Targeting NF-κB in hematologic malignancies

The transcription factor nuclear factor kappa B (NF-kappaB) can intervene in oncogenesis by virtue of its capacity to regulate the expression of a plethora of genes that modulate apoptosis, and cell survival as well as proliferation, inflammation, tumor metastasis and angiogenesis. Different reports demonstrate the intrinsic activation of NF-kappaB in lymphoid and myeloid malignancies, including preneoplastic conditions such as myelodysplastic syndromes, underscoring its implication in malignant transformation. Targeting intrinsic NF-kappaB activation, as well as its upstream and downstream regulators, may hence constitute an additional approach to the oncologist's armamentarium. Several small inhibitors of the NF-kappaB-activatory kinase IkappaB kinase, of the proteasome, or of the DNA binding of NF-kappaB subunits are under intensive investigation. Currently used cytotoxic agents can induce NF-kappaB activation as an unwarranted side effect, which confers apoptosis suppression and hence resistance to these drugs. Thus, NF-kappaB inhibitory molecules may be clinically useful, either as single therapeutic agents or in combination with classical chemotherapeutic agents, for the treatment of hematological malignancies.

Surgical results for meningiomas of the craniocervical junction

OBJECTIVE

We have undertaken a retrospective analysis of 38 patients who were operated on for 40 meningiomas of the craniocervical junction between September 1977 and August 1995 to determine which factors influenced resectability, complications, and postoperative outcomes.

METHODS

Radiological examinations, clinical data, and operation notes were evaluated, and additional follow-up information was obtained from outpatient examinations, telephone calls, and questionnaires.

RESULTS

Four groups could be distinguished according to dural attachment as follows: 1) 15 spinocranial meningiomas originated from the spinal canal and extended intracranially; 25 craniocervical meningiomas of intracranial origin were divided into 2) meningiomas of the lower clivus (10 patients with 11 tumors), 3) lateral meningiomas (11 patients with 12 tumors), and 4) posterior meningiomas (2 patients). Standard midline or lateral suboccipital approaches with opening of the foramen magnum and laminectomy of the involved cervical segments were sufficient for the great majority of tumors. In seven instances only, drilling the posterior third of an occipital condyle was needed. Twelve of 15 spinocranial meningiomas and 13 of 25 craniocervical meningiomas could be removed totally. One patient underwent ventriculoperitoneal shunting only. With a rate of 63% of totally removed and 30% of subtotally removed meningiomas in this region, we observed clinical recurrences for two patients only. Complications were encountered in 30% of patients, predominantly with recurrent and/or infiltrative or en plaque meningiomas. Whereas motor weakness and gait ataxia tended to improve postoperatively, cranial nerve deficits usually remained unaltered.

CONCLUSION

The relationship of the tumor to neighboring structures, i.e., the vertebral artery in particular, determines its resectability. We recommend using extreme caution with recurrent or en plaque meningiomas and tumors associated with extensive arachnoid scarring.

Metabolic shift of polyphosphate-accumulating organisms with different levels of polyphosphate storage

Previous studies have shown that polyphosphate-accumulating organisms (PAOs) are able to behave as glycogen-accumulating organisms (GAOs) under different conditions. In this study we investigated the behavior of a culture enriched with Accumulibacter at different levels of polyphosphate (poly-P) storage. The results of stoichiometric ratios Gly(degraded)/HAc(uptake), PHB(synthesized)/HAc(uptake), PHV(synthesized)/HAc(uptake) and P(release)/HAc(uptake) confirmed a metabolic shift from PAO metabolism to GAO metabolism: PAOs with high poly-P content used the poly-P to obtain adenosine tri-phosphate (ATP), and glycogen (Gly) to obtain nicotinamide adenine dinucleotide (NADH) and some ATP. In a test where poly-P depletion was imposed on the culture, all the acetate (HAc) added in each cycle was transformed into polyhydroxyalkanoate (PHA) despite the decrease of poly-P inside the cells. This led to an increase of the Gly(degraded)/HAc(uptake) ratio that resulted from a shift towards the glycolytic pathway in order to compensate for the lack of ATP formed from poly-P hydrolysis. The shift from PAO to GAO metabolism was also reflected in the change in the PHA composition as the poly-P availability decreased, suggesting that polyhydroxyvalerate (PHV) is obtained due to the consumption of excess reducing equivalents to balance the internal NADH, similarly to GAO metabolism. Fluorescence in situ hybridization analysis showed a significant PAO population change from Type I to Type II Accumulibacter as the poly-P availability decreased in short term experiments. This work suggests that poly-P storage levels and GAO-like metabolism are important factors affecting the competition between different PAO Types in enhanced biological phosphorus removal systems.

