Evaluation of a battery of biotests to improve waste ecotoxicity assessment (HP 14), using incineration bottom ash as a case study

The assessment of waste ecotoxicity (hazardous property HP14 in the European Union) is fundamental for proper waste classification and safe application/disposal. Biotests are relevant for evaluating waste complex matrices, but their efficiency is crucial to encourage their adoption at the industrial level. This work aims at evaluating possibilities of improving the efficiency of a biotest battery previously suggested in the literature, regarding test selection, duration, and/or laboratory resources optimization. Fresh incineration bottom ash (IBA) was the case study. The test battery analysed included standard aquatic (bacteria, microalgae, macrophytes, daphnids, rotifers, fairy shrimp) and terrestrial (bacteria, plants, earthworms, collembolans) organisms. The assessment followed an Extended Limit Test design (three dilutions of eluate or solid IBA) and the Lowest Ineffective Dilution (LID-approach) for ecotoxicity classification. The results emphasize the importance of testing different species. It was also evidenced that tests with daphnids and earthworms may be shortened to 24 h; the miniaturization of tests is suitable as e.g. differential sensitivity of microalgae and macrophytes was captured with low variability; alternative testing kits can be used when methodological difficulties are found. Microalgae were more sensitive than macrophytes. Similar results were found for the Thamnotoxkit and daphnids test for eluates with natural pH, so the former may be used as an alternative. B. rapa was the most sensitive organism, suggesting that it may be tested as the only terrestrial plant species and that minimum test duration is appropriate. F. candida does not appear to add information to the battery. The differences in sensitivity of A. fischeri and E. fetida compared to the remaining species were not significant enough to exclude them from the battery. Thus, this work suggests a biotest battery to test IBA comprising aquatic tests - Aliivibrio fischeri, Raphidocelis subcapitata (miniaturised test), and Daphnia magna (24 h when clear deleterious effects are observed) or Thamnocephalus platyurus (toxkit) - and terrestrial tests - Arthrobacter globiformis, Brassica rapa (14 d), and Eisenia fetida (24 h). Testing waste with natural pH is also recommended. The Extended Limit Test design considering the LID-approach seems useful in waste testing, particularly for the industry, involving low effort, test material requirements, and few laboratory resources. The LID-approach allowed for differentiating ecotoxic from non-ecotoxic effects and captured different sensitivities between species. Ecotoxicological assessment of other waste may benefit from these recommendations, but caution should be taken given the properties of each waste type.

An integrated characterisation of incineration bottom ashes towards sustainable application: Physicochemical, ecotoxicological, and mechanical properties

Environmental protection is a central concern regarding municipal solid waste incineration bottom ash (IBA) management, but the assessment of waste Hazardous Property HP14 (ecotoxicity) is still under debate. Civil engineering applications may be a suitable management strategy. This work aimed at evaluating IBA regarding mechanical behaviour and environmental hazardous potential, including a biotest battery for ecotoxicity assessment (comprising miniaturised tests), to explore its potential for safe utilization. Physical, chemical, ecotoxicological (Aliivibrio fischeri, Raphidocelis subcapitata, Lemna minor, Daphnia magna, Lepidium sativum), and mechanical (one-dimensional compressibility, shear strength) analyses were performed. The low leaching for potentially toxic metals and ions complied with European Union (EU) limit values for non-hazardous waste landfills. No relevant ecotoxicological effects were found. The biotest battery seems suitable for ecotoxicological assessment in the aquatic ecosystem, providing wide information on waste impact on different trophic/functional levels and chemical uptake routes, simultaneously involving short-duration tests and reduced amounts of waste. IBA presented more compressibility than sand, but its mixture with sand (30%:70%) was closer to sand compressibility. IBA (lower stresses) and the mixture (higher stresses) showed slightly higher shear strength than sand. Overall, IBA presented the potential for valorisation as loose aggregates from an environmental and mechanical viewpoint in a circular economy framework.

