AB1237 COMPARISON BETWEEN ENZYME IMMUNOASSAY AND CHEMILUMINESCENCE TO DETERMINE THE CONCENTRATION OF SERUM CALPROTECTIN AND ITS ASSOCIATION WITH CLINICAL VARIABLES IN PEDIATRIC RHEUMATOLOGY

Background

Serum calprotectin (SC) is an emerging biomarker in the measurement of inflammation. It can be determined by different techniques, such as enzyme immunoassay (EIA) or chemiluminescence (CLIA). However, there are no studies comparing whether there is a correlation between the two diagnostic methods in paediatric rheumatologic diseases.

Objectives

(i) To assess whether there are differences between serum calprotectin (SC) levels determined by EIA (Bühlmann) method and CLIA (QUANTA Flash) in pediatric age patients with systemic autoimmune rheumatic disease (SARD). (ii) To evaluate which clinical and analytical variables are associated with an increase of SC in each method.

Methods

Analytical cross-sectional study that included patients from a pediatric rheumatology specialized unit between 02/2017 and 05/2021. We included 41 patients with SARD who had at least one SC analysis determined by EIA in their routine controls (144 serum) and afterwards had SC determined again, this time using the CLIA method.

The collected variables were sex, age, remission according to clinical judgment, swollen joint count according to physical examination (PE Count) and ultrasound (US Count), Juvenile Arthritis Disease Activity Score according to physical examination (PE JADAS-27) and ultrasound (US JADAS-27), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

As for the statistical analysis, intraclass correlation (ICC) and paired samples t-test were performed to compare the two methods. Univariate linear regression was performed to study the association between EIA, CLIA and both clinical and analytical variables.

Results

We included 41 patients, 50.1% were women with a mean age (± SD) of 13.1 (± 3.8) years. The details of their descriptive characteristics were: mean SC (EIA) of 3.1 (±1.8) µg/ml, mean SC (CLIA) of 2.5 (±1.6) µg/ml, mean CRP of 2.6 (± 6.5) mg/l, mean ESR of 10.1 (± 11) mm/h, and mean PE JADAS-27 of 2.8 (± 8). Most frequent diagnosis was oligoarticular juvenile idiopathic arthritis (JIA) (24.4%), followed by enthesitis-related (ERA) JIA (12.2%) and polyarticular JIA (12.2%), familial Mediterranean fever (FMF) (9.8%), psoriatic JIA (4.9%), systemic JIA (4.9%) and syndrome of periodic fever, aphtous stomatitis, pharyngitis, and cervical adenitis (PFAPA) (4.9%), vasculitis (4.8%), and undifferentiated JIA (2.4%). Clinical diagnosis was unspecific in 9.8% of the patients. In our sample, 66.7% were in clinical remission at the discretion of the specialist.

A statistically significant Pearson’s CCI of 0.77 (95%CI 0.70-0.83; p=0.00) was observed as a single measure between EIA and CLIA and with an average of 0.87 (95%CI=0.82-0.91; p=0.000). Figure 1 shows the dispersion of this correlation.

On the other hand, we observed a statistically significant difference in the mean between both methods of 0.58 (95%CI=0.40-0.77; p=0.000), observing a greater difference in SC (EIA) > 4 µg/ml.

A significant association was observed between EIA and clinical remission, joint count, JADAS and CRP; and also between CLIA and clinical remission, JADAS and CRP. The analysis performed is shown in Table 1.

Table 1.

Association between EIA and CLIA with clinical and analytical variables.

RemissionPE CountUS CountPE JADASUS JADASbpbpbpbpbpSC(EIA)0.430.0110.140.0270.080.0240.090.0000.060.000SC(CLIA)0.530.000-0.000.9450.310.3200.050.0210.040.015SexGenderESRCRPbpbpbpbpSC(EIA)0.000.9970.050.2070.000.4870.050.027SC(CLIA)-0.240.3620.010.7950.020.1050.080.000

b, regression coefficient; p, statistical significance.

Conclusion

There is a good correlation between EIA and CLIA methods to determine SC in pediatric patients with SARD. Significant differences were observed between both methods above the value of 4 µg/ml. This fact could be explained by methodological differences, since CLIA discriminates better at higher values than EIA.

An association was observed between both methods and variables of remission or disease activity.

Disclosure of Interests

None declared

AB0997 IS HEIGHT ADJUSTMENT NECESSARY IN PEDIATRIC DENSITOMETRY IN ALL CHILDREN?

Background:

The current guidelines of the International Society for Clinical Densitometry (1) recommend that in children with linear growth or maturational delay, Z score results should be adjusted. Height for age Z score (HAZ) adjustment is valid and can be calculated using the formula the formula proposed by Zemmel et al(2).

It is possible that pediatric populations without linear growth or maturational delay, also benefit from HAZ, to prevent bone size from influencing the final Z score.

Objectives:

To evaluate Z score variability adjusted and without adjusting for height for age.

Methods:

We analysed data from densitometry performed on patients 2-20 years of age, from 2016 to 2018, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for low bone mass/osteoporosis. The HAZ was calculated according to Zemel’s formula.

Results:

Data from 103 patients are presented. Its characteristics are summarized in Table 1

Table 1.Mean age9,8 yearsFemale52,4%Height Percentil ≤ 36,8%Height Percentil ≥ 974,9%LBM (Z score ≤ -2) spine8,2%LBM HAZ spine6,4%LBM whole body10,5%LBM HAZ whole body7,2%

The table shows that the proportion of patients with BMD decreases in both the spine region and the whole body when adjusting for HAZ.

When evaluating the relationship between densitometric measurements we found that spine Z score (ZsS) and whole body Z score (ZsWB) had a correlation coefficient of 0,73 (p<0,001). There were no differences between their averages (p=0,170).

At the LBM cut-off point (Z score ≤ -2) there were discrepancies in 7%, where 5% presented LBM in ZsWB but not in ZsS. The concordance index at this point was 0,557.

When comparing these measures with their HAZ adjusted equivalents, we observe:

Conclusion:

There are discrepancies at the LBM cut-off point depending on the HAZ adjustment.

The pediatric population without linear growth or maturational delay, can also benefit from HAZ adjustment, especially those with high height percentiles in which their size can hide a diagnosis of LBM.

References:

[1]Weber DR, Boyce A, Gordon C, Hogler W, Kecskemethy HH, Misra M, et al. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. Journal of clinical densitometry: the official journal of the International Society for Clinical Densitometry. 2019;22(4):567-89.

[2]Zemel BS, Leonard MB, Kelly A, Lappe JM, Gilsanz V, Oberfield S, et al. Height adjustment in assessing dual energy x-ray absorptiometry measurements of bone mass and density in children. The Journal of clinical endocrinology and metabolism. 2010;95(3):1265-73.

Disclosure of Interests:

None declared

AB0998 TRABECULAR BONE SCORE IN PEDIATRICS, IS IT USEFUL?

Background:

Bone fragility depends not only on bone mineral density (BMD), but also on bone microarchitecture. In adults, Trabecular Bone Score (TBS) is being used as an indirect marker of bone microarchitecture

It is a software that applicated to the vertebral image obtained by conventional densitometry, informs about the thickness of the trabeculae, the trabecular connectivity and the space between them. A high score indicates a better bone microstructure. In adults, a TBS equal to or greater than 1,350 is considered to represent a normal microarchitecture

Objectives:

To evaluate the usefulness of TBS in pediatric population with risk factors for Low Bone Mass (LBM)

Methods:

TBS was assessed by analyzing vertebral densitometries performed on patients from 4 to 20 years of age, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for LBM, consecutively from 2016 until 2018

Data were compared with normal pediatric population

Results:

Data from 83 patients are shown, with an average age of 11.2 years, 62% female, 80% Caucasian

The main risk factors for LBM were (%): Insufficient calcium intake (84,5), medications with osteopenizing potential (31), corticosteroids (39), sedentary lifestyle (13,6), fractures of long or vertebral bones (12,6) and hypovitaminosis D (8,1)

Table 1.