Incorporating microbial ecology into the metabolic modelling of polyphosphate accumulating organisms and glycogen accumulating organisms

In the enhanced biological phosphorus removal (EBPR) process, the competition between polyphosphate accumulating organisms (PAO) and glycogen accumulating organisms (GAO) has been studied intensively in recent years by both microbiologists and engineers, due to its important effects on phosphorus removal performance and efficiency. This study addresses the impact of microbial ecology on assessing the PAO-GAO competition through metabolic modelling, focussing on reviewing recent developments, discussion of how the results from molecular studies can impact the way we model the process, and offering perspectives for future research opportunities based on unanswered questions concerning PAO and GAO metabolism. Indeed, numerous findings that are seemingly contradictory could in fact be explained by the metabolic behaviour of different sub-groups of PAOs and/or GAOs exposed to different environmental and operational conditions. Some examples include the glycolysis pathway (i.e. Embden-Meyerhof-Parnas (EMP) vs. Entner-Doudoroff (ED)), denitrification capacity, anaerobic tricarboxylic acid (TCA) cycle activity and PAOs' ability to adjust their metabolism to e.g. a GAO-like metabolism. Metabolic modelling may further yield far-reaching influences on practical applications as well, and serves as a bridge between molecular/biochemical research studies and the optimisation of wastewater treatment plant operation.

Analysis of 65 pharmaceuticals and personal care products in 5 wastewater treatment plants in Portugal using a simplified analytical methodology

Pharmaceuticals and personal care products (PPCPs) are becoming increasingly recognised as important micropollutants to be monitored in wastewater treatment plants (WWTPs), since WWTP effluents represent an important point source to natural aquatic systems. In this study, the abundance of 65 PPCPs was analysed in 5 Portuguese WWTPs during the spring and autumn. Due to the fact that analytical approaches normally used to quantify the abundance of these compounds are labour intensive and require various specific procedures, this study proposes a set of simplified analytical methods for the quantification of pharmaceutically active compounds (PhACs) and polycyclic musks in liquid and sludge samples. The analytical methods were validated using influent wastewater matrices, showing comparable limits of detection and quantification as literature values for most PPCPs, with the exception of the estrogenic compounds. The PhAC concentrations detected in the WWTP survey were in the range of 0.050-100 µg L(-1) in the influent and up to 50 µg L(-1) in the effluent, where the non-steroidal anti-inflammatory drugs (NSAIDs) were the most abundant and frequently detected group. Some musks were detected up to 11.5 µg L(-1) in the influent and 0.9 µg L(-1) in the effluent, and adsorbed in the sludge up to 22.6 µg g(-1).

