Liver resection and ablation for squamous cell carcinoma liver metastases

Background

Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS).

Method

Members of the European–African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS.

Results

Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30).

Conclusion

Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.

Treatment patterns and survival in patients with hepatocellular carcinoma in the Swedish national registry SweLiv

BACKGROUND

Consistent data on clinical features, treatment modalities and long-term survival in patients with hepatocellular carcinoma (HCC) using nationwide quality registers are lacking. This study aimed to describe treatment patterns and survival outcomes in patients diagnosed with HCC using a national maintained database.

METHODS

Characteristics and treatment patterns in patients diagnosed with HCC and registered in the national register of liver and bile duct tumours (SweLiv) between 2009 and 2016 were reviewed. Overall survival (OS) was estimated using Kaplan-Meier analysis and the log rank test to compare subgroups for clinical features, treatment modalities and outcomes according to the year of treatment.

RESULTS

A total of 3376 patients with HCC were registered over 8 years, 246 (7·3 per cent) of whom underwent transplantation. Some 501 (14·8 per cent) and 390 patients (11·6 per cent) had resection and ablation as primary treatment. Transarterial chemoembolization and systemic sorafenib treatment were intended in 476 (14·1 per cent) and 426 patients (12·6 per cent) respectively; the remaining 1337 (39·6 per cent) were registered but referred for best supportive care (BSC). The 5-year survival rate was approximately 75 per cent in the transplantation group. Median OS was 4·6 (i.q.r. 2·0 to not reached) years after resection and 3·1 (2·3-6·7) years following ablation. In patients referred for palliative treatment, median survival was 1·4 (0·8-2·9), 0·5 (0·3-1·2) and 0·3 (0·1-1·0) years for the TACE, sorafenib and BSC groups respectively (P < 0·001). Median survival was 0·9 years for the total HCC cohort in 2009-2012, before publication of the Swedish national treatment programme, increasing to 1·4 years in 2013-2016 (P < 0·001).

CONCLUSION

The survival outcomes reported were in line with previous results from smaller cohorts. The introduction of national guidelines may have contributed to improved survival among patients with HCC in Sweden.

Identification of Inequalities in the Selection of Liver Surgery for Colorectal Liver Metastases in Sweden

BACKGROUND:

Liver resection for colorectal liver metastases offers a 5-year survival rate of 25%-58%. This study aimed to analyze whether patients with colorectal liver metastases undergo resection to an equal extent and whether selection factors play a role in the selection process.

MATERIAL AND METHODS:

Data were retrieved from the Swedish Colorectal Cancer Registry (2007-2011) for colorectal cancer and colorectal liver metastases. The patients identified were linked to the Swedish Registry of Liver and Bile surgery and the National Patient Registry to identify whether liver surgery or ablative treatment was performed. Analyses for age, sex, type of primary tumor and treating hospital (university, county, or district), American Society of Anesthesiologists class, and radiology for detection of metastatic disease were performed.

RESULTS:

Of 28,355 patients with colorectal cancer, 21.6% (6127/28,355) presented with liver metastases. Of the patients with liver metastases, 18.5% (1134/6127) underwent liver resection or ablation. The cumulative proportion of liver resection/ablation was 4% (1134/28,355) of all colorectal cancer. If "not bowel resected" were excluded, the proportion slightly increased to 4.7% (1134/24,262). Around 15% of the patients with metastases were registered as referrals for liver surgery. In a multivariable analysis patients treated at a university hospital for primary tumor were more frequently surgically treated for liver metastases (p < 0.0001). Patients with liver metastases from rectal cancer (p < 0.0001) and men more often underwent liver resection (p = 0.006). A difference was found between health-care regions for the frequency of liver surgery (p < 0.0001). Patients >70 years and those with American Society of Anesthesiologists class >2 underwent liver resection less frequently. Magnetic resonance imaging of the liver was more often used in diagnostic work-up in men.

CONCLUSION:

Patients with colorectal liver metastases are unequally treated in Sweden, as indicated by the low referral rate. The proximity to a hepatobiliary unit seems important to enhance the patient's chances of being offered liver surgery.

Associating Liver Partition and Portal Vein Ligation for Primary Hepatobiliary Malignancies and Non-Colorectal Liver Metastases

Background and Aims:

Associating liver partition and portal vein ligation for staged hepatectomy may increase the possibility of radical resection in the case of liver malignancy. Concerns have been raised about the high morbidity and mortality associated with the procedure, particularly when applied for diagnoses other than colorectal liver metastases. The aim of this study was to analyze the initial experience with associating liver partition and portal vein ligation for staged hepatectomy in cases of non-colorectal liver metastases and primary hepatobiliary malignancies in Scandinavia.

Materials and Methods:

A retrospective analysis of all associating liver partition and portal vein ligation for staged hepatectomy procedures performed at two Swedish university hospitals for non-colorectal liver metastases and primary hepatobiliary malignancies was performed. The primary focus was on the safety of the procedure.

Results and Conclusion:

Ten patients were included: four had hepatocellular cancer, three had intrahepatic cholangiocarcinoma, one had a Klatskin tumor, one had ocular melanoma metastasis, and one had a metastasis from a Wilms’ tumor. All patients completed both operations, and the highest grade of complication (according to the Clavien-Dindo classification) was 3A, which was observed in one patient. No 90-day mortality was observed. Radical resection (R0) was achieved in nine patients, while the resection was R2 in one patient. The low morbidity and mortality observed in this cohort compared with those of earlier reports on associating liver partition and portal vein ligation for staged hepatectomy for diagnoses other than colorectal liver metastases may be related to the selection of patients with limited comorbidity. In addition, procedures other than associating liver partition and portal vein ligation for staged hepatectomy had been avoided in most of the patients. In conclusion, associating liver partition and portal vein ligation for staged hepatectomy can be applied to primary hepatobiliary malignancies and non-colorectal liver metastases with acceptable rates of morbidity and mortality.

Associating liver partition and portal vein ligation for staged hepatectomy in patients with colorectal liver metastases--Intermediate oncological results

BACKGROUND

Colorectal liver metastases (CRLM) not amenable for resection have grave prognosis. One limiting factor for surgery is a small future liver remnant (FLR). Early data suggests that associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) effectively increases the volume of the FLR allowing for resection in a larger fraction of patients than conventional two-stage hepatectomy (TSH) with portal vein occlusion (PVO). Oncological results of the treatment are lacking. The aim of this study was to assess the intermediate oncological outcomes after ALPPS in patients with CRLM.

MATERIAL AND METHODS

Retrospective analysis of all patients with CRLM operated with ALPPS at the participating centres between December 2012 and May 2014.

RESULTS

Twenty-three patients (16 male, 7 female), age 67 years (28-80) were operated for 6.5 (1-38) metastases of which the largest was 40 mm (14-130). Six (27.3%) patients had extra-hepatic metastases, 16 (72.7%) synchronous presentation. All patients received chemotherapy, 6 cycles (3-25) preoperatively and 16 (70%) postoperatively. Ten patients (43%) were rescue ALPPS after failed PVO. Severe complications occurred in 13.6% and one (4.5%) patient died within 90 days of surgery. After a median follow-up of 22.5 months from surgery and 33.5 months from diagnosis of liver metastases estimated 2 year overall survival was 59% (from surgery) and 73% (from diagnosis). Liver only recurrences (n = 8), were treated with reresection/ablation (n = 7) while lung recurrences were treated with chemotherapy.