TBS por age groups and in patients with and without LBM

Age groupsnMeanSDMinimum-MaximumScholars (4-9a)221,3210,0931,119-1,502Adolescence (10-17a)541,3090,0881,073-1,493Youth (18-20a)61,3590,0851,258-1,460Spine Z scorenMean (SD)pMinimum-Maximum ≤-281,270 (0,075)0,1261,419-1,162 >-2741,321 (0,090)1,502-1,073Whole Body Z score ≤-291,246 (0,060)0,0121,323-1,145 >-2731,324 (0,089)1,502-1,073Table 2.

TBS in healthy population and study population for age

Healthy girls (n=2535)Healthy boys (n=1459)Study girls (n=47)Study boys (n=36)Age (y)Spine BMDTBSSpine BMDTBSTBSTBS1-20,401,3250,371,2722-30,511,3630,461,2671,1273-40,521,3460,511,2641,2044-50,601,3460,601,2671,2371,2435-60,601,2880,561,2691,3301,3686-70,651,2800,601,2321,3181,4227-80,671,2680,641,2441,3391,3458-90,711,2660,681,2281,2449-100,751,2780,701,2081,2531,34110-110,81,2850,731,2311,2291,29211-120,841,3370,761,2501,3031,31512-130,991,3550,811,2481,3811,36813-141,061,3860,891,2731,3941,33814-151,101,3980,991,3031,4741,28515-161,141,4051,081,3111,3681,40616-171,171,4051,151,3341,3321,37117-181,171,4041,201,3281,3741,28518-191,171,4041,161,314

Conclusion:

TBS was lower in the patients with LBM by whole body Z score, but not in those with LBM by spine Z score. We observed a decrease in TBS in adolescence, not corresponding with a decrease in BMD, and that should not be interpreted as a pathological finding

Similar results have been described in other pediatric populations (1, 2), but larger studies are needed to evaluate this phenomenon. We hypothesize that it may be due to a higher rate of growth in adolescence, with a lower rate of calcium apposition into the osteoid material

References:

[1]Del Rio DS, Winthenrieth R. BONE MICROARCHITECTURE (TBS) AND BONE MASS DEVELOPMENT DURING CHILDHOOD AND ADOLESCENCE IN A SPANISH POPULATION GROUP. . WCO-IOF-ESCEO; Seville2014.

[2]Shawwa K, Arabi A, Nabulsi M, et al. Predictors of trabecular bone score in school children. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016;27(2):703-10.

Disclosure of Interests:

None declared

SAT0217 PERFORMANCE OF ACR/EULAR 2019, SLICC 2012 AND ACR 1997 CLASSIFICATION CRITERIA IN A COHORT OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITH LONGSTANDING DISEASE

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease with variable clinical features and a complex physiopathology. In 2019, EULAR and ACR have jointly developed new classification criteria with both high sensitivity and specificity. These criteria have the particularity of including the presence of ANA as an obligatory entry criterion and the existence of clinical and immunological domains with weighted scores.

Objectives:

To evaluate the performance and characteristics of the ACR/EULAR 2019, SLICC 2012 and ACR 1997 classification criteria in a cohort of SLE patients with longstanding disease.

Methods:

Descriptive observational study that enrolled a cohort of SLE patients with longstanding disease followed in a tertiary level hospital. Demographic and clinical data were gathered along with the fulfillment of classification criteria. The sensitivity of each classification criteria and the statistically significant associations between criteria fulfillment and clinical and immunological data were calculated. Statistical analyses were performed using the Chi2, T-student and ANOVA tests. Statistical significance was assumed in p values <0.05.

Results:

A total of 79 patients (88.6% women) with a mean age of 51.8±14 years, disease duration of 15.2±11.5 years and SLEDAI of 2.65±2.1 were included. The sensitivity of the different classification criteria was 51.9% for ACR 1997, 87.3% for SLICC 2012 and 86.1% for ACR/EULAR 2019 (Table 1).

Table 1.

Sensitivity and average scores.

ACR/EULAR 2019SLICC 2012ACR 1997Sensitivity (%)86.187.351.9Average score of patients classified as SLE(±SD)18.6±5.85.3±1.45±0.9Average score of patients NOT classified as SLE(±SD)6.1±2.52.8±0.42.8±0.8

51.9% of patients met all three classification criteria, 29.1% met SLICC 2012 and ACR/EULAR 2019, 5% only met SLICC 2012 and 3.7% exclusively met ACR/EULAR 2019. 11.4% of patients did not meet any classification criteria and were characterized by having a low SLEDAI (0.6±0.9) and fulfilling only skin domains (alopecia or oral ulcers), antiphospholipid antibodies or hypocomplementemia.

Statistically significant associations were found between meeting ACR/EULAR 2019 classification criteria and the presence of low C3 and C4 (p<0.04), DNA (p<0.001), lupus nephritis III-IV (p<0.05) and arthritis (p<0.001), highlighting that all patients with arthritis met these criteria.

In the SLICC 2012 evaluation, significant associations were found between meeting these criteria and the presence of arthritis (p<0.01), renal involvement (p<0.04), leukopenia/lymphopenia (p=0.05), DNA (p<0.03) and hypocomplementemia (p=0.02).

Fullfilment of ACR 1997 was associated to the presence of malar rash (p<0.001), discoid lupus (p<0.05), photosensitivity (p<0.001) and oral ulcers (p<0.04), as well as arthritis (p<0.001), serositis (p=0.02), renal (p<0.05) and hematologic (p=0.05) involvement.

The Kappa concordance coefficient among classification criteria is detailed in Table 2.

Table 2.

Kappa concordance coefficient.

ACR/EULAR 2019 - SLICC 2012ACR/EULAR 2019 - ACR 1997SLICC 2012 - ACR 1997Kappa concordance coefficient0.610.270.30

Conclusion:

The ACR/EULAR 2019 classification criteria maintain a high sensitivity similar to the SLICC 2012 in SLE patients with longstanding disease, both of which are much higher than ACR 1997. Patients with serological, articular or renal involvement are more likely to meet SLICC 2012 or ACR/EULAR 2019 criteria. It is noteworthy the relevance of dermatological manifestations in ACR1997 classification criteria against the increased weight that a better understanding of SLE physiopathology has provided to analytic and immunological criteria in the subsequent classification criteria.

Disclosure of Interests:

David Lobo Prat: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, HyeSang Park: None declared, Patricia Moya: None declared, Ignasi Gich: None declared, Ana Laiz: None declared, Cesar Díaz-Torné: None declared, Ana Milena Millán Arciniegas: None declared, Susana P. Fernandez-Sanchez: None declared, Hector Corominas: None declared

Patient self-management of oral anticoagulation with vitamin K antagonists in everyday practice: clinical outcomes in a single centre cohort after long-term follow-up

Background

Patient self-management (PSM) of vitamin K antagonists (VKA) seems a very promising model of care for oral anticoagulation in terms of efficacy and safety. In comparison with other management models of VKA therapy, the number of scientific publications supporting the advantages of PSM is more limited. Currently, most of the scarce information comes from randomized clinical trials. Moreover, a small number of studies have assessed PSM of VKA therapy in real life conditions.

Methods

We analyzed clinical outcomes of 927 patients in a single center (6018.6 patient-years of follow-up). Recruitment took place between 2002 and 2017. All patients followed a structured training program, conducted by specialized nurses.