Ecotoxicity of ketoprofen, diclofenac, atenolol and their photolysis byproducts in zebrafish (Danio rerio)

The occurrence of pharmaceutical compounds in wastewater treatment plants and surface waters has been detected worldwide, constituting a potential risk for aquatic ecosystems. Adult zebrafish, of both sexes, were exposed to three common pharmaceutical compounds (atenolol, ketoprofen and diclofenac) and their UV photolysis by-products over seven days. The results show that diclofenac was removed to concentrations<LOD after 5 min of UV irradiation. The oxidative stress response of zebrafish to pharmaceuticals and their photolysis by-products was evaluated through oxidative stress enzymes (glutathione-S-transferase, catalase, superoxide dismutase) and lipid peroxidation. Results suggest that the photolysis by-products of diclofenac were more toxic than those from the other compounds tested, showing an increase in GST and CAT levels, which are also supported by higher MDA levels. Overall, the toxicity of waters containing atenolol and ketoprofen was reduced after the parent compounds were transformed by photolysis, whereas the toxicity increased significantly from the by-products generated through diclofenac photolysis. Therefore, diclofenac photolysis would possibly necessitate higher irradiation time to ensure that the associated by-products are completely degraded to harmless form(s).

NF-kappaB inhibition sensitizes to starvation-induced cell death in high-risk myelodysplastic syndrome and acute myeloid leukemia

CD34(+) bone marrow blasts from high-risk myelodysplastic syndrome (MDS) patients as well as MDS patient-derived cell lines (P39 and MOLM13) constitutively activate the nuclear factor-kappaB (NF-kappaB) pathway and undergo apoptosis when NF-kappaB is inhibited. Here, we show that the combination of conventional chemotherapeutic agents (daunorubicin, mitoxantrone, 5-azacytidine or camptothecin) with the NF-kappaB inhibitor BAY11-7082 did not yield a synergistic cytotoxicity. In contrast, BAY11-7082 (which targets the NF-kappaB-activating I-kappaB kinase (IKK) complex) or knockdown of essential components of the NF-kappaB system (such as the IKK1 and IKK2 subunits of the IKK complex and the p65 subunit of NF-kappaB), by small interfering RNAs sensitized MDS cell lines to starvation-induced apoptosis. The combination of BAY11-7082 and nutrient depletion synergistically killed the acute myeloid leukemia (AML) cell line U937 as well as primary CD34(+) bone marrow blasts from AML and high-risk MDS patients. The synergistic killing by BAY11-7082, combined with nutrient depletion, led to cell death accompanied by all hallmarks of apoptosis, including an early loss of the mitochondrial transmembrane potential, the release of cytochrome c and apoptosis-inducing factor (AIF) from mitochondria, activation of caspase-3, phosphatidylserine exposure on the plasma membrane surface and nuclear chromatin condensation. Transmission electron microscopy revealed the presence of numerous autophagic vacuoles in the cytoplasm before cells underwent nuclear apoptosis. Nonetheless, cell death was neither inhibited by the pan-caspase inhibitor z-VAD-fmk nor by knockdown of AIF or of essential components of the autophagy pathway (ATG5, ATG6/Beclin-1, ATG10, ATG12). In contrast, external supply of glucose, insulin or insulin-like growth factor-I could retard the cell death induced by BAY11-7082 combined with starvation. These results suggest that in MDS cells, NF-kappaB inhibition can precipitate a bioenergetic crisis that leads to an autophagic stress response followed by apoptotic cell death.

Long-term in vivo cochlear transgene expression mediated by recombinant adeno-associated virus

Adeno-associated virus (AAV) integrated transgene expression within guinea pig cochlea has been previously documented. This article extends these studies by characterizing the AAV-mediated gene transfer for duration of transgene expression within the cochlea and its effect upon cochlear cytoarchitecture over a period of 6 months. All animals infused with AAV expressed the transgene product, bacterial beta-galactosidase (beta-gal) enzyme, in the spiral limbus, spiral ligament, spiral ganglion cells and the organ of Corti at 2-24 weeks after infusion. However, the level of beta-gal expression, as determined from intensity of immunoreactivity, was relatively lower at 24 weeks as compared with 2 weeks. The cellular and tissue architecture within the AAV-beta-gal perfused cochleae, harvested 2-8 weeks after AAV infusion, was generally intact, ie free from inflammation and cellular degeneration. However, cellular degeneration and degradation was apparent in the cochleae of some but not all animals harvested at 12 and 24 weeks after AAV infusion.