CONCLUSION

The overall survival, rate of severe complications and perioperative mortality associated with ALPPS for patients with CRLM is comparable to TSH.

Long-term persistence of a multi-resistant methicillin-susceptible Staphylococcus aureus (MR-MSSA) clone at a university hospital in southeast Sweden, without further transmission within the region

The objective of this study was to characterise isolates of methicillin-susceptible Staphylococcus aureus (MSSA) with resistance to clindamycin and/or tobramycin in southeast Sweden, including the previously described ECT-R clone (t002) found in Östergötland County, focusing on clonal relatedness, virulence determinants and existence of staphylococcal cassette chromosome (SCC) mec remnants. MSSA isolates with resistance to clindamycin and/or tobramycin were collected from the three county councils in southeast Sweden and investigated with spa typing, polymerase chain reaction (PCR) targeting the SCCmec right extremity junction (MREJ) and DNA microarray technology. The 98 isolates were divided into 40 spa types, and by microarray clustered in 17 multi-locus sequence typing (MLST) clonal complexes (MLST-CCs). All isolates with combined resistance to clindamycin and tobramycin (n = 12) from Östergötland County and two additional isolates (clindamycin-R) were designated as spa type t002, MREJ type ii and were clustered in CC5, together with a representative isolate of the ECT-R clone, indicating the clone's persistence. These isolates also carried several genes encoding exotoxins, Q9XB68-dcs and qacC. Of the isolates in CC15, 83% (25/30) were tobramycin-resistant and were designated spa type t084. Of these, 68% (17/25) were isolated from new-borns in all three counties. The persistence of the ECT-R clone in Östergötland County, although not found in any other county in the region, carrying certain virulence factors that possibly enhance its survival in the hospital environment, highlights the fact that basic hygiene guidelines must be maintained even when MRSA prevalence is low.

Expression of Thioredoxins and Glutaredoxins in Human Hepatocellular Carcinoma: Correlation to Cell Proliferation, Tumor Size and Metabolic Syndrome

Thioredoxins (Trx) and glutaredoxins (Grx) are thiol oxidoreductases that are ubiquitously expressed, and are involved in several biological processes. The expression of thioredoxins and glutaredoxins is induced in many neoplasms, and correlates with prognosis in gallbladder and colorectal carcinoma. The aim of the present study was to examine the expression pattern of these proteins (redoxins) in hepatocellular carcinoma (HCC) and to correlate their levels with clinical features. Paraffin-embedded tissues from 25 patients resected for HCC and 15 patients resected for colorectal carcinoma (CRC) liver metastases were analyzed with immunohistochemistry. Our results showed that Trx1, Trx2 and Grx5 were upregulated in HCCs as compared to the respective surrounding liver. In comparison, almost all redoxins were upregulated in CRC liver metastases, with Trx1 and Grx3 being significantly more increased in the CRC liver metastases than in the primary HCC tumors. In HCC, Trx1 correlated significantly with cell proliferation, and with a trend towards increased levels with micro-vascular invasion, while expression of Trx2 decreased with tumor size. Trx1 levels were lower in tumors of males, smokers, and patients with high alcohol consumption. Grx2 levels were significantly higher in patients with metabolic syndrome. In conclusion, this study illustrates specific correlations of individual redoxins to clinical features of HCC, and implicates the redoxins in the pathogenesis of HCC.

Late-onset neonatal sepsis, risk factors and interventions: an analysis of recurrent outbreaks of Serratia marcescens, 2006-2011

BACKGROUND

Between 2006 and 2011, 11 patients with Serratia marcescens sepsis and 47 patients colonized due to the spread of various clones were observed. These recurrent clusters brought about interventions to reduce spread between patients.

AIM

To evaluate the effect of stepwise interventions to prevent S. marcescens colonization/sepsis and to analyse risk factors for late-onset sepsis (LOS).

METHODS

An open retrospective observational study was performed to evaluate the interventions. A retrospective case-control study was performed to analyse the risk factors for LOS.

FINDINGS

S. marcescens sepsis and colonization decreased after the stepwise adoption of hygiene interventions. Low gestational age, low birth weight, indwelling central venous or umbilical catheter, and ventilator treatment were identified as risk factors for LOS. Compliance with basic hygiene guidelines was the only intervention monitored continuously from late 2007. Compliance increased gradually to a steady high level in early 2009. There was a decrease in S. marcescens LOS, clustering after the second quarter of 2008. After the first quarter of 2009, S. marcescens colonization decreased.

CONCLUSION

It was not possible to identify the specific effects of each intervention, but it is likely that an update of the hospital's antibiotic policy affected the occurrence of S. marcescens LOS. The delayed effect of interventions on S. marcescens colonization was probably due to the time it takes for new routines to have an effect, illustrated by the gradual increase in compliance with basic hygiene guidelines.

Detection and characterisation of SCCmec remnants in multiresistant methicillin-susceptible Staphylococcus aureus causing a clonal outbreak in a Swedish county

The purpose of this study was to investigate if multiresistant methicillin-susceptible Staphylococcus aureus (MR-MSSA) causing a clonal outbreak in Östergötland County, Sweden, were derived from methicillin-resistant S. aureus (MRSA) by carrying remnants of SCCmec, and, if so, to characterise this element. A total of 54 MSSA isolates with concomitant resistance to erythromycin, clindamycin and tobramycin from 49 patients (91% clonally related, spa type t002) were investigated with the BD GeneOhm MRSA assay and real-time polymerase chain reaction (PCR) targeting the SCCmec integration site/SCCmec right extremity junction. DNA sequencing of one isolate representing the MR-MSSA outbreak clone was performed by massive parallel 454 pyrosequencing. All isolates that were part of the clonal outbreak carried SCCmec remnants. The DNA sequencing revealed the carriage of a pseudo-SCC element 12 kb in size, with a genomic organisation identical to an SCCmec type ΙΙ element, except for a 41-kb gap. This study demonstrates the presence of a pseudo-SCC element resembling SCCmec type II among MR-MSSA, suggesting possible derivation from MRSA. The presence of SCCmec remnants should always be considered when SCCmec typing is used for MRSA detection, and may not be suitable in locations with a high prevalence of MR-MSSA, since this might give a high number of false-positive results.

Adipose tissue pathways involved in weight loss of cancer cachexia

Background:

The regulatory gene pathways that accompany loss of adipose tissue in cancer cachexia are unknown and were explored using pangenomic transcriptome profiling.

Methods:

Global gene expression profiles of abdominal subcutaneous adipose tissue were studied in gastrointestinal cancer patients with (n=13) or without (n=14) cachexia.

