated with mitochondrial uncoupling and alteration in glucose-stimulated insulin secretion. However, it is not clear whether an increase in uncoupling protein-2 per se induces mitochondrial uncoupling and affects ATP generation and insulin secretion.

MATERIALS AND METHODS

Transgenic mice with beta cell-specific overexpression of the human UCP2 gene and INS-1 cells with doxycycline-inducible overproduction of the protein were generated and the consequences of increased levels of UCP2 on glucose-induced insulin secretion and on parameters reflecting mitochondrial uncoupling were determined.

RESULTS

In transgenic mice, an increase in beta cell UCP2 protein concentration did not significantly modify plasma glucose and insulin levels. Glucose-induced insulin secretion and elevation in the ATP/ADP ratio were unaltered by an increase in UCP2 level. In INS-1 cells, a similar increase in UCP2 level did not modify glucose-induced insulin secretion, cytosolic ATP and ATP/ADP ratio, or glucose oxidation. Increased levels of UCP2 did not modify the mitochondrial membrane potential and oxygen consumption. Increased UCP2 levels decreased cytokine-induced production of reactive oxygen species.

CONCLUSION/INTERPRETATION

The results obtained in transgenic mice and in the beta cell line do not support the hypothesis that an increase in UCP2 protein per se uncouples the mitochondria and decreases glucose-induced insulin secretion. In contrast, the observation that increased UCP2 levels decrease cytokine-induced production of reactive oxygen species indicates a potential protective effect of the protein on beta cells, as observed in other cell types.

Cultural and Immunological Detection Methods for Salmonella spp. in Animal Feeds - A Review

Food-borne salmonellosis continues to be a major public health concern, and contamination with Salmonella spp. in pre-harvest animal production is considered a primary contributor to this problem. Animal feeds can easily become contaminated during primary production, feed mixing and processing as well as during feeding. Consequently, monitoring and surveillance of feeds and feed ingredients for Salmonella spp. contamination may be useful or necessary in the prevention and control of this organism. Cultural and immunological detection methods for salmonellae have been used or suggested as possible approaches for use in animal feeds. Cultural methods remain advantageous owing to their ability to detect viable bacterial cells, while immunological methods have the capability of detecting nonculturable bacterial cells. Advancements and improvements in both methodologies offer opportunities for eventual routine use of these detection technologies in animal feed assays.

[Intraoperative high frequency oscillatory ventilation in 2 children undergoing lung surgery]

Over the past 10 years, the application of high frequency oscillatory ventilation (HFOV) has been extended beyond the neonatal period. The technique is now used in various respiratory disease settings when conventional mechanical ventilation fails. Even though HFOV has become increasingly routine in some pediatric intensive care units, familiarity with it is still limited among anesthesiologists and surgeons and it is not often applied during surgery. We report our experience using HFOV during thoracic surgery on 2 pediatric patients, one aged 5 years and the other aged 1 month. The respective surgical procedures were to close a bronchopleural fistula and to obtain a lung biopsy in order to provide guidance for limiting therapeutic intervention. In both cases the procedure was performed without adverse effects and allowed medical interventions to be carried out. We conclude that it is possible to perform thoracic surgery in pediatric patients undergoing HFOV. This ventilation mode can be useful during surgery and teams that care for critically ill children should be familiar with the equipment.

[Cerebrospinal fluid drainage in endovascular repair of thoracic aortic lesions: preliminary report of experience with 5 patients]

Endovascular repair of thoracic or thoracoabdominal aortic lesions as an alternative to open surgery, to avoid the high complication and mortality rates associated with the conventional approach, does not eliminate the risk of postoperative paraplegia. We report on a series of 5 patients with different thoracic aortic lesions who underwent endovascular stent-graft repair procedures. We describe measures to drain cerebrospinal fluid to prevent ischemic spinal cord injury. We also review the anesthetic management of patients undergoing this type of surgery.