Assessing the neurotoxicity of the carbamate methomyl in Caenorhabditis elegans with a multi-level approach

The neurotoxicity and developmental effects of a widely applied insecticide (methomyl) was investigated by a multi-level approach (behavior and biometry, biochemical alterations and neurodegeneration) in Caenorhabditis elegans upon a short-term exposure (1 h) and a post-exposure period (48 h). The 1-h exposure to sub-lethal concentrations of methomyl (lower than 0.320 g L^-1; i.e. below the estimated LC₁₀) triggered significant changes on motor behavior and development impairment. The type of movement was significantly altered in methomyl-exposed worms, as well as biometric parameters (worms frequently idle and moving more backwards than controls; small body area, length and wavelength). These effects were followed by an increase of acetylcholine levels. Interestingly, after the 48-h recovery period, movement of previously exposed worms was similar to controls, and a concentration-dependent reversion of biometric endpoints was recorded, pointing out the transient action of the carbamate in line with an apparent absence of cholinergic neurons damage. This study provided new insight on the neurotoxicity of methomyl by showing that effects on movement and development were transient, and apparently did not result in neurodegeneration in cholinergic neurons. Moreover, these findings reinforced the advantages of using C. elegans in a multi-level approach for pesticide effects assessment.

Assessing the impact of climate change on the worldwide distribution of Dalbulus maidis (DeLong) using MaxEnt

BACKGROUND

For the first time, a model was applied at the global scale to investigate the effects of climate change on Dalbulus maidis. D. maidis is the main vector of three plant pathogens of maize crops and has been reported as one of the most important maize pests in Latin America. We modelled the effects of climate change on this pest using three Global Climate Models under two Representative Concentration Pathways (RCPs) using MaxEnt software.

RESULTS

Overall, climate change will lead to a decrease in suitable areas for D. maidis. In South America, climate change will decrease the areas suitable for the pest, especially in Brazil. However, Argentina, Chile, Colombia, Ecuador, Peru and Venezuela will have small areas that are highly suitable for the corn leafhopper. Outside the pest's range, Ethiopia, Kenya, Rwanda, Burundi and South Africa also should be concerned about the risk of corn leafhopper invasions in the future because they are projected to have conditions that are highly suitable for this insect in some areas.

CONCLUSION

This study allows the relevant countries to increase their quarantine measures and guide researchers to develop new Zea mays varieties that are resistant or tolerant to D. maidis. In addition, the maize-stunting pathogens for the areas are highlighted in this modelling. © 2019 Society of Chemical Industry.

Environmental benchmarks based on ecotoxicological assessment with planktonic species might not adequately protect benthic assemblages in lotic systems

Freshwater ecosystems face widespread diffuse and point-source contamination. Species Sensitivity Distributions (SSDs) have been used as a tool to determine chemical concentration benchmarks that represent protective levels for most species in the environment. Here we used a SSD approach to assess on the adequacy of standard planktonic organisms to reflect the response of benthic communities, critically supporting the structure and function of lotic ecosystems. For the purpose, SSDs reflecting non-lethal responses of standard planktonic and selected benthic organisms were built based on EC50 values (collected in the literature or estimated following testing herein) regarding three model contaminants: potassium dichromate (PD), 3,5-dichlorophenol (DCP) and lead chloride (LC). The derived HC5 estimates were discriminatory between chemicals and the uncertainty associated with the estimate was remarkably low. The HC5 estimates with corresponding uncertainty were generally within the same order of magnitude for the three chemicals tested, with better discrimination between chemicals regarding their hazardous potential being achieved for benthic organisms: DCP was clearly less hazardous than PD, but LC tends to be as hazardous as PD and DCP (assuming the confidence interval ranges). Moreover, benthic communities were more sensitive to both DCP and PD, in this later case the HC5 being lower by more than one order of magnitude than that found for planktonic communities; for LC, confidence intervals overlapped, preventing a feasible assumption regarding differential sensitivity of the compared communities. Microphytobenthos was highlighted as the most sensitive group to the three tested chemicals in SSDs covering the benthic compartment, while SSDs with planktonic organisms did not consistently show trends in sensitivity ordering. Overall, our results suggest that protective benchmarks retrieved from SSDs built with the responses of standard planktonic organisms (which are the most commonly used for regulation purposes) do not adequately protect benthic communities.