Results

Fifty percent of individuals had a mechanical heart valve (MHV), 23% suffered from recurrent venous thromboembolism (VTE) or high-risk thrombophilia, and 13% received VKA therapy because of atrial fibrillation (AF). Median follow-up was 6.5 years (range 0.1–15.97 years), median age was 58.1 years (IQR 48–65.9) and 46.5% were women. The incidence of major complications (either hemorrhagic or thromboembolic) was 1.87% patient-years (pt-ys) with a 95% CI of 1.54–2.27. The incidence of major thromboembolic events was 0.86% pt-ys (95% CI 0.64–1.13) and that of major hemorrhagic events was 1.01% pt-ys (95% CI 0.77–1.31). The incidence of intracranial bleeding was 0.22% pt-ys (95% CI 0.12–0.38). In terms of clinical indication for VKA therapy, the incidence of total major complications was 2.4% pt-ys, 2.0% pt-ys, 0.9% pt-ys and 1.34% pt-ys for MHV, AF, VTE and other (including valvulopathies and myocardiopathies), respectively. Clinical outcomes were worse in patients with multiple comorbidities, previous major complications during conventional VKA therapy, and in older individuals. The percentage of time in therapeutic range (TTR) was available in 861 (93%) patients. Overall, the mean (SD) of TTR was 63.6 ± 13.4%, being higher in men (66.2 ± 13.1%) than women (60.6 ± 13.2%), p < 0.05.

Conclusions

In terms of clinically relevant outcomes (incidence of major complications and mortality), PSM in real life setting seems to be a very good alternative in properly trained patients.

Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial)

BACKGROUND

Several non-randomized and retrospective studies have suggested that intracorporeal anastomosis (IA) has advantages over extracorporeal anastomosis (EA) in laparoscopic right colectomy, but scientific evidence is lacking. The aim was to compare short-term outcomes and to define the possible benefits of IA compared with EA in elective laparoscopic right colectomy.

METHODS

An RCT was conducted from May 2015 to June 2018. The primary endpoint was duration of hospital stay. Secondary endpoints were intraoperative technical events and postoperative clinical outcomes.

RESULTS

A total of 140 patients were randomized. Duration of surgery was longer for procedures with an IA than in those with an EA (median 149 (range 95-215) versus 123 (60-240) min; P < 0·001). Wound length was shorter in the IA group (median 6·7 (4-9·5) versus 8·7 (5-13) cm; P < 0·001). Digestive function recovered earlier in patients with an IA (median 2·3 versus 3·3 days; P = 0·003) and the incidence of paralytic ileus was lower (13 versus 30 per cent; P = 0·022). Less postoperative analgesia was needed in the IA group (mean(s.d.) weighted analgesia requirement 39(24) versus 53(26); P = 0·001) and the pain score was also lower (P = 0·035). The postoperative decrease in haemoglobin level was smaller (mean(s.d.) 8·8(1·7) versus 17·1(1·7) mg/dl; P = 0·001) and there was less lower gastrointestinal bleeding (3 versus 14 per cent; P = 0·031) in the IA group. IA was associated with a significantly better rate of grade I and II complications (P = 0·016 and P = 0·037 respectively). The duration of hospital stay was slightly shorter in the IA group (median 5·7 (range 2-19) versus 6·6 (2-23) days; P = 0·194).

CONCLUSION

Duration of hospital stay was similar, but IA was associated with less pain and fewer complications. Registration number: NCT02667860 ( http://www.clinicaltrials.gov).

Clinical factors that affect perceived quality of life in arthroscopic reconstruction for acromioclavicular joint dislocation

OBJECTIVE

To analyse the results of arthroscopic repair of acromioclavicular dislocation in terms of health-related quality of life.

MATERIAL AND METHOD

Prospective study of patients with acromioclavicular dislocation Rockwood grade iii-v, treated arthroscopically with a mean follow up of 25.4 months. The demographics of the series were recorded and evaluations were performed preoperatively, at 3 months and 2 years with validated questionnaires as Short Form-36 Health Survey (SF-36), visual analogue scale (VAS), The Disabilities of the Arm, Shoulder and Hand (DASH), Constant-Murley Shoulder Outcome Score (Constant) and Walch-Duplay Score (WD).

RESULTS

Twenty patients, 17 men and 3 women with a mean age of 36.1 years, were analysed. According to the classification of Rockwood, 3 patients were grade iii, 3 grade iv and 14 grade v. Functional and clinical improvement was detected in all clinical tests (SF-36, VAS and DASH) at 3 months and 2 years follow up (P<.001). The final Constant score was 95.3±2.4 and the WD was 1.8±0.62. It was not found that the health-related quality of life was affected by any variable studied except the evolution of DASH.

CONCLUSIONS

The health-related quality of life (assessed by SF-36) in patients undergoing arthroscopic repair of acromioclavicular joint dislocation grades iii-v was not influenced by gender, age, grade, displacement, handedness, evolution of the VAS, scoring of the Constant or by the WD. However, it is correlated with the evolution in the DASH score.

Predictive model of mortality in patients with spontaneous bacterial peritonitis

BACKGROUND

Hospital mortality in patients with spontaneous bacterial peritonitis (SBP) is high despite albumin treatment, particularly in those with worse liver and/or renal function.

AIM

To determine the independent predictive factors of in-hospital mortality and to create and validate a predictive model of mortality in patients with SBP.

METHODS

We analysed all cirrhotic patients with high-risk SBP (serum urea ≥11 mmol/L and/or serum bilirubin ≥68 μmol/L) between 2001 and 2011. We developed a predictive model of in-hospital mortality and validated this in a different cohort.

RESULTS

We included 118 high-risk SBP episodes treated with antibiotics and albumin. In-hospital mortality was 33/118 (28%). The independent predictive factors of in-hospital mortality at SBP diagnosis were serum urea, blood leucocyte count, Child-Pugh score and mean arterial pressure. A predictive model including these four variables showed a discrimination accuracy (AUC) of 0.850, 95% CI 0.777-0.922. A cut-off point of 0.245 showed a sensitivity of 0.85 and specificity of 0.75. The in-hospital mortality was 28/49 (57.1%) in patients with a model value ≥0.245, and 5/69 (7.2%) in patients with a model value <0.245 (P < 0.001). The validation series included 161 patients with an in-hospital mortality of 40/161 (24.8%), 30/77 (39.0%) in patients with a model value ≥0.245, and 10/84 (11.9%) in those with a model value <0.245 (P < 0.001).

CONCLUSIONS

We developed and validated a predictive model of mortality that includes serum urea, blood leucocyte count, Child-Pugh score and mean arterial pressure in high-risk patients with spontaneous bacterial peritonitis. These findings may help to identify patients who would benefit from additional therapeutic strategies.

Can We Predict Immediate Outcome After Laparoscopic Splenectomy for Splenomegaly? Multivariate Analysis of Clinical, Anatomic, and Pathologic Features After 3D Reconstruction of the Spleen

The laparoscopic approach is the treatment of choice for splenectomy, but its definitive role in splenomegaly is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathological. The aim of this study was to evaluate the predictive factors on outcome after laparoscopic splenectomy in splenomegaly. We reviewed patients submitted to laparoscopic splenectomy with a final spleen weight superior to 700 g. Three-dimensional reconstruction of the spleen was performed, and spleen volume and diameters were measured. Multivariate analysis showed that factors that predicted for conversion were mediolateral diameter ( P = .039, RR: 1.43) and platelet count ( P < .05, RR: 1). For intraoperative bleeding, the predictive factor was spleen volume ( P < .03, RR: 1.003). Anteroposterior spleen diameter was related to operative time ( P = .011), and the factor related to postoperative morbidity was age ( P = .049, RR: 0.941). Local anatomy and clinical factors affect surgical outcome in laparoscopic splenectomy for splenomegaly. These factors should be taken into account when planning this kind of procedure.