Results:

Cachexia was accompanied by preferential loss of adipose tissue and decreased fat cell volume, but not number. Adipose tissue pathways regulating energy turnover were upregulated, whereas genes in pathways related to cell and tissue structure (cellular adhesion, extracellular matrix and actin cytoskeleton) were downregulated in cachectic patients. Transcriptional response elements for hepatic nuclear factor-4 (HNF4) were overrepresented in the promoters of extracellular matrix and adhesion molecule genes, and adipose HNF4 mRNA was downregulated in cachexia.

Conclusions:

Cancer cachexia is characterised by preferential loss of adipose tissue; muscle mass is less affected. Loss of adipose tissue is secondary to a decrease in adipocyte lipid content and associates with changes in the expression of genes that regulate energy turnover, cytoskeleton and extracellular matrix, which suggest high tissue remodelling. Changes in gene expression in cachexia are reciprocal to those observed in obesity, suggesting that regulation of fat mass at least partly corresponds to two sides of the same coin.

The study of women in Gothenburg 1968-1969. Intake of energy and nutrients in five age groups

Women from five age groups (38, 46, 50, 54, and 60 years), participating in the population study "Women in Gothenburg 1968-1969", were subjected to a 24-hour recall dietary interview (n = 1361). In a randomized subsample (n = 418), a dietary history was obtained and individuals in another randomized subsample (n = 755) submitted a 24-hour urine specimen for nitrogen analyses. There were significant differences between the 24-hour recall and dietary history figures in all five age groups with respect to energy and all nutrients. The mean protein intake calculated indirectly from the urinary nitrogen excretion came close to the figures calculated from the dietary histories in four out of five age groups. The energy intake and, consequently, the intake of most nutrients calculated from the dietary histories were higher than generally ascribed to Swedish women, as most previous data have been obtained by 24-hour dietary recall interviews. Most women (71-89% in the different age groups) consumed too much fat and most women of fertile age (80-92%) consumed too little iron. A significant decrease in the mean energy intake was apparent only in the age group 60, i.e. 1870 kcal versus 1965--2 105 in the other groups.

Body composition, intraerythrocyte sodium content, volume regulation and blood pressure during moderate sodium restriction in hypertensive men

Eleven moderately obese middle-aged male outpatients with untreated mild hypertension reduced their sodium intake by about 120 mmol per day during 4-6 weeks. Diastolic blood pressure was then significantly reduced in comparison with a matched control group. The reduction of urinary sodium excretion was significantly correlated to the change in mean arterial pressure. Mean body mass showed a small significant decrease, although there were no significant changes in total body water or body fat as determined from measurements of 40K and tritiated water. Nor did mean extracellular water or plasma volume (Evan's blue) show any significant change. The decrease in urinary sodium excretion was associated with increases in plasma renin activity and urinary aldosterone excretion, while a sympathetic nervous natriuretic index (urinary dopamine to noradrenaline excretion ratio) decreased. The low sodium diet period was followed by a period of energy reduction as well as sodium restriction for 15 weeks. Mean body mass was then reduced by about 8 kg. The systolic but not the diastolic blood pressure showed a significant decrease. The intraerythrocyte content of water, sodium and potassium did not change significantly during any of the diet periods. We conclude that moderate sodium restriction lowered the blood pressure and affected the renin-aldosterone and sympathetic nervous system to retain sodium which might explain the constancy of the plasma volume.

Effect of a moderately energy- and salt-reduced diet on body compartments and blood pressure control in obese men with mild hypertension

Ten middle-aged moderately obese men with untreated mild hypertension were studied during a 6-week weight maintenance period and a 9-week period on a diet containing 5 MJ when body mass decreased by 8.4 kg (SE 1.4). According to urinary sodium excretion there was a mean reduction of 89 mmol/day (SE 16) in sodium intake. Mean arterial pressure fell by 2.5 to 14.1 mmHg (95% confidence interval) which was correlated to the reduction of body mass. The sympathetic nervous activity diminished with decreasing noradrenaline excretion and heart rate. There were no changes in the renin-aldosterone system. Estimation of the body composition with a four-compartment model utilizing determinations of body mass, total body potassium and total body water (TBW) showed reductions of body fat (8.4 kg (SE 1.4] and body cell mass (BCM) (2.4 kg (SE 0.6], but not of TBW. Extracellular water (ECW) increased significantly as judged from ECW/BCM calculations. Plasma volume was determined by Evan's blue and did not change significantly. We suggest that the observed changes in body composition represent one aspect of the adjustment to a weight reducing diet, while blood pressure is lowered by another mechanism in the adaptive response to dieting, i.e. reduction in sympathetic nervous activity.

Nosocomial hepatitis C in a thoracic surgery unit; retrospective findings generating a prospective study

We describe the transmission of hepatitis C virus (HCV) to two patients from a thoracic surgeon who was unaware of his hepatitis C infection. By partial sequencing of the non-structural 5B gene and phylogenetic analysis, the viruses from both patients were found to be closely related to genotype 1a strain from the surgeon. Two further hepatitis C cases were found in relation to the thoracic clinic. Their HCV sequences were related to each other but were of genotype 2b and the source of infection was never revealed. To elucidate the magnitude of the problem, we conducted a prospective study for a period of 17 months in which patients who were about to undergo thoracic surgery were asked to participate. Blood samples were drawn prior to surgery and at least four months later. The postoperative samples were then screened for anti-HCV and, if positive, the initial sample was also analysed. The only two patients (0.4%) identified were confirmed anti-HCV positive before surgery, and none out of 456 evaluable cases seroconverted to anti-HCV during the observation period. Despite the retrospectively identified cases, nosocomial hepatitis C is rare in our thoracic unit. The study points out the risk of transmission of hepatitis C from infected personnel and reiterates the need for universal precautions.

Optimising islet engraftment is critical for successful clinical islet transplantation

Clinical islet transplantation is currently being explored as a treatment for persons with type 1 diabetes and hypoglycaemia unawareness. Although 'proof-of-principle' has been established in recent clinical studies, the procedure suffers from low efficacy. At the time of transplantation, the isolated islets are allowed to embolise the liver after injection in the portal vein, a procedure that is unique in the area of transplantation. A novel view on the engraftment of intraportally transplanted islets is presented that could explain the low efficacy of the procedure.

Intramuscular autotransplantation of pancreatic islets in a 7-year-old child: a 2-year follow-up

A 7-year-old girl with severe hereditary pancreatitis underwent total pancreatectomy. A total of 160,000 islet equivalents (6400 islet/kg) were transplanted to the brachioradialis muscle of the right forearm. Her plasma C-peptide level was undetectable after pancreatectomy but increased to 1.37 ng/mL after 17 days; at this time point, her insulin requirement was 0.75 units of insulin/kg/day. At 5- and 27-months, her hemoglobin A1c (HbA1c) and insulin requirements were 4.5 and 5.3% and 0.3 and 0.18 units/kg/day, respectively. Basal and stimulated C-peptide levels were 0.67 +/- 0.07 and 3.36 +/- 1.37 ng/mL, respectively. Stimulated insulin levels were 30% higher in the islet-bearing arm compared to the contralateral arm after glucagon stimulation. After surgery and islet transplantation, the quality of life improved dramatically and she gained 8 kg of weight. In summary, a normal HbA1c, a low insulin requirement and the absence of recurrent hypoglycemia and the gradient of insulin between the arms indicate that the intramuscularly transplanted islets contribute to a long-term clinically significant metabolic control.