Effects of glyphosate on the non-target leaf beetle Cerotoma arcuata (Coleoptera: Chrysomelidae) in field and laboratory conditions

This study aimed to assess the glyphosate application effects on the Cerotoma arcuata Oliver (Coleoptera: Chrysomelidae) population in glyphosate-resistant soybean crops. Field studies were conducted with glyphosate and the insecticide endosulfan to observe the effects of these pesticides on C. arcuata, on its damages in the crop and on the populations of natural enemies in glyphosate-resistant soybean crops. Moreover, the lethal and behavioral sublethal response of C. arcuata to glyphosate and endosulfan was conducted in the laboratory. The results of the field and laboratory experiments showed that glyphosate caused moderate toxicity and high irritability in C. arcuata and that endosulfan caused high toxicity and irritability. Therefore, the direct effect of glyphosate on C. arcuata was negative and does not explain the population increases of this pest in glyphosate-resistant soybean. However, the glyphosate also decreased the density of predators. Thus, the negative effect of glyphosate on the predators may be related to population increases of C. arcuata in glyphosate-resistant soybean crops, however, more studies are needed to better evidence this relationship. This study suggests that glyphosate can impact other non-target organisms, such as herbivorous insects and natural enemies and that the use of this herbicide will need to be carefully stewarded to prevent potential disturbances in beneficial insect communities in agricultural systems.

Hemangiomatosis Associated with Osteolysis of the Mandible in a Dog Resembling Gorham-Stout Disease in Humans

A 6-month-old female German Shepherd Dog died as a result of profuse oral bleeding. At postmortem examination, the oral cavity showed visible roots of the right mandibular fourth premolar and first molar teeth and, in addition, they were very mobile and compressible. Radiographs showed a generalized radiolucency in the body of the right mandible, with evidence of resorption of the affected alveolar bone. Histologically, the lesion of the right mandible was characterized by the lysis of bony structures and a non-malignant proliferation of blood-filled vascular spaces lined by a single layer of well-differentiated endothelial cells. The clinical, radiographic, and histologic presentation of this dog is consistent with that associated with Gorham-Stout disease, a rare bone disorder in humans.

The effects of acrylamide polyelectrolytes on aquatic organisms: relating toxicity to chain architecture

Understanding the inherent toxicity of water-soluble synthetic polyelectrolytes is critical for adequate risk management as well as enhancing product design when biological activity is a key performance index (e.g. for application in biofouling bivalves' control). The toxicity of two cationic acrylamide copolymers with different chain branching degree was evaluated. Standard ecotoxicity tests were conducted with microalgae and daphnids. The susceptibility of Corbicula fluminea, as a biofouling bivalve, was also evaluated. The effect of polyelectrolyte on the test media viscosity and the polymer chain size distributions under the experimental conditions were also examined. The susceptibility of the microalgae to both polymers was similar. As the complexity and size of the test organisms increased, differences in toxicity due to different chain architecture were noticeable. The more branched polymer was significantly less toxic to both daphnids and the bivalves, which could be linked to the distinctive features of its bimodal size chain distribution. This architecture resulted in both more compact globular molecules and the formation of aggregates, which reduce the polymer interaction with the biological surfaces. The results of this study promote the incorporation of environmental considerations in polyelectrolyte development and contribute to the design of improved solutions for controlling biofouling bivalves.

[Home parenteral nutrition in Spain 2011 and 2012; a report of the home and ambulatory artificial nutrition group NADYA]

OBJECTIVE

To report the data of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group for the years 2011 and 2012.

METHODOLOGY

We compiled the data from the on-line registry introduced by reviewers of NADYA group responsible for monitoring of NPD introduced by since January 1, 2011 to december 31, 2012. Included fields were: age, sex, diagnosis and reason for HPN, access path, complications, beginning and end dates, complementary oral or enteral nutrition, activity level, autonomy degree, product and fungible material supply, withdrawal reason and intestinal transplant indication.

RESULTS

Year 2010: 184 patients from 29 hospitals , representing a rate of 3.98 patients/million inhabitants/ year 2011, with 186 episodes were recorded NPD . During 2012, 203 patients from 29 hospitals , representing a rate of 4.39 patients/million inhabitants/year 2012 , a total of 211 episodes were recorded NPD .

CONCLUSIONS

We observe an increase in registered patients with respect to previous years.Neoplasia remains as the main pathology since 2003. Although NADYA is consolidated registry and has been indispensable source of information relevant to the understanding of the progress of Home Artificial Nutrition in our country, there is ample room for improvement. Especially that refers to the registration of pediatric patients and the registration of complications.