Pelvic MRI findings in relapsed prostate cancer after radical prostatectomy

PURPOSE/OBJECTIVE

Little is known about the clinical impact of using multiparametric MRI to plan early salvage radiotherapy after radical prostatectomy. We aimed to evaluate the incidence and location of recurrence based on pelvic multiparametric MRI findings and to identify clinical variables predictive of positive imaging results.

MATERIALS AND METHODS

We defined radiological criteria of local and lymph node malignancy and reviewed records and MRI studies of 70 patients with PSA recurrence after radical prostatectomy. We performed univariate and multivariate analysis to identify any association between clinical, pathological and treatment-related variables and imaging results.

RESULTS

Multiparametric MRI was positive in 33/70 patients. We found local and lymph node recurrence in 27 patients and 7 patients, respectively, with a median PSA value of 0.38 ng/ml. We found no statistically significant differences between patients with positive and negative multiparametric MRI for any variable. Shorter PSADT was associated with positive lymph nodes (median PSADT: 5.12 vs 12.70 months; p: 0.017).

CONCLUSIONS

Nearly half the patients had visible disease in multiparametric MRI despite low PSA. Positive lymph nodes incidence should be considered when planning salvage radiotherapy, particularly in patients with a short PSADT.

Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial

BACKGROUND

Postoperative blood loss in patients after total knee arthroplasty may cause local and systemic complications and influence clinical outcome. The aim of this study was to assess whether fibrin glue or tranexamic acid reduced blood loss compared with routine hemostasis in patients undergoing total knee arthroplasty.

METHODS

A randomized, single-center, parallel, open clinical trial was performed in adult patients undergoing primary total knee arthroplasty. Patients were divided into four groups. Group 1 received fibrin glue manufactured by the Blood and Tissue Bank of Catalonia, Group 2 received Tissucol (fibrinogen and thrombin), Group 3 received intravenous tranexamic acid, and Group 4 (control) had no treatment other than routine hemostasis. The primary outcome was total blood loss collected in drains after surgery. Secondary outcomes were the calculated hidden blood loss, transfusion rate, preoperative and postoperative hemoglobin, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and seventy-two patients were included. The mean total blood loss (and standard deviation) collected in drains was 553.9 ± 321.5 mL for Group 1, 567.8 ± 299.3 mL for Group 2, 244.1 ± 223.4 mL for Group 3, and 563.5 ± 269.7 mL for Group 4. In comparison with the control group, Group 3 had significantly lower total blood loss (p < 0.001), but it was not significantly lower in Groups 1 and 2. The overall rate of patients who had a blood transfusion was 21.1% (thirty-five of 166 patients analyzed per protocol). Two patients required transfusion in Group 3 compared with twelve patients in Group 4 (p = 0.015). No significant difference was observed between the two fibrin glue groups and the control group with regard to the need for transfusion. There was no difference between groups with regard to the percentage of adverse events.

CONCLUSIONS

Neither type of fibrin glue was more effective than routine hemostasis in reducing postoperative bleeding and transfusion requirements, and we no longer use them. However, this trial supports findings from previous studies showing that intravenous tranexamic acid can decrease postoperative blood loss.

[Viscosity changes in thickened water due to the addition of highly prescribed drugs in geriatrics]

INTRODUCTION

Dysphagia is a swallowing disorder with a high incidence in the geriatric patient related with an increased risk for undernutrition and pneumonia due to bronchial aspiration. In this condition, it is usual to add commercial thickeners in liquids, as well as the addition of drugs in this mixture to improve their administration. However, there are no studies regarding the possible change in viscosity produced by their addition.

OBJECTIVES

To assess the change in viscosity of water thickened with commercial products by adding the drugs frequently used in elderly patients.

METHODS

Samples of water mixed with the commercial thickener Resource (modified corn starch) or Nutilis (modified corn starch, maltodextrin, and gums: tara, xhantan, and guar) to achieve an intermediate consistence as "honey". The viscosity of these samples was measured as well as for similar samples to which one of the following drugs was added: galantamine, rivastigmin, ciprofloxacin, cholecalciferol, memantine, fosfomycin, calcium, and amoxicillin/clavulanic acid.

RESULTS

In the samples with Resource thickener we observed decreased viscosity by adding galantamine, memantine, fosfomycin or calcium, and increased viscosity with amoxicillin/clavulanic acid. The viscosity of the samples with Nutilis® decreased with galantamine, rivastigmine, amoxicillin/clavulanic acid, fosfomycin and calcium.

CONCLUSION

The viscosity of water with commercial thickeners may be affected by some drugs or their preservatives, which may influence the swallowing capability. It is recommended to perform further in vitro and in vivo studies in order to adjust these formulations if necessary.

Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction

AIMS/HYPOTHESIS

The aim of the study was to analyse the insulin requirements of women with type 1 diabetes mellitus throughout pregnancy.

METHODS

We have examined the weekly mean blood glucose (mmol/l), insulin requirements (U kg(-1) day(-1)) and total insulin requirements (U/day) in 65 women with type 1 diabetes mellitus and tight metabolic control since before pregnancy (HbA(1c) < or =6.0%).

RESULTS

Both insulin requirement and total insulin requirement displayed a peak in week 9, a nadir in week 16 and a second peak in week 37. For the change in insulin requirement (4.08% per week) and in total insulin requirement (5.19% per week), the sharpest slope was observed from week 16 to week 37. However, two changes of direction took place in the first 11 weeks and eight out of nine episodes of severe hypoglycaemia requiring treatment with glucagon or i.v. glucose took place in the first 16 weeks.

CONCLUSIONS/INTERPRETATION

Pregnant women with type 1 diabetes mellitus and tight metabolic control since before pregnancy displayed changes in insulin requirement and total insulin requirement with successive changes of direction. The sharpest slope was observed between 16 and 37 weeks, but insulin requirements were more unstable in the first 16 weeks. This information could help patients and physicians to react to changes in glycaemic pattern in a prompt and adequate way.

Prevalence evolution and impact of cardiovascular risk factors on allograft and renal transplant patient survival

OBJECTIVE

The prevalence of traditional cardiovascular risk factors in renal transplantation is high. Studying the evolution of cardiovascular risk factors over time may help us to design better strategies to control them. The relative impact of traditional cardiovascular risk factors on allograft survival and mortality in transplant recipients is not clear. This study was performed to determine the incidence and risk factors for allograft survival and mortality among renal transplant patients.

PATIENTS AND METHODS

We enrolled 250 patients who had undergone transplantation between 1980 and 2004. They were followed for various periods, and we analyzed the impact of traditional and nontraditional risk factors on renal allograft survival.

RESULTS

The prevalence of hypertension was >80% during all the follow-up periods. Blood pressure diminished, antihypertensive drug prescription increased, and 15% of patients had adequate blood pressure control during follow-up. The prevalence of pretransplant diabetes mellitus was 6.8%; the incidence of posttransplant diabetes mellitus (PTDM) was 14.2%. The prevalence of PTDM increased over the course of patient evolution. The prevalence of dyslipidemia was in all cases >70%; total cholesterol and low-density lipoprotein (LDL)-cholesterol decreased; prescription of statins increased; and the percentage of patients with good lipid control also increased. The 25% prevalence of active smoking at the time of transplantation decreased to 13.6% at 10 years posttransplantation. The mean patient follow-up was 8 +/- 4.6 years. Sixty-five patients (26%) lost their grafts and 40 (16%) died during follow-up. Donor age, exercise, diastolic blood pressure, renal function, and albumin levels were independent risk factors for graft loss. Charlson comorbidity index at transplantation, recipient and donor ages, exercise, diastolic blood pressure, and LDL-cholesterol posttransplantation were independent risk factors for mortality among renal transplant recipients.