Efficacy of preoperative radiochemotherapy in patients with locally advanced pancreatic carcinoma

15073

Background: The optimal care for patients with irresectable, non-metastatic pancreatic carcinoma (PAC) is debated. We treated 17 consecutive cases with preop radiochemotherapy (RCT) as a means for downstaging their tumors and compared outcome with 35 patients undergoing direct surgery for primarily resectable PAC during the same time period. Methods: The patients had biopsy proven, irresectable, non-metastatic PAC which engaged >50% of the circumference of a patent mesenteric/portal vein for a distance >2 cm and/or <50% of the circumference of a regional artery for <2 cm. The preop therapy included 2 courses of Xelox (oxaliplatin 130mg/m2 d1; capecitabine 1000mg/m2 X 2 d1–14 q 3 w) followed by 3-D conformal radiotherapy (50.4 Gy; 1.8 Gy fractions) with reduced Xelox (d1–5 q 1 w X 6). Results: 6 cases of RCT-related CTC Grade 3–4 non-hematologic side-effects were diagnosed. Sixteen patients completed the RCT and were rescanned with CT/reevaluated for surgery 4 weeks post-RCT. Five cases were diagnosed with new metastases to the liver. Eleven patients were accepted for surgery and 8 underwent a curative R0-resection. The median overall survival for the latter group was 29 mos, which compared favorably with our control group of patients undergoing direct surgery for primarily resectable PAC (median OS: 16 mos (P=0.02). RO- rate: 75%). Periop morbidity was similar in the two cohorts but the duration of surgery was longer (576 vs 477 min; P<0.05) and the op blood loss was greater (3288 vs 1460 ml; P<0.05) in the RCT-cohort. The 30-day mortality was zero in both cohorts. Conclusions: Preop RCT in fit patients with locally advanced PAC resulted in a high rate of curative resections and promising median survival in our treatment series. This trimodality approach merits further exploration in new studies, which are currently underway at our Department.

No significant financial relationships to disclose.

Minimized weight gain between hemodialysis contributes to a reduced risk of death

The risk of death is higher in dialysis patients compared to age matched healthy subjects, the main reason being cardiovascular. This prospective study investigated if the extent of ultrafiltration was of importance for the outcome.

MATERIAL AND METHODS

88 hemodialysis patients were included and followed prospectively. The outcome was registered in regard to death, acute myocardial infarction or coronary vascular intervention. The extent of ultrafiltration needed at dialysis was calculated as a mean during the observation period as were other variables. The mean extent of ultrafiltration was compared for patients who had survived without end-points (group 1, n=53) versus those who reached any end-point during the period (group 2, n=35).

RESULTS

In total, 40% of the patients reached end-point during the observation period. There was no difference at baseline between the groups in regard to age, prevalence of diabetes mellitus or history of previous cardiovascular disease, KT/V, residual renal function ultrafiltration need, C-reactive protein, s-albumin, cholesterol, LDL-cholesterol, HDL-cholesterol, appetite or wellbeing, while triglyceride was lower in group 2 (p=0.035). The observation period for group 1 was at a mean 24.7 months (SD13.1) and for those in group 2 at a mean 13.8 (+/-11.7 months, p<0.001). Patients representing group 1 at 24 and 30 months had less need of ultrafiltration than those in group 2. Thus, the need of ultrafiltration was about 27% lower at 24 months (for 29 persons in group 1: 3.63+/-1.93 weight% versus 4.97+/-1.70 weight% for 9 patients from group 2, p=0.046) and 46% at 30 months (for 18 from group 1: 3.48+/-1.95 versus 6.45+/-1.55 for 3 from group 2, p=0.030). C-reactive protein did not differ significantly between the groups during the period.

CONCLUSION

After a prolonged period of 24 months the extent of ultrafiltration need seems to be important for the outcome of the patients. Thereby those with higher need of ultrafiltration had worse prognosis. It seems important to motivate patients to reduce the extent of fluid intake between dialysis to prolong survival.

Retinal function and histopathology in rabbits treated with Topiramate

PURPOSE

To evaluate retinal function and histopathology in rabbits treated orally with the anti-epileptic drug topiramate.

METHODS

Six rabbits were treated with a daily oral dose of topiramate during a period of eight months. Six rabbits receiving water served as controls. Blood samples were analyzed for determination of topiramate serum levels in order to ensure successful drug exposition. Standardized full-field electroretinograms (ERGs) were performed before treatment and then at 2, 3 and 8 months during the treatment period. After terminating treatment the rabbits were sacrificed and the morphology of the sectioned retina was studied.

RESULTS

After eight months of treatment the full-field ERG demonstrated normal rod function in treated and control rabbits, but the light adapted 30 Hz flicker b-wave amplitude was significantly reduced in the treated rabbits. This was the case for both the light adapted (Wilcoxon signed ranks test, P = 0.046) and the dark adapted (Wilcoxon signed ranks test, P = 0.028) 30 Hz flicker response from the treated rabbits. Retinal immunohistology revealed a severe accumulation of GABA in amacrine cells and in the inner plexiform layer in 4 of 6 treated rabbits compared to the controls.

CONCLUSIONS

Topiramate, orally administrated to rabbits, may cause a significant reduction of the retinal function demonstrated by the reduced b-wave amplitude in the full-field ERG, as well as changes in immunohistology characterized by a severe accumulation of GABA in the inner retina. The retinal dysfunction and the morphological changes indicate that topiramat may damage the retina, similarly to vigabatrin (another anti-epileptic drug).

Safety and efficacy of atorvastatin in patients with severe renal dysfunction

OBJECTIVE

To investigate the efficacy and safety of a daily dose of 10 mg of atorvastatin in patients with chronic kidney disease (CKD) stages 4 and 5 and a glomerular filtration rate of <30 ml/min.

MATERIAL AND METHODS

This was an open, prospective, randomized study. A total of 143 patients were included: 73 were controls and 70 were prescribed 10 mg/day of atorvastatin. As efficacy variables, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglyceride levels were determined at the start of the study and at 1, 3, 6, 12, 18, 24, 30 and 36 months.

RESULTS

The follow-up period was a mean of 20+/-14.4 months (range 1-36 months) for those on atorvastatin versus 22+/-12.7 months (range 0.5-36 months) for the controls. Compared with baseline values, patients treated with atorvastatin had significantly lower concentrations of total cholesterol at Month 36 (5.8 vs 4.4 mmol/l; -23%; p<0.001), of LDL cholesterol at Month 36 (3.6 vs 2.2 mmol/l; -35%; p<0.001) and of triglycerides at Months 24 (2.5 vs 1.9 mmol/l) and 36 (2.5 vs 1.8 mmol/l). The controls had significantly reduced levels of total cholesterol at Month 36 (p<0.21) and of LDL cholesterol at Months 30 and 36. Compared with the controls, the atorvastatin group had lower levels of total cholesterol and LDL cholesterol at Months 1-30. Fifteen patients (21%) stopped taking their medication as they could not tolerate the side-effects, the most frequent complaints being gastrointestinal discomfort and headache.