Recommendations of the GARIN group for managing non-critically ill patients with diabetes or stress hyperglycaemia and artificial nutrition

BACKGROUND & AIMS

By means of this update, the GARIN working group aims to define its position regarding the treatment of patients with diabetes or stress hyperglycaemia and artificial nutrition. In this area there are many aspects of uncertainty, especially in non-critically ill patients.

METHODS

Bibliographical review, and specific questions in advance were discussed and answered at a meeting in the form of conclusions.

RESULTS

We propose a definition of stress hyperglycaemia. The indications and access routes for artificial nutrition are no different in patients with diabetes/stress hyperglycaemia than in non-diabetics. The objective must be to keep pre-prandial blood glucose levels between 100 and 140 mg/dl and post-prandial levels between 140 and 180 mg/dl. Hyperglycemia can be prevented through systematic monitoring of capillary glycaemias and adequately calculate energy-protein needs. We recommend using enteral formulas designed for patients with diabetes (high monounsaturated fat) to facilitate metabolic control. The best drug treatment for treating hyperglycaemia/diabetes in hospitalised patients is insulin and we make recommendations for adapt the theoretical insulin action to the nutrition infusion regimen. We also addressed recommendations for future investigation.

CONCLUSIONS

This recommendations about artificial nutrition in patients with diabetes or stress hyperglycaemia can add value to clinical work.

Establishing a multicentre clinical research network: lessons learned

BACKGROUND

Within many health care disciplines, research networks have emerged to connect researchers who are physically separated, to facilitate sharing of expertise and resources, and to exchange valuable skills. A multicentre research network committed to studying difficult cancer pain problems was launched in 2004 as part of a Canadian initiative to increase palliative and end-of-life care research capacity. Funding was received for 5 years to support network activities.

METHODS

Mid-way through the 5-year granting period, an external review panel provided a formal mid-grant evaluation. Concurrently, an internal evaluation of the network by survey of its members was conducted. Based on feedback from both evaluations and on a review of the literature, we identified several components believed to be relevant to the development of a successful clinical cancer research network.

RESULTS

THESE COMMON ELEMENTS OF SUCCESSFUL CLINICAL CANCER RESEARCH NETWORKS WERE IDENTIFIED: shared vision, formal governance policies and terms of reference, infrastructure support, regular and effective communication, an accountability framework, a succession planning strategy to address membership change over time, multiple strategies to engage network members, regular review of goals and timelines, and a balance between structure and creativity.

CONCLUSIONS

In establishing and conducting a multi-year, multicentre clinical cancer research network, network members were led to reflect on the factors that contributed most to the achievement of network goals. Several specific factors were identified that seemed to be highly relevant in promoting success. These observations are presented to foster further discussion on the successful design and operation of research networks.

Feasibility of administering zoledronic acid in palliative patients being cared for in the community: results of a pilot study

Tumour-induced hypercalcemia (TIH) and pain from bone metastases are common complications of advanced malignancy and have a significant negative impact on quality of life. Many cancer patients in the advanced stages of their palliative illness prefer to avoid hospitalization and to receive their care in the community setting. This small open-label prospective pilot study explored the feasibility of administering zoledronic acid intravenously in the community setting (home and residential hospices). It enrolled a convenience sample of 12 patients with advanced cancer and TIH (n = 7), malignant bone pain (n = 3), or TIH and malignant bone pain (n = 2). The mean duration of infusion was 15 minutes (range: 14-30 minutes). The total nursing time required was 95 minutes, and the mean total cost, including nursing time, travel time, and drug costs was $708.97 per infusion. This cost was compared with costs for clodronate and pamidronate ($402.52 and $406.12 respectively). Calcium fell from a mean of 2.97 mmol/L on day 0 to 2.63 mmol/L on day 4 and to 2.54 mmol/L on day 10. Delirium resolved in 2 of 5 patients with TIH-associated delirium. Intravenous zoledronic acid administered in the community to palliative patients at the end of life is feasible and safe, and the short duration of infusion offers advantages to patients and nursing resources alike. The higher cost of zoledronic acid per infusion may be offset by the advantage of its short infusion time.