CONCLUSION

Blood pressure and lipid control improved during follow-up, however, insufficiently among renal transplant patients. The prevalence of diabetes gradually increased, and the incidence of smoking cessation was low. Diastolic blood pressure, exercise, and albuminemia were the most significant modifiable cardiovascular risk factors for renal allograft survival. Diastolic blood pressure, LDL-cholesterol level, and exercise were the most relevant modifiable cardiovascular risk factors for the survival of renal transplant patients.

Maternal and fetal outcome in women with type 2 versus type 1 diabetes mellitus: a systematic review and metaanalysis

CONTEXT

Glycemic disturbance is usually less severe in pregnant women with type 2 than in those with type 1 diabetes mellitus (DM). Nevertheless, a worse perinatal outcome in women with type 2 DM has been reported in some studies.

OBJECTIVE

Our objective was to review maternal and fetal outcomes in pregnant women with type 2 vs. type 1 DM.

STUDY SELECTION

We conducted a systematic review of papers providing original data on pregnancy outcomes in both type 2 and type 1 DM (Medline search of the period January 1, 1987, to June 30, 2008). Two independent investigators considered papers for eligibility, and a third one solved discrepancies.

DATA EXTRACTION

Metaanalysis tools were used to compare four main outcomes (major congenital malformations, stillbirth, and neonatal and perinatal mortality) and 15 secondary ones (five maternal, 10 fetal). Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were used to assess quality.

DATA SYNTHESIS

Thirty-three studies qualified for inclusion of 3743 citations retrieved. Women with type 2 DM had lower glycated hemoglobin (HbA1c) at booking and throughout pregnancy but a higher risk of perinatal mortality [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.15-1.96] without significant differences in the rates of major congenital malformations, stillbirth, and neonatal mortality. As to secondary outcomes, women with type 2 DM had less diabetic ketoacidosis (OR 0.09, 95% CI 0.02-0.34) and cesarean section (OR 0.80, 95% CI 0.59-0.94) without differences in other outcomes.

CONCLUSIONS

Despite a milder glycemic disturbance, women with type 2 DM had no better perinatal outcomes than those with type 1, indicating that type 2 DM in pregnancy is a serious condition.

[Psychopathological symptoms in patients suffering from chronic cephalea with or without fibromyalgia]

INTRODUCTION

The presence of psychopathological symptoms as anxiety and depression in chronic daily headache and in fibromyalgia is common.

AIM

To study whether there are any difference in the psychopathological profile and treatment response between patients with chronic headache and fibromyalgia (CHFM) and patients with chronic headache without fibromyalgia (CH).

PATIENTS AND METHODS

A comprehensive psychological test battery was administered to 30 patients with CH and 30 patients with CHFM, diagnosed by a rheumatologist. We included chronic migraine and chronic tensional headache in CH group. Patients were matched for age and gender. Depression, anxiety and obsession scores, and the profile of psychopathological symptoms (MMPI-2, SCL-90-R) were compared (t-test). Correlations between symptoms and treatment response were examined.

RESULTS

Patients with CHFM showed significant highest scores on hypochondriasis, depression, hysteria, paranoia, psychasthenia and schizophrenia (MMPI-2) and more somatization, obsession and anxiety according to SCL-90-R. A poorer response to treatment was observed in CHFM (17.85%) versus CH (42,85%) group.

CONCLUSIONS

Patients with CHFM showed a psychopathological profile with highest scores and symptoms than patients without fibromyalgia. These differences correlated with the therapeutic response.

A novel GSK-3beta inhibitor reduces Alzheimer's pathology and rescues neuronal loss in vivo

Amyloid deposits, neurofibrillary tangles, and neuronal cell death in selectively vulnerable brain regions are the chief hallmarks in Alzheimer's (AD) brains. Glycogen synthase kinase-3 (GSK-3) is one of the key kinases required for AD-type abnormal hyperphosphorylation of tau, which is believed to be a critical event in neurofibrillary tangle formation. GSK-3 has also been recently implicated in amyloid precursor protein (APP) processing/Abeta production, apoptotic cell death, and learning and memory. Thus, GSK-3 inhibition represents a very attractive drug target in AD and other neurodegenerative disorders. To investigate whether GSK-3 inhibition can reduce amyloid and tau pathologies, neuronal cell death and memory deficits in vivo, double transgenic mice coexpressing human mutant APP and tau were treated with a novel non-ATP competitive GSK-3beta inhibitor, NP12. Treatment with this thiadiazolidinone compound resulted in lower levels of tau phosphorylation, decreased amyloid deposition and plaque-associated astrocytic proliferation, protection of neurons in the entorhinal cortex and CA1 hippocampal subfield against cell death, and prevention of memory deficits in this transgenic mouse model. These results show that this novel GSK-3 inhibitor has a dual impact on amyloid and tau alterations and, perhaps even more important, on neuronal survival in vivo further suggesting that GSK-3 is a relevant therapeutic target in AD.

Comparison of repeated-dose pharmacokinetics of prolonged-release and immediate-release torasemide formulations in healthy young volunteers

The major aim of the study was to compare the pharmacokinetic profile of repeated-dose administration of a prolonged-release (PR) formulation of torasemide with that of an immediate-release (IR) dosage. Sixteen volunteers received one daily dose, on four consecutive days, of 10 mg of torasemide-PR or torasemide-IR in a single-blind, two-treatment, two-period, repeated-dose, cross-over, sequence-randomized clinical trial. Blood samples were collected at various time points on day 1 (single-dose) and on day 4 (repeated-dose) and torasemide concentrations were analysed by LC/MS/MS. Diuretic effect and urine electrolytes were measured. Urinary urgency was subjectively assessed by visual analogue scales. Safety and tolerability were also determined. Based on logged values, bioequivalence parameters, were: on day 1, ratio = 1.07 (90% CI 1.02-1.1), C(max) ratio = 0.69 (90% CI 0.67-0.73); and on day 4, ratio = 1.02 (90% CI 0.98-1.05), C(max) ratio = 0.62 (90% CI 0.55-0.70). PR had longer t(max) than IR and showed significantly lower fluctuations of plasma concentrations. Urine evaluations were similar with both formulations, although PR showed a lower urine volume in the first hours post-administration. Episodes of acute urinary urgency occurred later and were subjectively less intensive with PR. No significant adverse events were reported.

Incidence of chemotherapy-induced nausea and vomiting after highly and moderately emetogenic chemotherapy in the era of NK-1 receptor antagonists. Perception versus reality

e20636

Background: Physicians and nurses had underestimated the incidence of chemotherapy-induced nausea and vomiting (CINV) after both high emetogenic chemotherapy (HEC) and moderately emetogenic chemotherapy (MEC) (Grumberg, Cancer 2004;100:2261–8; Erazo Valle, Curr Med Res Opin 2006;22:2403–10). We have assessed if physicians and nurses’ perception of CNIV in their own practices after the introduction of Aprepitant was closer to reality. Methods: A prospective, observational unicenter study of adult patients receiving their first chemotherapy cycle was performed. Medical oncologists and oncology nurses also estimated the incidence of acute (Day 1) and delayed (Days 2–5) CINV after first administration of HEC and MEC. Eligible patients completed a 6-day diary including emetic episodes, nausea assessment, and antiemetic medication use. Observed incidence rates of acute and delayed CINV were compared with physician/nurse predictions. Results: Twenty-nine physicians and nurses and 95 patients (86.3% receiving HEC and 13.7%MEC) were recruited. Acute nausea and emesis were observed in 14.3% and 2.4% respectively of HEC patients receiving Aprepitant, and delayed nausea and emesis were observed in 14.3% and 7.1% of these patients, respectively. Physicians and nurses accurately predicted the incidence of acute and delayed CINV after HEC patients receiving Aprepitant. Acute nausea and emesis were observed in 22.2% and 0% respectively of MEC patients and delayed nausea and emesis in 33.3% and 22.2% of MEC patients, respectively. All physicians and nurses underestimated the incidence of acute nausea and delayed nausea and emesis after MEC by 15, 28 and 18 percentage points, respectively. Conclusions: The addition of aprepitant in the prevention of CINV after HEC allows a better control of CINV that is perceived accurately by physicians and nurses. By contrary, physicians and nurses continue markedly underestimating the incidence of CINV after MEC. CINV still remain important targets for improved therapeutic intervention and physicians and nurses must be aware about the real incidence of CNIV.