Assessing the diurnal variability of pharmaceutical and personal care products in a full-scale activated sludge plant

An intensive sampling campaign has been carried out in a municipal wastewater treatment plant (WWTP) to assess the dynamics of the influent pharmaceutical active compounds (PhAC) and musks. The mass loadings of these compounds in wastewater influents displayed contrasting diurnal variations depending on the compound. The musks and some groups of PhACs tended to follow a similar diurnal trend as compared to macropollutants, while the majority of PhACs followed either the opposite trend or no repeatable trend. The total musk loading to the WWTP was 0.74 ± 0.25 g d(-1), whereas the total PhAC mass loading was 84.7 ± 63.8 g d(-1). Unlike the PhACs, the musks displayed a high repeatability from one sampling day to the next. The range of PhAC loadings in the influent to WWTPs can vary several orders of magnitude from one day or week to the next, representing a challenge in obtaining data for steady-state modelling purposes.

Assessment of the presence and dynamics of fungi in drinking water sources using cultural and molecular methods

A comparison of different isolation techniques and culture media for detection of filamentous fungi and yeasts in the aquatic environment revealed that the use of membrane filtration with the media dichloran rose bengal chloramphenicol (DRBC) optimized fungi detection in terms of abundance and variety in three untreated water sources with very different characteristics (surface water, spring water, and groundwater). The diversity of the fungi population captured by direct DNA extraction of fungi collected by membrane filtration was compared with the isolates obtained after selective growth using different culture media through amplification of the internal transcribed spacer gene and denaturing gradient gel electrophoresis (DGGE). The Czapek-Dox agar, Sabouraud dextrose agar, and DRBC media showed closer similarities to those obtained by the uncultured biomass for the different water sources. Based on these data and the best enumeration results, DRBC is recommended for the assessment of fungi in water sources using culture-based methods. DGGE was also used to monitor temporal variations in the fungal population structure and showed that each water matrix possessed a distinct population profile as well as that changes in the fungal community can be expected in the different matrices throughout the year.

Polyhydroxyalkanoates production by a mixed photosynthetic consortium of bacteria and algae

For the first time, a mixed photosynthetic culture (MPC) consisting of a consortium of bacteria and algae was investigated for its capacity to accumulate polyhydroxyalkanoates (PHA). The culture was subjected to a feast and famine regime in an illuminated environment without supplying oxygen or any other electron acceptor. The MPC accumulated PHA during the feast phase and consumed it in the famine phase, where the PHA consumption was made possible due to oxygen production by algae. The internal cycling of carbohydrates was also observed, which was likely linked to bacterial glycogen being used as an additional source of energy for acetate uptake during the feast phase, and restored in the famine phase via PHA degradation. The MPC reached a PHA content of 20%, with a PHA storage yield per acetate similar to aerobic systems, opening up the possibility of a new sunlight-driven PHA production process without the need for aeration.

Epidemiology of facial injury in blunt assault. Determinants of incidence and outcome in 802 patients

BACKGROUND

Facial assault trauma has reached epidemic proportions. While the biomechanics of injury, methods of repair, and general demography of blunt facial trauma are well known, statistical associations between epidemiological factors, incidence, and outcome are poorly understood.

OBJECTIVES

To provide a comprehensive epidemiological survey of this patient population. To assess factors determining outcome and pattern of injury.

DESIGN

Retrospective review of 802 patients admitted with blunt assault facial trauma. Statistical analysis of associations between epidemiological factors, incidence, and outcome with chi 2 test, 2-tailed t test, and Fisher exact test.

SETTING

Urban university and county hospital.

RESULTS

Statistically significant associations are demonstrated between gender and the context of assault, incidence of armed assault, presence of fracture, and rate of intoxication at injury. Poor prognostic indicators for outcome include use of tobacco and presence of a mandible fracture. Open reduction and internal fixation were found to bear a higher complication rate only in mandible fractures.