Influence of crop management practices on bean foliage arthropods

Crop management practices can affect the population of phytophagous pest species and beneficial arthropods with consequences for integrated pest management. In this study, we determined the effect of no-tillage and crop residue management on the arthropod community associated with the canopy of common beans (Phaseolus vulgaris L.). Abundance and species composition of herbivorous, detritivorous, predaceous and parasitoid arthropods were recorded during the growing seasons of 2003 and 2004 in Coimbra County, Minas Gerais State, Brazil. Arthropod diversity and guild composition were similar among crop management systems, but their abundance was higher under no-tillage relative to conventional cultivation and where residues from the preceding crop were maintained in the field. Thirty-four arthropod species were recorded, and those most representative of the impact of the crop management practices were Hypogastrura springtails, Empoasca kraemeri and Circulifer leafhoppers, and Solenopsis ants. The infestation levels of major insect-pests, especially leafhoppers (Hemiptera: Cicadellidae), was on average seven-fold lower under no-tillage with retention of crop residues relative to the conventional system with removal of residues, whereas the abundance of predatory ants (Hymenoptera: Formicidae) and springtails (Collembola: Hypogastruridae) were, respectively, about seven- and 15-fold higher in that treatment. Importantly, a significant trophic interaction among crop residues, detritivores, predators and herbivores was observed. Plots managed with no-tillage and retention of crop residues had the highest bean yield, while those with conventional cultivation and removal of the crop residues yielded significantly less beans. This research shows that cropping systems that include zero tillage and crop residue retention can reduce infestation by foliar insect-pests and increase abundance of predators and detritivores, thus having direct consequences for insect pest management.

[Competencies in palliative care: what should the physicians be able to do?]

Palliative patients (patients with progressive incurable illnesses) have a number of needs, early and late in their illness trajectories. This article highlights some of the most important competencies required by physicians to address these needs. They cover a broad spectrum of domains and include pain and symptom management, communication, disclosure, prognostication, and psychological, social and spiritual needs. All physicians, generalists and specialists alike, should possess the basic competencies but should also recognize that some patients, especially those not responding to initial strategies, require timely referrals to specialized palliative care teams.

Novel insights in the use of hydrolytic enzymes secreted by fungi with biotechnological potential

Entomopathogenic and mycoparasitic fungi synthesize hydrolytic enzymes such as chitinases, proteinases and beta-glucanases. These enzymes can act synergistically, helping fungi to control insect pests and pathogens that attack productive crops, and offer potential economic benefit to agribusiness. A number of hydrolytic enzymes have also been utilized in industrial applications. This review focuses on biochemical and structural analyses of fungal enzymes, together with current research information on secretion mechanisms.

Short-term effects of Quirlan (chlorfenvinphos) on the behavior and acetylcholinesterase activity of Gambusia holbrooki

Chlorfenvinphos is a widespread organophosphorous (OP) insecticide and it is a reported hazardous chemical for aquatic nontarget organisms. This study intended to evaluate the effects of sublethal concentrations of Quirlan(R) (commercial formulation of chlorfenvinphos) on several behavioral parameters of the mosquitofish, Gambusia holbrooki. The insecticide showed high toxicity to G. holbrooki by significantly impairing all the behavioral responses (location in the test vessel, activity/excitability, swimming, and feeding), exhibiting a time-dependent pattern. Behavioral EC50s, after a 96-h exposure, ranged from 5.2 to 9.0 microg L(-1). As OP pesticides are acutely neurotoxic, acetylcholinesterase (AChE) activity was also selected for use as a biomarker in this study for the establishment of a relationship with the observed behavior abnormalities. A strong inhibition of AChE was observed in fish exposed to chlorfenvinphos (IC50 = 3.55 microg L(-1)). Behavioral impairment was registered in fish with >40% AChE inhibition levels, while mortality was only observable in fish exhibiting AChE inhibition levels >80%. Additionally, significant correlations were found between behavioral impairment and AChE inhibition, suggesting a mechanistic link. These results show the usefulness of integrating biochemical and individual endpoints in a small-sized model species, and confirm a potential hazard of chlorfenvinphos to nontarget aquatic organisms.