[Severe hemodynamic deterioration during epidural anesthesia for endovascular treatment of thoracic aortic stenosis]

A 72-year-old woman diagnosed with critical descending aortic stenosis was scheduled for endovascular treatment by angioplasty and implantation of an aortic stent. Her medical history included arterial hypertension, lipid metabolic disorder, obesity, Takayasu disease, dermatopolymyositis, and alleged allergy to iodine contrast and local anesthetics. After the allergies were ruled out, it was decided to use a regional anesthetic technique to avoid the postoperative complications of general anesthesia and achieve better hemodynamic control during surgery. Surgery was carried out under epidural anesthesia and intravenous sedation. After angioplasty and during self-expansion of the stent, the patient's hemodynamics deteriorated rapidly; she lost consciousness and required orotracheal intubation and immediate resuscitation measures. The literature describes in detail the management of patients with thoracic aortic lesions, including the most appropriate way to provide anesthesia. General anesthesia seems to be preferred, although care is taken to individualize the decision. We analyze this case of a patient with severe thoracic aortic stenosis undergoing endovascular treatment under epidural anesthesia.

Comparisons of molting diets on skeletal quality and eggshell parameters in hens at the end of the second egg-laying cycle

A study was conducted to evaluate skeletal quality and eggshell parameters of molted hens at the end of the second laying cycle. Sixty Single Comb White Leghorn hens were used for this study. There were 2 controls and 4 molting treatments: full-fed control 1 (82 wk old; FF1), full-fed control 2 (122 wk old; FF2), feed withdrawal (FW), 100% alfalfa (A100), 90% alfalfa/10% layer ration (A90), and 70% alfalfa/30% layer ration (A70). At the end of the second laying cycle (approximately 122 wk of age), hens were euthanized by CO2. Tibia and femur were collected. There were no differences in bone parameters between FF1 and FF2 (P > 0.05) hens. There were no differences in bone parameters among the different molting dietary treatments (P > 0.05). In the eggshell parameters, the FF2 hens exhibited heavier egg weights than the FF1 (P < 0.05), whereas the percentage shell and egg production of the FF1 birds were significantly higher than those of the FF2 birds. Shell weights of the FW and A90 birds were significantly heavier than that of the A100. The correlation analysis showed that overall bone parameters were negatively correlated with eggshell parameters. Bone parameters were highly correlated with each other. Shell weight, percentage shell, and shell thickness were positively correlated with each other, whereas egg weight was negatively correlated with percentage shell. These results suggest that age of hens and molting dietary treatments influence egg parameters, and eggshell formation is closely related to bone metabolism in laying hens.

Utilizing different ratios of alfalfa and layer ration for molt induction and performance in commercial laying hens

Molting is a common practice used by the commercial egg industry to rejuvenate flocks for a second or third laying cycle. During this time the hens rest from production, and the reproductive organs are rejuvenated to increase production and quality during the next laying cycle. Although feed withdrawal (FW) is the most popular and effective method of molt induction, it has come under scrutiny due to food safety issues and animal welfare issues. This study involved feeding alfalfa mixed with layer ration at different ratios to hens to determine their ability to induce molt. The treatment ratios were 100% alfalfa (A100), 90% alfalfa and 10% layer ration (A90), and 70% alfalfa and 30% layer ration (A70). In addition, a fully fed (FF) nonmolted control and a FW negative control were used. Alfalfa is an insoluble, high fiber feedstuff with low metabolizable energy. Egg production for A90 and FW treatments ceased completely by d 6, whereas birds fed A100 and A70 ceased egg production by d 8. Ovary and oviduct weight of hens fed all molting diets decreased (P < 0.05) by an average of 1.5 to 2.5% (BW basis) compared with FF control during the 9-d molt induction period. As the percentage of layer ration increased, feed intake also increased and percentage of BW loss decreased during the 9-d molt induction period. Hens molted by FW lost an average of 25.8% BW, whereas A70 hens lost 18.9% BW. Nonmolted hens (FF) and A70 treatment hens had significantly lower (P < 0.05) egg production when compared with all other treatments over the 39-wk postmolt period. FF treatment hens also had lower (P < 0.05) albumen heights when compared with all other treatments. From these results, alfalfa or alfalfa mixed with layer ration appears to be viable alternatives to conventional FW methods for the successful induction of molt and retention of postmolt performance.