CONCLUSIONS

While choice of treatment carries a statistically significant association with outcome, social variables, including gender, tobacco use, intoxication, and low socioeconomic status, produce dramatic worsening of both injury incidence and outcome.

Inhibition of NEMO, the regulatory subunit of the IKK complex, induces apoptosis in high-risk myelodysplastic syndrome and acute myeloid leukemia

In high-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML), blasts constitutively activate the antiapoptotic transcription factor nuclear factor-kappaB (NF-kappaB). Here, we show that this NF-kappaB activation relies on the constitutive activation of the IkappaB kinase (IKK) complex, which is formed by the IKKalpha, IKKbeta and IKKgamma/NF-kappaB essential modulator (NEMO) subunits. A cell-permeable peptide that mimics the leucine zipper subdomain of IKKgamma, thus preventing its oligomerization, inhibited the constitutive NF-kappaB activation and induced apoptotic cell death in a panel of human MDS and AML cell lines (P39, MOLM13, THP1 and MV4-11). Small interfering RNA-mediated knockdown of the p65 NF-kappaB subunit or the three IKK subunits including IKKgamma/NEMO also induced apoptotic cell death in P39 cells. Cell death induced by the IKKgamma/NEMO-antagonistic peptide involved the caspase-independent loss of the mitochondrial transmembrane potential as well as signs of outer mitochondrial membrane permeabilization with the consequent release of cytochrome c, apoptosis-inducing factor and endonuclease G. Primary bone marrow CD34(+) cells from high-risk MDS and AML patients also succumbed to the IKKgamma/NEMO-antagonistic peptide, but not to a mutated control peptide. Altogether, these data indicate that malignant cells in high-risk MDS and AML cells critically depend on IKKgamma/NEMO to survive. Moreover, our data delineate a novel procedure for their therapeutic removal, through inhibition of IKKgamma/NEMO oligomerization.

River basin-related genetic structuring in an endangered fish species, Chondrostoma lusitanicum, based on mtDNA sequencing and RFLP analysis

Chondrostoma lusitanicum is a Portuguese endemic cyprinid with a restricted distribution and reduced numbers in some basins, justifying its status as a threatened species. We examined genetic population structure using samples from throughout its geographical range in Portugal, using sequencing of b cytochrome and restriction fragment length polymorphism analysis of the NADH subunits 5 and 6. There was reduced within-population genetic variability but considerable among-population differentiation, particularly marked between both the Mira and Arade basins in the extreme south and other populations. These results confirm phylogeographic relationships suggested by previous fragmentary allozyme studies for C. lusitanicum, and are in accordance with allozyme and mitochondrial DNA data on phylogeography of coexisting cyprinid species of the genus Leuciscus. The levels of genetic divergence revealed by sequence and RFLP data showed strongly concordant patterns: geographical genetic structuring, with the definition of three distinct groups, was observed. The high values of nucleotide divergence and pairwise sequence divergence of the Mira and Arade groups, when compared with all other samples, support a distinct taxonomic status probably at the species level. Results are also discussed in relation to conservation of this highly fragmented species, in terms of Evolutionary Significant Units and Management Units.

Assessing the removal of pharmaceuticals and personal care products in a full-scale activated sludge plant

PURPOSE

This study aimed to investigate the removal mechanisms of pharmaceutical active compounds (PhACs) and musks in a wastewater treatment plant (WWTP). Biological removal and adsorption in the activated sludge tank as well as the effect of UV radiation used for disinfection purposes were considered when performing a mass balance on the WWTP throughout a 2-week sampling campaign.

METHODS

Solid-phase extraction (SPE) was carried out to analyse the PhACs in the influent and effluent samples. Ultrasonic solvent extraction was used before SPE for PhACs analysis in sludge samples. PhAC extracts were analysed by LC-MS. Solid-phase microextraction of liquid and sludge samples was used for the analysis of musks, which were detected by GC-MS. The fluxes of the most abundant compounds (13 PhACs and 5 musks) out of 79 compounds studied were used to perform the mass balance on the WWTP.