CONCLUSION

Although the medication caused no severe adverse events, we recommend caution when using atorvastatin for severe CKD patients until further evidence of its safety and efficacy is verified.

Phene Plate (PhP) biochemical fingerprinting. A screening method for epidemiological typing of enterococcal isolates

Pulsed-field gel electrophoresis (PFGE) is currently considered the gold standard for genotyping of enterococci. However, PFGE is both expensive and time-consuming. The purpose of this study was to investigate whether the PhP system can be used as a reliable clinical screening method for detection of genetically related isolates of enterococci. If so, it should be possible to minimize the number of isolates subjected to PFGE typing, which would save time and money. Ninety-nine clinical enterococcal isolates were analysed by PhP (similarity levels 0.90-0.975) and PFGE (similarity levels < or =3 and < or =6 bands) and all possible pairs of isolates were cross-classified as matched or mismatched. We found that the probability that a pair of isolates (A and B) belonging to the same type according to PhP also belong to the same cluster according to PFGE, i.e. p(A(PFGE)=B(PFGE) * A(PhP)=B(PhP)), and the probability that a pair of isolates of different types according to PhP also belong to different clusters according to PFGE, i.e. p(A(PFGE) not equalB(PFGE) * A(PhP) not equalB(PhP)), was relatively high for E. faecalis (0.86 and 0.96, respectively), but was lower for E. faecium (0.51 and 0.77, respectively). The concordance which shows the probability that PhP and PFGE agree on match or mismatch was 86%-93% for E. faecalis and 54%-66% for E. faecium, which indicates that the PhP method may be useful for epidemiological typing of E. faecalis in the current settings but not for E. faecium.

Chronically administered islet amyloid polypeptide in rats serves as an adiposity inhibitor and regulates energy homeostasis

AIMS/HYPOTHESIS

Islet amyloid polypeptide (IAPP) reduces food intake and body weight in laboratory animals. In addition, IAPP appears to regulate nutrient metabolism. In the present studies, we investigated the effect of chronic IAPP treatment on different aspects of energy homeostasis.

METHODS

IAPP was infused (25 pmol/kg/min) from subcutaneous osmotic pumps for 2-7 days. Rats in 2 saline-infused control groups were fed ad libitum (AF) or pair-fed (PF) against the IAPP-treated rats.

RESULTS

As expected, the IAPP infusion reduced food intake and body weight gain. In addition, the IAPP treatment decreased the epididymal fat pad (vs. PF rats, p < 0.05) and lowered circulating levels of triglycerides (vs. PF rats, p < 0.05), free fatty acids (vs. PF rats, p < 0.05), leptin (vs. both AF and PF rats, p < 0.05) and insulin (vs. AF rats, p < 0.05). In contrast, glucose and protein metabolism in the IAPP-treated rats was largely unchanged, as shown in results regarding serum glucose, glucose transport in skeletal muscle, blood urea nitrogen, and glycogen and protein content in the liver and in skeletal muscle.

CONCLUSION/INTERPRETATION

In summary, chronic IAPP exposure led to a changed lipid metabolism, which was characterized by decreased adiposity, hypolipidemia and hypoleptinemia, and to unchanged glucose and protein homeostasis. These results were similar to those seen in rodents during chronic exposure to another satiety/adiposity regulator, leptin. In conclusion, chronically administered IAPP plays a role as a satiety and adiposity signal in rats, and helps regulate energy homeostasis.

Hepatic encephalopathy verified by psychometric testing and EEG in cirrhotic patients: effects of mesocaval interposition shunt or sclerotherapy

BACKGROUND

The aim of this randomised prospective study was to evaluate hepatic encephalopathy after mesocaval interposition shunt operation and after repeated endoscopic sclerotherapy.

METHODS

Forty-five patients with bleeding oesophageal varices due to liver cirrhosis were randomised to the two treatment groups, 24 to the shunt group and 21 to the sclerotherapy group. The patients were evaluated preoperatively regarding blood tests, hepatic encephalopathy as measured by electroencephalogram with spectral analysis and by a battery of psychometric tests. The direction of portal flow in the shunt group was investigated by shunt phlebography and ultrasonography with Doppler. During follow-up the same investigations were performed twice at median 6.7 and 14.7 months after operation.

RESULTS

No statistically significant difference was found during follow-up regarding blood tests and electroencephalography with spectral analysis. Although the preoperative psychometric tests showed that the shunt group performed significantly better than the sclerotherapy group, the first follow-up showed that the shunt group performed statistically worse than the sclerotherapy group in seven of the tests: Synonyms (measuring verbal ability), Block Design Test (measuring visuo-spatial ability), Memory for Design Test, Error Score (measuring memory function), Revised Visual Retention Test, correct answers and the same test error answers (measuring visuo-spatial memory, ability and immediate memory), Digit Symbol Test (measuring perceptual ability) and Trial Making Test B (measuring cognitive motor abilities).

CONCLUSIONS

Patients treated by mesocaval interposition shunt showed a progressive general reduction in psychometric performance compared with patients treated with repeated sclerotherapy, in whom a general intellectual improvement was observed. This finding corresponds to the reverse direction of the preoperative portal flow to a hepatofugal pattern at first follow-up and at 12 months among two-thirds of the patients.

Clustering of enterococcal infections in a general intensive care unit

This is a retrospective study comparing patients' characteristics, antibiotic consumption and environmental contamination before the impact of a new regimen of intensified infection control measures in a general intensive care unit (ICU) at a university-affiliated tertiary-care teaching hospital. The new regimen consisted of (1) reorganization of patient rooms (2) improved hygienic measures including strict hygiene barrier nursing (3) more isolated patient care and (4) more restrictive use of antibiotics. The regimen was introduced after a cluster of enterococcal infections. All patients admitted to the ICU from 1 March 1995 to 28 february 1997 were included. A study period of 12 months after reorganization of the ward was compared with the 12 months immediately before it. The antibiotic consumption, the individual patient's severity of disease (APACHE score), and the extent of therapeutic interventions (TISS score) were recorded. Enterococci were typed biochemically, antibiograms were established and the relation between the isolates was investigated with pulsed-field gel electrophoresis. The bacteriological results and the patient data suggested a hospital-acquired spread as the cause of the ICU enterococcal outbreak. After implementation of the new regimen, we observed a reduction in the rate of enterococcal bloodstream infections from 3.1 to 1.8%. The consumption of antibiotics fell from 6.11 to 4.24 defined daily doses per patient. The introduction of strict hygiene and barrier nursing, more restrictive use of antibiotics, isolation of infected patients, thorough cleaning and disinfection of the unit was followed by an absence of enterococcal infection clustering and reduction in incidence of enterococcal bacteraemia. We were not able to determine whether the reduction in antibiotic consumption was due to the intervention programme.