Research Note: Effects of Different Bone Preparation Methods (Fresh, Dry, and Fat-Free Dry) on Bone Parameters and the Correlations Between Bone Breaking Strength and the Other Bone Parameters

A study was conducted to evaluate effects of different bone preparation methods on bone parameters and the correlations between bone breaking strength and the other bone parameters. Bone breaking strength is dramatically changed depending on bone preparation methods, whereas other bone parameters such as ash content and ash concentration are not significantly influenced by bone preparation methods. Thus, the objective of this study was to evaluate the effects of 3 bone preparations (fresh, dry, and fat-free dry) on bone parameters and the relationship between bone breaking strength and bone parameters. Sixty Single Comb White Leghorn hens were used for this study. Hens were euthanized by CO2 gas, and the right tibia and femur were collected. The bones were divided into 3 treatment groups: fresh, dry, and fat-free dry. There were no significant differences in fresh weight, bone volume, dried weight, ash weight, and ash concentration of tibia and femur among the treatments. However, fresh tibia (24.13 kg) exhibited more bone breaking strength compared with the dried (9.90 kg) and fat-free dried bones (7.41 kg) (P < 0.05). The bone breaking strength (20.97 kg) of fresh femur was also significantly higher than the dried (9.22 kg) and fat-free dried femurs (6.94 kg). The bone breaking strength of the fresh bone was highly correlated with dried weight, ash weight, and ash concentration, whereas that of the fat-free dried bone was poorly correlated with the other bone parameters. The results indicate that fresh bone gives better bone breaking strength correlated to the other bone parameters than dry or fat-free dry preparation.

[Obsessive-compulsive symptoms in schizophrenia during treatment with clozapine and conventional antipsychotic drugs]

INTRODUCTION

We compare the prevalence of obsessive-compulsive symptoms in schizophrenic patients in treatment with clozapine and those who receive classic antipsychotic drugs.

METHOD

Outpatients with schizophrenia treated with clozapine (n = 56) or classic antipsychotic drugs (n = 54) at the Honorio Delgado-Hideyo Noguchi Specialized Institute in Mental Health (Lima-Peru), were evaluated for the presence of obsessive-compulsive symptoms by means of the Obsessive-Compulsive Disorder Module of Structured Clinical Interview for DSM-IV and Yale-Brown Obsessive-Compulsive Symptoms Checklist.

RESULTS

46.4 % of patients treated with clozapine presented obsessive-compulsive symptoms while this occurred in 20.4 % of those with classic antipsychotic drugs (p = 0.005). In addition, 21.4 % of patients with clozapine and 13 % of those treated with classic antipsychotics presented obsessive-compulsive disorder according to DSM-IV criteria (p = 0.31).

CONCLUSION

In schizophrenic patients, treatment with clozapine is associated with a higher rate of obsessive-compulsive symptoms than treatment with classic antipsychotic drugs.

Pharyngo-esophageal reconstruction by free jejunal graft and microvascular anastomosis in a 10-year-old girl

Pharyngeal and upper esophagus substitution is an ordinary procedure in adults, performed mainly for oncologic purposes, but it is rarely done in children. The authors present a case report of a free jejunal graft pharyngo/esophageal reconstruction with microvascular anastomosis to the primitive carotid artery and the internal jugular vein in a a 10-year-old girl who had a loss of lower pharynx and cervical esophagus secondary to esophageal perforation by foreign body. Other surgical approaches for pharyngo-esophageal reconstruction in children are revisited.

Percutaneous endoscopic gastrostomy: the technique of choice?

BACKGROUND/PURPOSE

The percutaneous endoscopic gastrostomy (PEG) is contested on the ground that it could cause gastroesophageal reflux (GER). The authors studied the complications of PEG to ponder the validity of this contraindication.

METHODS

The authors followed up with a group of 81 patients subjected to PEG to assess their complications, GER in particular.

RESULTS

In half of the patients, PEG was performed under deep sedation in the intensive care unit and the other half under general anesthesia. The procedure lasted about 12 minutes in both subgroups. Early complications were not observed. Late complications relating to the care of the tube were similar to those reported for other techniques. GER appeared in 8%, but surgical treatment was unnecessary, whereas in patients that presented GER before surgery, it subsided in 38%. A colocutaneous fistula observed in one patient was a consequence of previous interventions.

CONCLUSIONS

PEG is minimally invasive, general anesthesia may be avoided, the procedure is rapid, major complications are conspicuously absent, and the incidence of GER is smaller than that associated with alternative techniques. In addition, the cost is low. The authors consider PEG the technique of choice because it has important advantages compared with open or laparoscopic techniques.