RESULTS

Results show that incomplete removal of diclofenac, the compound that was found in the highest abundance, was observed via biodegradation and adsorption, and that UV photolysis was the main removal mechanism for this compound. The effect of adsorption to the secondary sludge was often negligible for the PhACs, with the exceptions of diclofenac, etofenamate, hydroxyzine and indapamide. However, the musks showed a high level of adsorption to the sludge. UV radiation had an important role in reducing the concentration of some of the target compounds (e.g. diclofenac, ibuprofen, clorazepate, indapamide, enalapril and atenolol) not removed in the activated sludge tank.

CONCLUSIONS

The main removal mechanism of PhACs and musks studied in the WWTP was most often biological (45%), followed by adsorption (33%) and by UV radiation (22%). In the majority of the cases, the WWTP achieved >75% removal of the most detected PhACs and musks, with the exception of diclofenac.

Modelling the population dynamics and metabolic diversity of organisms relevant in anaerobic/anoxic/aerobic enhanced biological phosphorus removal processes

In this study, enhanced biological phosphorus removal (EBPR) metabolic models are expanded in order to incorporate the competition between polyphosphate accumulating organisms (PAOs) and glycogen accumulating organisms (GAOs) under sequential anaerobic/anoxic/aerobic conditions, which are representative of most full-scale EBPR plants. Since PAOs and GAOs display different denitrification tendencies, which is dependent on the phylogenetic identity of the organism, the model was separated into six distinct biomass groups, constituting Accumulibacter Types I and II, as well as denitrifying and non-denitrifying Competibacter and Defluviicoccus GAOs. Denitrification was modelled as a multi-step process, with nitrate (NO(3)), nitrite (NO(2)), nitrous oxide (N(2)O) and di-nitrogen gas (N(2)) being the primary components. The model was calibrated and validated using literature data from enriched cultures of PAOs and GAOs, obtaining a good description of the observed biochemical transformations. A strong correlation was observed between Accumulibacter Types I and II, and nitrate-reducing and non-nitrate-reducing PAOs, respectively, where the abundance of each PAO subgroup was well predicted by the model during an acclimatization period from anaerobic-aerobic to anaerobic-anoxic conditions. Interestingly, a strong interdependency was observed between the anaerobic, anoxic and aerobic kinetic parameters of PAOs and GAOs. This could be exploited when metabolic models are calibrated, since all of these parameters should be changed by an identical factor from their default value. Factors that influence these kinetic parameters include the fraction of active biomass, relative aerobic/anoxic fraction and the ratio of acetyl-CoA to propionyl-CoA. Employing a metabolic approach was found to be advantageous in describing the performance and population dynamics in such complex microbial ecosystems.

The link between nitrous oxide emissions, microbial community profile and function from three full-scale WWTPs

Few attempts have been made in previous studies to link the microbial community structure and function with nitrous oxide (N₂O) emissions at full-scale wastewater treatment plants (WWTPs). In this work, high-throughput sequencing and reverse transcriptase-qPCR (RT-qPCR) was applied to activated sludge samples from three WWTPs for two seasonal periods (winter and summer) and linked with the N₂O emissions and wastewater characteristics. The total N₂O emissions ranged from 7.2 to 937.0 g N-N₂O/day, which corresponds to an emission factor of 0.001 to 0.280% of the influent NH₄-N being emitted as N₂O. Those emissions were related to the abundance of Nitrotoga, Candidatus Microthrix and Rhodobacter genera, which were favored by higher dissolved oxygen (DO) and nitrate (NO₃^-) concentrations in the activated sludge tanks. Furthermore, a relationship between the nirK gene expression and N₂O emissions was verified. Detected N₂O emission peaks were associated with different process events, related to aeration transition periods, that occurred during the regular operation of the plants, which could be potentially associated to increased emissions of the WWTP. The design of mitigation strategies, such as optimizing the aeration regime, is therefore important to avoid process events that lead to those N₂O emissions peaks. Furthermore, this study also demonstrates the importance of assessing the gene expression of nosZ clade II, since its high abundance in WWTPs could be an important key to reduce the N₂O emissions.