Perspectives on hepatitis B infections and the efficacy of vaccination (hepatitis B and pneumococci) in dialysis patients

Hepatitis B is a well known problem in dialysis units. We therefore examined the historical frequency of hepatitis B carriers in our unit, our vaccination program to hepatitis B virus (HBV), the response to hepatitis B vaccine, the IgG subclass response of anti-HBs and the response and IgG subclass response to pneumococcal vaccination (another vaccine) in dialysis patients. From 1970 and onwards 23 HBV carriers were found, but no new cases of hepatitis B occurred during the study period, i.e. from 1980 and onwards. Only one of the carriers was alive by the end of 2001. In four patients liver disease (in one of them liver cirrhosis) may have been a concomitant cause of death. The antibody response to hepatitis B vaccine was significantly lower in patients than in staff. In four patients a fourth injection was cancelled due to transplantation and bad health, while such data were lacking in 8 cases. In anti-HBs positive patients and controls a significant difference in the response of healthy adults was observed in anti-HBs IgG1 (p < 0.001) vs all other IgG subclasses. Dialysis patients had low levels, or negative findings, in all cases, with IgG1 as the highest proportion found (3/11 patients). An antibody response to pneumococcal vaccination was registered in 25 out of 29 dialysis patients (in all 86%). The IgG-subclass vaccination response to pneumococci in 28 dialysis patients was mainly IgG2 and IgG1 but also occurred in IgG3 and IgG4. Prevaccination antibody levels of the controls were higher in IgG1 and IgG2 (p < 0.01) (n = 21) than in dialysis patients (n = 28). Hepatitis B is nowadays a rare, but still dangerous disease in nephrology units. Dialysis patients have a reduced response to hepatitis B vaccine and vaccination schedules should be started early as some patients otherwise may not receive a fourth injection. The adequate antibody response to pneumococcal vaccination mainly due to IgG2 and IgG1 antibodies indicates that the antigen involved is important in vaccination responses in dialysis patients.

Antibiotic prescription practices, consumption and bacterial resistance in a cross section of Swedish intensive care units

BACKGROUND

The purpose of this work was to study usage of antibiotics, its possible determinants, and patterns of bacterial resistance in Swedish intensive care units (ICUs).

METHODS

Prospectively collected data on species and antibiotic resistance of clinical isolates and antibiotic consumption specific to each ICU in 1999 were analyzed together with answers to a questionnaire. Antibiotic usage was measured as defined daily doses per 1000 occupied bed days (DDD1000).

RESULTS

Data were obtained for 38 ICUs providing services to a population of approximately 6 million. The median antibiotic consumption was 1257 DDD1000 (range 584-2415) and correlated with the length of stay but not with the illness severity score or the ICU category. Antibiotic consumption was higher in the ICUs lacking bedside devices for hand disinfection (2193 vs. 1214 DDD1000, p=0.05). In the ICUs with a specialist in infectious diseases responsible for antibiotic treatment the consumption pattern was different only for use of glycopeptides (58% lower usage than in other ICUs: 26 vs. 11 DDD1000,P=0.02). Only 21% of the ICUs had a written guideline on the use of antibiotics, 57% received information on antibiotic usage at least every 3 months and 22% received aggregated resistance data annually. Clinically significant antimicrobial resistance was found among Enterbacter spp. to cephalosporins and among Enterococcus spp. to ampicillin.

CONCLUSIONS

Availability of hand disinfection equipment at each bed and a specialist in infectious diseases responsible for antibiotic treatment were factors that correlated with lower antibiotic consumption in Swedish ICUs, whereas patient-related factors were not associated with antibiotic usage.

A clone of coagulase-negative staphylococci among patients with post-cardiac surgery infections

Coagulase-negative staphylococci (CoNS) are important causes of hospital-acquired infections such as infections after cardiac surgery. Efforts to reduce these infections are hampered by the lack of knowledge concerning the epidemiology of CoNS in this setting. Forty strains of CoNS collected during the surgical revision of 27 patients operated on between 1997 and 2000 were analysed. Strains were also collected from the ambient air in the operating suite. Their pulsed-field gel electrophoresis (PFGE) characteristics and antibiotic resistance were analysed. Using PFGE 19 of 40 strains from 15 of 27 patients were shown to belong to one clone, and strains from this clone were also isolated from the ambient air. This clone had caused infections throughout the period. Antibiotic resistance did not correlate with PFGE patterns. Using PFGE one clone could be identified that caused 56% of the CoNS infections during this period. A strain from this clone was also found in the air of the operating suite suggesting the origin of the CoNS causing infections was the hospital environment.

The common -675 4G/5G polymorphism in the plasminogen activator inhibitor -1 gene is strongly associated with obesity

AIMS/HYPOTHESIS

Plasminogen activator inhibitor 1 (PAI-1) increases in several insulin-resistant conditions such as obesity. We tested the hypothesis that the PAI-1 gene might be a candidate for obesity and Type II (non-insulin-dependent) diabetes mellitus.

METHODS

We investigated the frequency of a common and functional -675 4G/5G promoter polymorphism in the PAI-1 gene in 188 lean, 70 overweight (BMI 25-30 kg/m(2)) and 247 obese otherwise healthy Scandinavian subjects.

RESULTS

The genotypic ( p = 0.002), or allelic ( p = 0.0004) distribution differed markedly between the three groups. Homozygosity for 4G was more common among obese people, whereas homozygosity for 5G was more common among lean subjects. Heterozygosity was evenly distributed. The lean and overweight groups did not differ in frequency distribution. The relative risk for being obese in comparison to being lean for 4G/4G was threefold higher ( p = 0.0003). Also, carriers of the 4G allele in the heterozygous or homozygous form were distributed differently between the three groups ( p = 0.006). The 4G carriers were more common among the obese than the lean group. The latter group did not differ from the overweight group. The relative risk of being obese in comparison with lean was twofold increased in 4G carriers ( p = 0.0015). Similar results were obtained in men and women.

CONCLUSION/INTERPRETATION

Thus, the common -675 4G/5G polymorphism in the PAI-1 gene is strongly linked to obesity and a markedly increased risk for obesity is associated with the 4G allele in its homozygous form.

Changes in the appearance and treatment of deep sternal infections

The Department of Thoracic Surgery at the University Hospital, Linköping, Sweden, has actively followed up infectious complications of cardiac surgery since 1989. The aim of this study was to investigate whether changes occurred during the 1990s in the appearance and the management of deep infections. This was done by studying patients undergoing surgical revision of infected wounds. We studied 42 patients during 1990-94 and 49 during 1997-98 (total number of operations in these periods, 3075 and 1646, respectively). Pre-operative and intra-operative variables were recorded for the two patient populations. The proportion of cardiac surgery procedures followed by a surgical revision for an infection in the sternal wound increased between the two periods (1.4% vs. 3.0%). Variables associated with the surgical procedures preceding the infection remained unchanged. In the later period, treatment was started earlier (64 vs. 24 days), and the length of antibiotic treatment was decreased (115 vs. 72 days). The incidence of osteomyelitis of the sternal bone was lower (61% vs. 27%). It appears that as the proportion of patients undergoing surgical revision increased, management of the infections became more effective, with aggressive surgical and antibiotic treatment policies and shorter treatment periods. This indicates that in order to evaluate the overall impact of measures designed to reduce infections after cardiac surgery, not only the incidence of infection needs to be followed up but other factors also need to be taken into account.