No significant financial relationships to disclose.

[Total enteral nutrition vs. total parenteral nutrition in patients with severe acute pancreatitis]

OBJECTIVE

To compare the efficacy of early total enteral nutrition (TEN) vs. total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP).

METHODS

A total of 22 consecutive patients with SAP were randomized to receive TPN (group I) or TEN (group II). SAP was defined applying APACHE II score, C-reactive protein (CRP) measurements and/or Balthazar CT scan score. Acute inflammatory response (CRP, TNF-a, IL-6), visceral proteins (pre-albumin, albumin), complications (systemic inflammatory response syndrome, multiorgan failure, infections), surgical interventions, length of hospital stay and mortality were evaluated.

RESULTS

No significant differences were found between the two groups in the APACHE II score, in CRP, TNF-a and IL-6 concentrations or in pre-albumin and albumin levels over the first 10 days. Seven patients in group I and 4 in group II suffered severe complications. Three patients in group I required surgical intervention. Length of hospital stay was alike in the two groups. Two patients from group I died in the course of the hospitalization.

CONCLUSIONS

SAP patients with TEN feeding showed a tendency towards a better outcome than patients receiving TPN.

Microtubule-regulatory phosphoproteins and NER system are involved in platinum and paclitaxel-based chemotherapy resistance in ovarian cancer

5567

Background: The treatment of ovarian cancer is hindered by intrinsic resistance to platinum and paclitaxel-based chemotherapy (CT). Nucleotide excision repair system plays a central role in DNA repair and is related with resistance to platinum compounds. Excision repair cross-complementation 1 (ERCC1) and 3 (ERCC3) genes confer a differential sensitivity to CT. OP18/stathmin and mDIA are involved in regulation of microtubules dynamics and may represent a mechanism of resistance to paclitaxel. Both mechanisms have been recently investigated in ovarian cancer (OC). Methods: Formalin and paraffin-embedded tissues obtained from 33 patients with advanced OC were retrospectively collected to investigate ERCC1, ERCC3, OP18, and mDIA mRNA levels by quantitative RT- PCR. All patients received a median of 6 cycles platinum based CT in combination with taxanes. Median age was 62 years. Tumors were classified: 52% serous, 9% endometrioid, 27% clear cell, and 12% poorly differentiated carcinomas. FIGO stage: 4 (12%) stage II, 19 (58%) stage III, and 10 (30%) stage IV. 12 chemoresistant tumors (time to recurrence (TTR) < 6 months) and 21 chemosensitive tumors (TTR = 6 months) were analyzed. Median follow-up was 31 months. Results: An increase in mRNA levels was consistently observed in the chemoresistent group: 1.9-fold increased in ERCC1 and 1.6-fold increased in ERCC3. Both genes exhibited comparable expression levels. Statistically significant differences on ERCC1 and ERCC3 mRNA levels were encountered when chemoresistant and chemosensitive tumors were compared (p=0.01 and p= 0.03, respectively). Statistically differences on OP18 mRNA levels were found when chemoresistant and chemosensitive tumors were compared (p=0.05). No differences in mDIA mRNA levels were encountered. Conclusions: Our results suggest that determination of ERCC1-ERCC3 before chemotherapy is potentially useful to predict the effectiveness of platinum-based therapy. Microtubule drug resistance in OC may be associated with altered OP18/stathmin expression. Novel treatment approaches based on molecular markers could be useful predictors of response and could identify targets for therapeutic strategies. Further studies are required.

No significant financial relationships to disclose.

Aspirin or Anticoagulants in Stenosis of the Middle Cerebral Artery:A Randomized Trial

BACKGROUND

We report the results of an open, randomized, multicenter trial that compared the efficacy of aspirin to oral anticoagulants (OA) for the prevention of vascular events in patients with symptomatic stenosis of the middle cerebral artery (MCA).

METHODS

Participants were randomly assigned to receive 300 mg/day of aspirin or a dose of OA (target INR 2-3). The MCA stenosis was demonstrated by conventional angiography or by at least two noninvasive examinations. Patients had either transient ischemic attack or cerebral infarct (CI) attributable to the MCA stenosis within 90 days before inclusion. The primary endpoint was: nonfatal CI, nonfatal acute myocardial infarct, vascular death and major hemorrhage. The patients were followed-up for a minimum of 1 year and a maximum of 3 years.

RESULTS

The study included 28 patients (14 in each treatment group); the average age was 67 +/- 9.9 years. Men constituted 68% of the patients. After a mean follow-up of 23.1 +/- 10.9 months, there were no recurrences of CI in both groups. No endpoint was reported in the aspirin group, but 2 patients in the OA group (14.3%) exhibited vascular events: 1 acute myocardial infarct and 1 intracerebral hemorrhage). However, this difference was not statistically significant (p = 0.48).

CONCLUSIONS

Our study suggests that aspirin is the treatment of choice for the prevention of vascular events in patients with symptomatic MCA stenosis.

Multicentric descriptive study of the lung cancer treatment

20109

Background: Given the insufficient available information on the clinical characteristics and the results of the lung cancer treatment at a population level, we performed a large multicentric descriptive study in the main hospitals in our city. Methods: We analyzed the patients diagnosed and treated for lung cancer during 1999 in five University Hospitals in Barcelona (Spain). We performed a retrospective analysis of the individual data obtained from the clinical records using a specifically validated questionnaire. A descriptive analysis was performed, stratifying for type of tumor, stage, and institution. The follow-up for the complete population was 5 years. Results: We included 836 patients (94.6% male, 5.4% female) with an average age of 64 years. Karnofsky was ≥ 70% in 85% of patients. Histologic distribution was non-small cell (NSCLC) 85.5%, small-cell (SCLC) 14.5%. 42% of cases were stage IV (38% NSCLC, 67.8% SCLC). First treatment was performed in 82% of cases with therapeutic intention (52% was chemotherapy). Pulmonary resection with lobectomy and platinum-based chemotherapy were the more frequent treatments. Complete remission was obtained in 25% of cases. Survival was 42.0, 17.9 and 12.6% at 1, 3 and 5 years respectively (NSCLC: 43.8, 19.4, 13.1%; SCLC: 31.9, 9.5, 9.5%). The mean interval first visit - treatment start was 2 months. The mean of direct costs per patient was 9000 €. The cost per life-year gained was 5200 € for NSCLC and 7600 € for SCLC patients. Conclusions: The obtained results allow to describe the clinical characteristics of a wide cohort of patients diagnosed of lung cancer and their survival to 5 years. Globally, these results are similar to those who have been published in our country and others, and constitute a very thorough referent for assessing the impact of future therapeutic advances. The comparison among hospitals can also be the matter of further analysis for identifying the causes of the observed differences. Equally, specific strategies for some patients’ subgroups could be designed in order to improve the cost-effectiveness of their treatment.

No significant financial relationships to disclose.