Modelling the biodegradation of non-steroidal anti-inflammatory drugs (NSAIDs) by activated sludge and a pure culture

A model describing ibuprofen and ketoprofen biodegradation by activated sludge from three different wastewater treatment plants (WWTP) was developed in this study. This model successfully described the biodegradation profiles observed at two different initial concentrations of each compound, where a lag-phase was observed prior to the biodegradation of each compound. Twelve ibuprofen and ketoprofen degrading isolates were identified in this study from the WWTP sludge showing the best removal performance. One of these isolates was characterised via another model, where biodegradation was dependent on biomass growth rate as well as the ibuprofen concentration. The fact that different models were needed to describe the biodegradation by activated sludge and a pure culture suggests that the biodegradation of non-steroidal anti-inflammatory drugs (NSAIDs) depends on the microbial community, thus pharmaceutical biodegradation models may require adaptation depending upon the system. This study provides an advance towards modelling pharmaceutical biodegradation in WWTPs.

Epidemiology of facial injury in female blunt assault trauma cases

BACKGROUND

Etiology of trauma in the female population differs from that of the male population. To date, domestic violence has been researched extensively, but little has been published about the epidemiology of facial injury in the female population.

OBJECTIVES

To analyze the differences in the circumstances under which males and females are injured, to identify gender-specific patterns of injury, and to assess whether differences in the demographics, health status, and drug-use profile exist between female and male assault cases and whether these factors lead to a difference in outcome.

METHODS

A cohort of 91 female assault cases was compared with a control group of 706 males with similar injuries resulting from blunt assault trauma. Information was gathered by retrospective review of 797 consecutive cases requiring admission for facial injuries resulting from blunt assault trauma. Fisher exact, chi 2, and t tests were used to assess statistically significant differences between the male and female cohorts.

RESULTS

The female cohort comprised 12% of all cases admitted for blunt assault facial trauma. One third of female blunt assault facial trauma patients were subjects of domestic violence. Statistically significant differences were found between males and females for the type of assault (rape, domestic violence, altercation, etc) with P < .0001. Females were more likely to be admitted with soft tissue injury only but no fracture (P < .05), less likely to be assaulted with a weapon, and unlikely to be involved in an altercation, gang violence, arrest, or robbery. Females were also less likely than males to be injured while intoxicated (P < .05). Incidence of specific injury patterns and outcomes, however, were similar between the 2 groups.

CONCLUSION

The present data support the hypothesis that the female blunt assault facial trauma population represents a distinct epidemiological entity, with significant differences in the circumstances of injury, mechanism of assault, and role of intoxication in the incidence of injury. The prevalence of facial trauma in female assault cases makes it critical for the facial plastic surgeon to be vigilant in the evaluation and treatment of these patients.

Randomized clinical trial of the impact of insulin therapy on liver function in patients undergoing major liver resection

BACKGROUND

Postoperative liver dysfunction is the major source of morbidity and mortality in patients undergoing partial hepatectomy. This study tested the benefits of a metabolic support protocol based on insulin infusion, for reducing liver dysfunction following hepatic resection.

METHODS

Consecutive consenting patients scheduled for liver resection were randomized to receive preoperative dextrose infusion followed by insulin therapy using the hyperinsulinaemic normoglycaemic clamp protocol (n = 29) or standard therapy (control group, n = 27). Patients in the insulin therapy group followed a strict dietary regimen for 24 h before surgery. Intravenous dextrose was started at 2 mg per kg per min the night before and continued until surgery. Hyperinsulinaemic therapy for a total of 24 h was initiated at 2 munits per kg per min at induction of anaesthesia, and continued at 1 munit per kg per min after surgery. Normoglycaemia was maintained (3.5-6.0 mmol/l). Control subjects received no additional dietary supplement and a conventional insulin sliding scale during fasting. All patients were tested serially to evaluate liver function using the Schindl score. Liver tissue samples were collected at two time points during surgery to measure glycogen levels.