General and conditional replacement of connexin43-coding DNA by a lacZ reporter gene for cell-autonomous analysis of expression

Using the Cre/loxP system, we have circumvented early postnatal lethality and possible pleiotropic effects of general Cx43 gene deletion, in order to determine the expression and function of connexin43 (Cx43) in defined cell types. General or cell type-specific, Cre-mediated deletion of the floxed (i.e. flanked by loxP sites) Cx43-coding region led to activation of the inserted lacZ reporter gene in cells with transcriptional activity of the Cx43 gene. As deduced from lacZ expression in mice with general deletion, transcriptional activity of the Cx43 gene was not only found in a broad range of cell types known to a express Cx43, but also inpancreatic duct cells and vascular cells of the gut and skeletal muscle. Cre-mediated deletion restricted to defined cell types led to lacZ activation highlighting corresponding subsets of cells expressing Cx43, such as vascular endothelial cells, hepatic duct cells and putative neural crest cells, which were otherwise masked by strong Cx43 expression in neighbouring cells. In Cx43 expressing cell types, the floxed Cx43 allele was useful as a Cre-excision reporter for the characterization of Cre transgenes.

BCR/ABL p210, p190 and p230 fusion genes in 250 Mexican patients with chronic myeloid leukaemia (CML)

There are two major forms of the BCR/ABL fusion gene, involving ABL exon 2, but including different exons of BCR gene. The transcripts b2a2 or b3a2 code for a p210 protein. Another fusion gene leads to the expression of an e1a2 transcript, which codes for a p190 protein. Another, less common fusion gene is c3a2[e19a2], which encodes a p230 protein. The incidence of one or the other rearrangement in chronic myeloid leukaemia (CML) patients varies in different reported series. This study was designed to determine the frequency of coexpresion of the p210, p190 and p230 transcripts in 250 Mexican patients with CML. We performed nested and multiplex reverse transcriptase polymerase chain reaction (RT-PCR) on bone marrow samples from adult patients and found that all cases were positive for some type of BCR/ABL rearrangement. In 226 (90.4%) patients it was p210, while the remaining 9.6% showed coexpression or one of the transcripts of p190/p210/p230. In 7% of patients with p210 expression there are both isoforms (b3a2/b2a2), presumably the result of alternative splicing. The rate of coexpression of the p190/p210 transcripts was 5%, which is much lower than in other reports. This may be due to the technical factors. These patients had high platelet counts, marked splenomegaly and chromosomal abnormalities in addition to Ph'. Other types of coexpression seen were p210/p230 and p190/p210/p230, in patients with high-risk clinical factors. Our study confirms the occurrence of coexpression of different BCR/ABL transcripts, although the rate (9.6%) was much lower than has been reported in other populations. This may reflect either the sensitivity of the detection techniques used or the possibility of genetic differences between the populations studied. Coexpression may be due to alternative splicing or to phenotypic variation, with clinical courses different from classical CML.

Reduced PTEN expression in the pancreas overexpressing transforming growth factor-beta 1

PTEN is a candidate tumour suppressor gene and frequently mutated in multiple cancers, however, not in pancreatic cancer. Recently, it has been demonstrated that PTEN expression is regulated by TGF-beta1. Using TGF-beta1 transgenic mice (n=7) and wildtype littermates (n=6), as well as pancreatic tissues obtained from organ donors (n=10) and patients with pancreatic cancer (n=10), we assessed the expression of PTEN by means of immunohistochemistry and semiquantitative PCR analysis. In addition, PANC-1 cells were treated with TGF-beta1 in vitro and the levels of PTEN mRNA were determined in these cells. In human pancreatic cancers PTEN mRNA levels were significantly decreased (P<0.05). In addition, in the pancreas of TGF-beta1 transgenic mice the expression of PTEN was significantly reduced (P<0.01), as compared to wildtype littermates and incubation of PANC-1 cells with TGF-beta1 decreased PTEN mRNA levels after 24 h. Inasmuch as TGF-beta1 decreases PTEN expression in human pancreatic cancer cells and human pancreatic cancers overexpress TGF-beta1, the reduced expression of PTEN in pancreatic cancer may be mediated by TGF-beta1 overexpression. Thus, although PTEN is not mutated in pancreatic cancers, the reduction of its expression may give pancreatic cancer cells an additional growth advantage.