Obstructive jaundice results in increased liver expression of uncoupling protein 2 and intact skeletal muscle glucose metabolism in the rat

BACKGROUND

A majority of patients with pancreatic cancer have obstructive jaundice and diabetes with skeletal muscle insulin resistance. Surgery for these patients is associated with significant morbidity. Uncoupling protein 2 (UCP2) has been proposed to regulate energy expenditure and promote liver vulnerability. The effects of obstructive jaundice on muscle glucose metabolism and expression of UCP2 in liver and muscle are unknown.

METHODS

Rats were operated with bile duct ligation (BDL). After 7 days, UCP2 mRNA levels were determined in liver and muscle. Simultaneously, insulin-stimulated glucose transport and glycogen synthesis in skeletal muscle were analyzed in vitro.

RESULTS

The jaundiced rats lost more weight than pair-fed controls. UCP2 mRNA levels were increased 5-fold in liver but not in muscle in jaundiced rats compared to pair-fed controls. The jaundiced rats were hypoglycemic and hypoinsulinemic but demonstrated intact or enhanced insulin action on skeletal muscle glucose transport and glycogen synthesis in vitro. Muscle glycogen content was increased in the jaundiced rats.

CONCLUSIONS

Experimental obstructive jaundice in the rat is associated with increased liver expression of UCP2, rapid weight loss, and intact insulin action on skeletal muscle glucose metabolism. Obstructive jaundice, by upregulated liver UCP2, may contribute to the cachexia and high surgical morbidity observed in these patients, but not to skeletal muscle insulin resistance in pancreatic cancer patients.

Effect of carbohydrate feeding on insulin action in skeletal muscle after surgical trauma in the rat

Metabolic stress after surgery is associated with peripheral insulin resistance. Recent studies have suggested that preoperative glucose can ameliorate postoperative decreases in insulin-stimulated glucose disposal. In the present experiments, we used a bowel-resection model of surgical trauma to test the hypothesis that elevations of serum insulin induced by preoperative oral glucose or ad libitum feeding affects postoperative insulin-stimulated glucose uptake in skeletal muscle. Insulin-stimulated glucose transport was measured in vitro in soleus muscles after surgical trauma in fasted rats given oral glucose or water before surgery. Insulin-stimulated glucose transport was also assessed in vitro in fasted or fed traumatized rats and non-traumatized control animals. In addition, stress hormones (glucagon, corticosterone, and adrenaline) were measured before and after surgical trauma in fasted rats and rats fed ad libitum. In vitro skeletal-muscle insulin sensitivity and responsiveness were reduced postoperatively in fasted animals that received oral glucose loads before bowel resections and in rats fed ad libitum or fasted before surgery versus non-traumatized rats (all P < 0.05). Stress-hormone concentrations after trauma did not differ between fed and fasted animals. In the current study, insulin sensitivity and responsiveness were reduced in isolated skeletal muscles after bowel resection, but neither preoperative glucose supplementation nor free intake of mixed nutrients ameliorated the development of postoperative insulin resistance.

Lowering of tumoral interstitial fluid pressure by prostaglandin E(1) is paralleled by an increased uptake of (51)Cr-EDTA

High intra-tumoral fluid pressure (TP(IF)) may impair uptake of anticancer drugs into tumors, contributing to poor efficiency in treatment of carcinomas. Here, we demonstrate that lowering of TP(IF) parallels increased transport of (51)Cr-EDTA (m.w. 341) into tumor interstitium. Introduction of 15 microg prostaglandin E(1) (PGE(1)) -methyl ester into the s.c. tissue surrounding transplanted rat colonic (PROb) carcinomas or chemically-induced rat mammary carcinomas, lowered TP(IF) by 30%. Transcapillary transport into the interstitium of PROb tumors quantified by microdialysis increased by 39.6% after PGE(1) treatment 40 min prior to administration of (51)Cr-EDTA (n=6; p<0.05) compared to vehicle (n=10). In mammary tumors, PGE(1) increased transport into the tumors by 86.9% over controls (n=16; p<0.05). Both tumors had well developed stroma containing collagen and hyaluronan. Our data demonstrate that adjuvant treatment with PGE(1) lowers TP(IF), and enhances transport into the tumors. This principle may be of value as adjuvant therapy in treatment of solid malignancies with currently used anticancer drugs.

High fruit intake may reduce mortality among middle-aged and elderly men. The Study of Men Born in 1913

OBJECTIVE

A number of long-term population-based studies have tried to study fruit and vegetable consumption in relation to cardiovascular disease, cancer and total mortality. Few of these studies are based on randomly selected population samples. The aim of the study was to investigate the long-term effect of fruit and vegetable consumption on mortality, cardiovascular disease, cardiovascular death, cancer morbidity and cancer death among middle-aged and elderly men.

DESIGN

Prospective cohort study.

SETTING

General community. The Study of Men Born in 1913.

SUBJECTS

792 men at age 54 who participated in a screening examination in 1967.

MAIN OUTCOME MEASURES

A food frequency questionnaire was used to obtain information of the dietary habits in 730 of the men (92%). All men were followed up with repeated examinations until the age of 80.

RESULTS

Cardiovascular as well as total mortality was significantly lower among men with high fruit consumption in univariate analysis. There was no correlation between fruit or vegetable consumption in relation to cancer incidence, cancer death and cardiovascular disease. In multivariate survival analysis where smoking, cholesterol and hypertension were taken into account, there was a significantly lower mortality among men with a high fruit consumption during 16 y follow up until the age of 70 (P=0.042), but this finding was no longer statistically significant during 26 y follow-up at the age of 80 (P=0.051).

CONCLUSIONS

Daily fruit consumption seems to have positive effect on long-term survival independently of other traditional cardiovascular risk factors like smoking, hypertension and cholesterol.

SPONSORSHIP

This study was supported by grants from the Swedish Medical Research Council (K98-274-06276-17) King Gustav V and Queen Victoria's Foundation, and the Göteborg University.