Stratification of the normal range of CA125 after chemotherapy as a predictive factor in carcinoma of the ovary

5059

Background: CA125 is an accurate and reliable marker for monitoring the response to treatment and detecting early relapse in ovarian cancer. The implications of the variation of its normal range are not known.The purpose of this study was to evaluate such variations as a prognostic indicator after first-line chemotherapy Methods: Over a 7 years period (1998–2005), 114 patients (pts) were treated with standard chemotherapy regimen for FIGO stage Ic-IV epithelial ovarian cancer. The median age was 63 years old (24–87) years. The tumors were classified: 56% serous, 12% endometroid, 16% poorly differentiated and 16% clear cell carcinomas. FIGO stage: 12 (11%) Ic, 14 (12%) II, 72 (63%) III, 16, (14%) IV. After surgery, 90% of the patients received a median of 6 cycles/patient with platinum based (cisplatin or carboplatin) chemotherapy in combination with taxane. Serial measurement of CA12.5 had been made before each cycle of chemotherapy and response was assessed according to RECIST or Rustin criteria. Median follow-up has been 31 months. 87 pts achieved levels below 35 u/ml after completion of treatment. The nadir value of CA125 was stratified into three arbitrary groups: group 1, ≤ 10 U/ml, group 2, 11–20 U/ml, and group 3, 21–35 U/ml. The χ2/Fisher’s exact test was used to examine patients characteristics for categorical variables. Survival analysis was performed by Kaplan-Meier method with long-rank test for determining statistical significance. Results: No statistical relationship between FIGO stage and gross residual tumor vs nadir groups (p = 0.48 and p = 0.2) was found. Median duration of progression free survival according to 3 groups was 34, 20, 14 months, respectively (p= 0.003). The median overall survival for the group 1 is not yet available, however, the corresponding median overall survival for groups 2 and 3 were 3.8 and 2.7 years, respectively (p = 0.006) Conclusions: Within normal range, the differences between CA125 levels could add prognostic information and stratify patients according to the risk of progression.

No significant financial relationships to disclose.

Factors involved in baseline hyperhomocysteinemia in renal transplantation

Hyperhomocysteinemia (hyperHcy) is one cardiovascular risk. The objective of this study was to establish the prevalence demographic, and clinical and analytical factors related to hyperhomocysteinemia among renal transplant patients. The mean Hcy level was 17.3 micromol/L; the prevalence of hyperHcy was 61.2%. The population was categorized as hyperHcy and normal-homocysteinemia (Hcy) patients. Those subjects with hyperHcy were mostly men, with lower intraerythrocyte folate and vitamin B(12) levels, higher fibrinogen levels, and poorer renal function. Multivariate evaluation showed that creatinine clearance, plasma intraerythrocyte folate and vitamin B(12) levels, and plasma fibrinogen levels were independently associated with Hcy levels. Even though the Hcy level was slightly higher among patients who suffered a posttransplantation cardiovascular event, this was statistically significant.

Determining Factors of the Response to Hyperhomocysteinemia Treatment in Renal Transplant Patients

Hyperhomocysteinemia (hyperHcy) is a risk factor for cardiovascular disease. The benefits of lowering homocysteinemia (Hcy) in renal transplant recipients through vitamin treatment are not clearly understood. The objective of this study was to establish the demographic, renal, Hcy metabolism, and microinflammation factors that determined the response to folic acid and vitamin B complex treatment in stable patients with renal transplants and hyperHcy. We studied 65 renal transplant patients with baseline hyperHcy. The mean baseline Hcy level of these patients was 22.5 micromol/L. Following treatment it fell to 14.5 micromol/L, an overall reduction of 35.5%. Forty-one patients (63%) were classified as responders; the remainder (37%), nonresponders. A bivariance analysis suggested the only significant differences between responding and nonresponding patients were the pre-treatment Hcy level and the renal function level.

Cardiovascular Risk Factors in Diabetic Patients With Renal Transplants

There is a progressive increase in cardiovascular events post-renal transplantation and diabetes mellitus (DM) is one of the major cardiovascular risk factors. The objective of this study was to analyze the prevalence of cardiovascular risk factors and nonfatal cardiovascular events among renal transplant recipients, according to the status of their carbohydrate metabolism. We studied 214 renal transplant recipients, among whom 18% diabetic and 82% were nondiabetic. The 16% prevalence of cardiovascular events were higher among the posttransplantation DM (PTDM) group (33%) compared with the other groups, 19% in pre-renal transplantation DM, 17% in altered baseline glycemia, and 13% in normal patients. Diabetic renal transplant recipients showed a greater prevalence of pretransplantation ischemic cardiopathy when they were older and had a higher pretransplantation body mass index (BMI) a heavier smoking habit, significantly increased microinflammation markers, and a greater need for antihypertensive and hypolipidemic treatment. Renal transplant recipients with altered baseline glycemia show greater BMI after transplantation, as well as higher Hb1Ac than patients with normoglycemia.

Immediate peritoneal response to bacterial contamination during laparoscopic surgery

BACKGROUND

Several studies have shown that laparoscopic surgery (LS) minimizes surgical trauma and the immune function is better preserved. Another major advantage of LS is the lower incidence of septic complications. However, several in vitro studies have shown that CO(2) severely impairs macrophage physiology. In theory, this would reduce the ability to respond to peritoneal contamination. However, there is some controversy in view of the evidence of a better preserved peritoneal response to sepsis. This study analyzed the early response of the peritoneum to contamination in a CO(2) ambience.

METHODS

A total of 192 CD-1 mice were distributed in three groups: group 1, laparotomy (LAP, n = 64); group 2, CO(2) laparoscopy (CO(2)-LC, n = 64); and group 3, wall lift laparoscopy (WL-LC, n = 64). Mice in each group were randomized to receive 1 ml of Escherichia coli suspension (1 x 10(4) colony-forming units/ml) or saline. Peritoneal fluid was obtained at 1.5, 3, 6, and 12 h after surgery. Monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), and prostaglandin E(2) (PGE(2)) were measured.

RESULTS

MCP-1 levels were significantly greater and higher earlier in group 2 (CO(2)-LC) than in group 1 (LAP) (p < 0.007). Simultaneously, the increment in the traction group (WL-LC, group 3) was significantly higher (p < 0.002) than after laparotomy, with no differences in group 2 (CO(2)-LC). When a contamination was added to the laparotomy subgroup, there was a significant increase compared to the group without contamination (p < 0.5). MCP-1 modifications after contamination in the LAP group were statistically significant and appeared later than in the WL-LC (p < 0.002) and CO(2)-LC groups (p < 0.02). For IL-6, the three models presented a significant increase in the noncontaminated groups. This occurred significantly later in the LAP group. Simultaneously, the increase in IL-6 occurred earlier and was significantly higher in the WL-LC group compared to the LAP group (p < 0.003), without differences between CO(2)-LC and wall lift groups. Significant differences between contaminated and noncontaminated subgroups were only observed in the LC-CO(2) groups. When contaminated, the traction model sustained a higher and earlier rise in IL-6 levels compared to the LAP and LC-CO(2) groups (p < 0.001). For PGE(2), The three models showed a significant increase in PGE(2) levels in the noncontaminated groups. However, there were no significant differences between them. In the contaminated groups, there was no statistical difference between the groups.

CONCLUSION

Despite a transient impairment of the immediate peritoneal response to a septic challenge, the degree of injury with LS is lower than that with open surgery, and abdominal infection can therefore be better controlled.