RESULTS

Demographics were similar in the two groups. More liver dysfunction occurred in the control cohort (liver dysfunction score range 0-8 versus 0-4 with insulin therapy; P = 0.031). Median (interquartile range) liver glycogen content was 278 (153-312) and 431 (334-459) µmol/g respectively (P = 0.011). The number of complications rose with increasing severity of postoperative liver dysfunction (P = 0.032) CONCLUSION: The glucose-insulin protocol reduced postoperative liver dysfunction and improved liver glycogen content.

REGISTRATION NUMBER

NCT00774098 (http://www.clinicaltrials.gov).

How good is the levothyroxine replacement in primary hypothyroidism patients in Brazil? Data of a multicentre study

BACKGROUND

Studies from every continent have shown that only around 50% of the patients subjected to thyroid hormone replacement have TSH in the normal range. However, to date, there are no consistent data about Brazil.

OBJECTIVES

To evaluate levothyroxine (LT4) replacement treatment in patients with primary hypothyroidism followed in referral centers in Brazil.

METHODS

Patients with primary hypothyroidism followed in referral centers (University Hospitals from Universidade Federal do Rio de Janeiro - UFRJ, Unicamp, Universidade Federal do Paraná - UFPR and Universidade Federal do Ceará-UFC) answered a questionnaire that inquired about clinical and biochemical conditions, social- economic status, life quality and clinicians' orientations as well as their understanding about the information given. Serum TSH was checked close to the interview.

RESULTS

2292 consecutive patients met the inclusion criteria. Mean age 51.2 yr and TSH values between 0.4 and 4.0 mUI/l were considered to be within the reference range. Among all patients taking thyroid medication, 42.7% had an abnormal serum TSH (28.3% were undertreated and 14.4% were overtreated). Approximately all patients (99%) took LT4 in the morning but less than 30 min before breakfast (85.4%). Regarding the clinicians' orientations: 97.5% of the patients were instructed to take the medication daily, and 92.6% to take 30 min before breakfast (92.6%). However, only 52.1% were told not to take LT4 along with other medication.

CONCLUSIONS

Our study found that a significant number of patients taking thyroid hormones were not in the therapeutic range. Clinicians should, therefore, consider monitoring patients on thyroid replacement more frequently and being more precise on giving recommendations about the correct use of LT4.

Contraceptive use and pregnancy before and after introducing lactational amenorrhea (LAM) in a postpartum program

There is good evidence that lactational amenorrhea (LAM) is an effective method of fertility regulation during the first 6 months postpartum, provided no other food is given to the baby and the mother remains amenorrheic. However, although breast-feeding is strongly promoted in many maternity hospitals that also run postpartum family planning programs, LAM is rarely included among the contraceptive options being offered. This paper presents the results of an operational study which compared the prevalence of contraceptive use and the cumulative pregnancy rate at 12-months postpartum among 350 women observed before and 348 women studied after introducing LAM as an alternative contraceptive option offered to women following delivery at the Instituto Materno Infantil de Pernambuco (IMIP), in Recife, Brazil. The percentage of women not using any contraceptive method was significantly lower (p<0.0001) after the intervention (7.4%) than before (17.7%). This difference remained statistically significant after controlling for age, number of living children, marital status and years of schooling. The proportion pregnant one year postpartum was also significantly lower (p<0.0001) after the introduction of LAM (7.4%) than before (14.3%), but the difference was no longer significant after controlling for the same variables. It is concluded that LAM is a useful addition to family planning postpartum programs.