Preoperative feeding does not reverse postoperative insulin resistance in skeletal muscle in the rat

Metabolic studies on injured and postoperative patients have shown impaired glucose disposal in peripheral tissues after trauma. Using small-bowel resection as a model of surgical trauma, we investigated whether substrate availability could ameliorate the changes in muscle glucose uptake induced by trauma. We also studied the effect of preoperative feeding on postoperative insulin-stimulated insulin receptor substrate-1 (IRS-1)-associated phosphatidylinositol (PI) 3-kinase activity in both Wistar rats and genetically non-insulin-dependent diabetic Goto-Kakazaki rats (GK rats). Serum glucose, insulin, plasma epinephrine, lactate, and plasma nonesterified free fatty acids (NEFAs) were measured as indicators of the metabolic state and surgical stress. Insulin-stimulated glucose transport was significantly reduced in fed traumatized Wistar rats compared with fed nontraumatized rats (P < .05). Significant increases in in vivo insulin-stimulated IRS-1-associated PI 3-kinase activity were found in fed traumatized Wistar rats compared with fed nontraumatized Wistar rats and fasted traumatized Wistar rats, as well as fed traumatized GK rats compared with fed nontraumatized GK animals (all P < .017). Serum insulin concentrations were significantly reduced in fed traumatized Wistar and GK rats compared with the respective fed nontraumatized groups (both P < .01). Serum glucose levels were significantly elevated in fed traumatized GK rats compared with fed nontraumatized animals (P < .01). In the present study, preoperative feeding did not prevent a postoperative reduction in insulin-stimulated glucose transport in skeletal muscle. The finding that insulin-stimulated PI 3-kinase activity increased after trauma in both Wistar and GK rats indicates that postoperative insulin resistance is not caused by an impairment in the early steps of the insulin signaling pathway. The postoperative decreases in serum insulin despite high blood glucose suggest that trauma impairs the insulin response to hyperglycemia.

Renal dopamine and noradrenaline excretion during CNS-induced natriuresis in spontaneously hypertensive rats: influence of dietary sodium

Abnormalities in dopamine (DA) and noradrenaline (NA) activities and sodium handling may be involved in the pathogenesis of hypertension. The present study was designed to investigate whether any differences exist between normotensive Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) in urinary excretion of DA, NA and sodium after 15 weeks on a low, medium or high sodium diet and during a subsequent elevation of the cerebroventricular fluid sodium concentration (CNS-induced natriuresis). Seven features were noted: (1) Basal sodium and DA excretion after the diet regimen was correlated to the dietary sodium content in both strains, except that sodium and DA excretion in SHR showed no further increase after the high sodium diet over and above that after medium sodium diet. (2) For any given sodium diet, SHR excreted more DA and NA as compared with WKY. (3) Blood pressure in SHR, as opposed to that in WKY, was higher after medium and high sodium diet than after low sodium diet. (4) During CNS-induced natriuresis NA excretion decreased or remained unchanged in WKY, but increased in SHR. (5) The DA/NA excretion ratio during CNS-induced natriuresis increased in WKY while decreased in SHR, which would not favour a natriuretic/vasodilatory response in the latter. (6) The ability of SHR to respond with CNS-induced natriuresis was attenuated after high sodium diet. (7) The magnitude of CNS-induced natriuresis was in both strains correlated to the sodium diet; the higher the dietary sodium content, the greater the natriuretic response. In conclusion, the study shows some clear differences in the catecholamine and sodium handling between WKY and SHR which may be involved in the pathogenesis of hypertension in SHR. Furthermore, increased sodium in the diet sensitizes the brain and kidney to increase the ability to respond with natriuresis for a given sodium stimulus.

Surveillance of antibiotic resistance in ICUs in southeastern Sweden. ICU Study Group of the South East of Sweden

BACKGROUND

A study was designed to assess a computer-based program for continuous registration of antibiotic resistance, statistics concerning severity of illness, and consumption of antibacterial drugs.

METHODS

The frequency of antibiotic resistance among bacteria in eight ICUs in southeastern Sweden was investigated yearly from 1995 through 1997. The antibiotic consumption in the ICUs was registered as defined daily doses (DDD) and compared to severity of illness (APACHE-II scores).

RESULTS

There was a statistically significant increase in ampicillin resistance among Enterococcus spp. between 1996 and 1997, which was due to a shift from Enterococcus faecalis to Enterococcus faecium. A high prevalence of resistance among coagulase-negative staphylococci to oxacillin (approximately 70%), ciprofloxacin (approximately 50%), fucidic acid (approximately 50%) and netilmicin (approximately 30%) was seen in all ICUs during the whole study period. There was a statistically significant increase in ciprofloxacin resistance among Escherichia coli and Enterococcus spp. The resistance among Enterobacter spp. to cefotaxime decreased but this change was not statistically significant. Efforts were made to avoid betalactam antibiotics, except carbapenems, for treatment of infections caused by Enterobacter spp. and the consumption of cephalosporins decreased whereas the consumption of carbapenems increased. The total antibiotic consumption decreased by 2.5% during the study period. There was no correlation between APACHE II scores and antibiotic consumption.

CONCLUSIONS

Each ICU within a hospital ought to have a program for "on-line" antibiotic resistance surveillance of drugs used in that unit so that changes in empirical treatment can be made when there is an increase in antibiotic-resistant isolates within that unit.

Effect of mesocaval interposition shunting and repeated sclerotherapy on blood levels of gastrointestinal regulatory peptides, amino acids, and lysosomal enzymes--a prospective randomised trial

AIMS/BACKGROUND

Patients with liver cirrhosis and portal hypertension frequently exhibit a multitude of alterations of hormones and metabolism, but the relation of these alterations to liver function, degree of blood shunting, and hepatic encephalopathy remains unclear.

METHODS

Twenty-four patients were randomised to mesocaval interposition shunt (MIS) and 21 patients to repeated sclerotherapy (ST). Several peptide hormones, amino acids and lysosomal enzymes were monitored during a 4 year follow-up period.

RESULTS

Insulin and glucagon levels were elevated in the MIS group compared to pre-therapy levels, whereas the gastrin level was significantly higher in the ST group. Pancreatic polypeptide, somatostatin and vasoactive intestinal peptide levels were not affected by either treatment. The branched chain amino acids valine, leucine and isoleucine serum levels were all elevated after ST, and the arginine, proline and tyrosine levels were higher in the MIS group at follow-up. Other amino acids were not changed, neither were the lysosomal enzymes beta-hexosaminidase nor beta-glucoronidase during this longterm follow-up.

CONCLUSION

MIS or repeated ST treatment only affected serum levels of hormones, amino acids and lysosomal enzymes to a limited extent. In this trial, the type of treatment had only a small influence on these parameters during long term follow-up.

Control of an outbreak of a highly beta-lactam-resistant Enterobacter cloacae strain in a neonatal special care unit

Two successive outbreaks of colonization and infection with Enterobacter cloacae resistant to third generation cephalosporins (cephalosporin-resistant E. cloacae, CREC) and involving 15 infants occurred within 12 months in a neonatal special care unit. Isolates of clinical significance were obtained from four infants (urine 2 cases, blood, pleural drainage). According to epidemiological typing using computerized biochemical fingerprinting and pulsed-field gel electrophoresis (PFGE) the same CREC strain was found in both outbreaks. The origin of the strain and its reservoir between the two outbreaks remained unknown. Emphasizing strict barrier nursing of the infants had little or no impact on the presence and transmission of the strain in the unit. In contrast, replacing ampicillin plus cefotaxime as standard empiric therapy with penicillin G plus netilmicin plus consequent cohorting of newborns and staff promptly halted both the outbreaks. During a 5-y follow-up after the last episode, the choice of antibiotics for empirical treatment has varied, and no further outbreaks of CREC have been seen, with the exception of two sporadic cases.