Eberconazole cream: topical and general tolerability, sensitisation potential, and systemic availability

Eberconazole is a topical imidazole derivative, which has shown high potency against dermatophytes and yeasts (several species of Candida, Malassezia) in vitro and in experimental models. Clinical trials have found that the compound has a high degree of efficacy against dermatophytes and good tolerability. Evaluation of its a) topical and general tolerability, b) eventual development of sensitisation, c) local availability, and d) degree of systemic absorption. Two clinical trials with 28 healthy young volunteers of both sexes were performed. In Study I, placebo or eberconazole cream (2%) were applied at increasing doses: day 1 (0.5 g), days 2-3 (1 g), days 4-5 (2 g), days 6-7 (4 g), days 8-9 (8 g), and days 10-11 (12 g). On day 1, each application area was washed with ethanol-soaked gauzes at different times to assess availability of the active compound. In Study II, eberconazole cream (1%) was applied on day 1 and again at least one week later. After the first application, blood and urine samples were obtained at different times to assess systemic absorption. The only change observed was slight redness in a few volunteers after both active and placebo applications. This remitted spontaneously without intervention and we were able to continue with the administration of repeated increasing-doses. A few participants described side effects; these were all of mild intensity, and occurred in areas where placebo or eberconazole were applied, mainly within the first hour postapplication. The most frequent effect after the first application was coldness, and after repeated increasing-doses there was itching. No signs or symptoms of skin reactivity were observed following reexposure to the product. No clinically relevant changes were observed in vital signs (systolic and diastolic blood pressure, heart rate, body temperature), ECG, or analytical parameters (clinical haematology and biochemistry). The quantity of compound collected through washing gauzes decreased progressively over time. Plasma and urine concentrations of eberconazole were below the quantification limit of the analytical method (5 ng/ml) at all times. Eberconazole cream is a topical antimycotic drug that has good local and general tolerability. It has acceptable topical availability, no detectable systemic drug levels, and does not appear to cause skin sensitivity.

Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making

OBJECTIVE

This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making.

DESIGN AND SETTING

Prospective, observational study in 79 intensive care units.

PATIENTS AND PARTICIPANTS

Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS.

MEASUREMENTS AND RESULTS

We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807.

CONCLUSIONS

This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.

Unmasking influenza virus infection in patients attended to in the emergency department

Background:

Infection by the influenza virus may pass undetected in many adult patients attended to in the emergency department because its diagnosis usually relies on clinical manifestations, which can be distorted by symptoms of a preexisting disease, superposed complications or nontypical manifestations of influenza virus infection (confusing symptoms).

Patients and Methods:

We performed this observational, prospective study with an antigen detection test by indirect immunofluorescence assay (IFA) to estimate the presence of influenza virus infection in such patients. No confirmatory test was performed to validate a positive or negative IFA result. Then we compared those who were antigen positive to those who were negative and also analyzed those who were positive classified by age, comorbidity and clinical presentation. We also evaluated the use of medical and hospital resources and vaccination status. Posterior pharynx swab specimens from 136 consecutive adult patients, 74 women and 62 men with a mean age of 68.7 ± 17.9 (range: 18–97) years attended to in the emergency department of a university hospital in Barcelona during the 1999–2000 influenza epidemic were examined. Tested patients presented either a classical influenza syndrome, a deterioration of a previous condition or any abrupt onset of symptoms without an obvious cause.

Results:

Influenza A virus antigen was detected in 99 (72.8%) of the 136 patients included in the study. Confusing symptoms were present in 86 patients with laboratoryconfirmed influenza and 40 of them lacked influenza syndrome. Prostration, aching and fever out of proportion to catarrhal symptoms (disproportionate prostration) and cough were independent predictors for this diagnosis (OR = 5.14; 95% CI: 1.98–13.35, p = 0.001 and OR = 4.40, 95% CI, 1.65–11.75, p = 0.03, respectively). Among the 99 patients who tested positive, 72 were ≥ 65 years of age. This older positive group compared to the 27 also positive < 65 (non-old) had a tendency to show symptoms mediated by cytokines less frequently: malaise was present in 76.4% of the older positive patients vs 92.6% in the non-old positive ones, p = 0.07. The equivalent percentages for muscle ache were: 56.9% vs 77.8%, p = 0.06; for dysthermia: 54.2% vs 70.4%, p = 0.08; for headache: 35.2% vs 66.7%, p = 0.005, and for disproportionate prostration: 47.2% vs 66.7%, p = 0.08. Cough was more frequent in the older positive group: 94.4% vs 77.8%, p = 0.02. Older positive patients were also hospitalized and received antibiotics more frequently than the non-old positive ones: 65.3% vs 40.7%, p = 0.03 and 81.9% vs 63.0%, p = 0.046, respectively. Hospitalization was independently correlated with the presence of complications (OR = 4.5, 95% IC 1.27–15.95, p = 0.02). Patients with the highest comorbidity, evaluated with the Charlson scale, were more inadequately vaccinated than those with moderate or low comorbidity.

Conclusion:

Influenza virus infection has a great and underestimated impact in the emergency department during influenza epidemics. High frequency of confusing symptoms, which overcome classical influenza syndrome in adult people with comorbidity, may explain this effect. Disproportionate prostration and cough are symptoms that independently predict its diagnosis in the global adult population, whereas in the elderly, fever and cough should arouse this suspicion whether or not they present classic symptoms. In our setting, individuals with high comorbidity are inadequately vaccinated.

[Assessment of the prognostic capacity improvement of the 5th edition of the TNM in patients with nasopharyngeal carcinoma]

OBJECTIVE

Evaluate the changes included in the 5th edition of the TNM classification in patients with nasopharyngeal carcinoma.

PATIENTS AND METHODS

Retrospective study of 103 patients with nasopharyngeal carcinoma treated with radical intention in our centre from 1985 to 1997. A reclassification according to the criteria defined in the 5th edition of the TNM was carried out. The loco-regional control and survival obtained when patients were classified with the 4th and 5th editions of the TNM were compared.

RESULTS

The use of the 5th edition of the TNM led to a decrease in local category (T) and stage grouping, improving the prognostic capacity in local control and survival. The changes included in the 5th edition of the TNM did not modify the regional classification in a essential way.

CONCLUSIONS

The changes included in the 5th edition of the TNM improved the classification of patients with nasopharyngeal carcinoma.

A Study Comparing the Inhibitory Effects of Single and Repeated Oral Doses of Ebastine and Fexofenadine against Histamine-Induced Skin Reactivity

OBJECTIVE

The aim of this double-blind, randomized, crossover, placebo-controlled clinical trial was to compare the inhibition of the histamine-induced skin reaction induced by ebastine 20 mg with respect to that induced by fexofenadine 120 mg or placebo.

METHODS

Eighteen volunteers (10 males, 8 females) received the three treatments once daily for 5 days, with a mean 7-day washout period between treatments. Intradermal tests, using 0.05 ml from a solution containing 100 microg/ml of histamine, were performed at baseline and at 1, 1.5, 2, 3, 10 and 24 h after a single dose and repeated 5-day dose, and in addition after 34, 48, 58 and 72 h after repeated 5-day dose.

RESULTS

After 24 h of acute administration, ebastine 20 mg was significantly more effective than fexofenadine 120 mg in reducing the wheal and flare induced by histamine challenge (p<0.001). Although fexofenadine 120 mg had the shortest onset of action (1.5 vs. 3 h in ebastine 20 mg), the duration of its antihistamine effect was the shortest (24 vs. 58 h in ebastine 20 mg) and wheal reduction after 24 h was not significantly different from placebo. The overall effect after single and repeated 5-day dose, expressed as the AUC of reduction of wheal and flare area (%/h), showed the following order of magnitude: ebastine 20 mg>fexofenadine 120 mg>placebo. No significant differences in the incidence of adverse events were found between the three treatments.

CONCLUSIONS

The present results clearly show a superior and long-acting effect of ebastine 20 mg compared with fexofenadine 120 mg on the skin response to histamine 24 h after dosing.