Heavy metal availability in soil amended with composted urban solid wastes

A study was performed to evaluate the pH and the availability of Zn, Cu, Mn, Pb, and Ni in soil amended with increasing doses of composted solid wastes, collected in Rio de Janeiro, Rio de Janeiro State and in Coimbra, Minas Gerais State, Brazil. The influence of the time elapsed between compost application to the soil and the sampling of the plant growth substrate (soil + compost) for pH and metal availability analyses was also examined. The availability of heavy metals in the soil, in the compost and in the substrate was evaluated using DTPA solution for metal extraction. The increase of the compost doses added to the soil resulted in the increase of the pH in the substrate. The addition of the compost from the bigger city, Rio de Janeiro, resulted in higher increase in soil pH and available Zn, Cu, Pb, and Ni levels as compared to the addition of the compost from the smaller city, Coimbra. Increasing the time elapsed between the compost application to the soil and the sampling of the mixture resulted in higher available Zn, Cu, Mn, and Pb levels. The addition of the compost from Rio de Janeiro resulted in substrate metal concentrations in the order Zn > Pb > Ni > Cu > Mn and for the Coimbra compost the metal concentrations in the substrate was Zn > Pb > Cu > Ni > Mn. The higher values of pH and available metals obtained for the bigger city were attributed to the greatest metal contamination of its compost.

One Living Donor and Two Donations: Sequential Kidney and Liver Donation With 20-Years Interval

The shortage of cadaveric donor organs remains the critical factor limiting the use of organ transplantation. In this environment of organ shortage, living donor transplantation has emerged as a reasonable therapeutic alternative. Simultaneous kidney-liver transplantation from the same donor has been described. We report a case of right liver lobe transplant from a living donor who had donated his kidney to the same recipient 20 years prior.

[Complications of enteral nutrition at home. Results of a multicentre trial]

AIM

In spite of the increasing number of home enteral nutrition (HEN) patients, only few articles had reported the frequency of complications related to this treatment. Our multicentric study analyzes the HEN complications in relation to access device and time of treatment.

METHOD

92 HEN patients from 8 hospitals were randomly selected. Patients were distributed in relation to the time of treatment and access device (nasogastric tube and percutaneous or surgical gastrostomies). After an educational program, they were filled in an initial questionnaire and repeated it the days 15 and 30. They received a mean of 1650 Kcal of enteral solution. A total of 2760 HEN prospective days were analyzed.

RESULTS

In prospective study 42% of patients had some complication (112 episodes). The most frequent were gastrointestinal (55%) and mechanical (29%); 0.16 complications of patient-year were registered. The most common complications were: extraction (15%), constipation (13%), vomiting (12%) and diarrhoea (10%). The gastrostomy group had more gastrointestinal complications. In retrospective evaluation, percutaneous gastrostomy group had the lowest ratio of complications and nasogastric tube group required more tube replacements (4 vs 2) and had 1.96 episodes/patient (percutaneous group 1.85 and surgical gastrostomy 3.1 episodes/patient).

CONCLUSION

HEN is safe with low incidence of complications. An adequate educational program is very important and we expect, in the future, to establish an proper National Home Care System.

Assessment of water systems for contaminants from domestic and industrial sewages

The State of Minas Gerais represents one of Brazil's most outstanding mining resources. The contamination of river water from kaolin processing activities may be harmful to people in the way of slow but chronic poisoning. On the other hand, the discharge of untreated or inadequately treated domestic sewage into aquatic environments can also cause deleterious effects to the health. However, no reliable figures are available for pollutant occurrences in river water. This draws attention to the very precarious situation that exists with respect to pollution by organic and inorganic toxic wastes, especially with respect to humans and fauna in all its expressions. Thus, with the purpose of establishing a preliminary report to trace out industrialisation outcomes, samples of river water, vegetation and fish were collected and analysed to detect pollutant inputs. The concentration of metals was determined in suspended particle, vegetation and fish, while those of nitrite, nitrate, phosphate and chloride were determined in river water samples. The concentration of dissolved oxygen (DO) was measured in river water at the time of collection. Chemical oxygen demand (COD) and biochemical oxygen demand (BOD) were also determined. Metal inputs in the samples analysed appeared to be related to effluent discharges into the rivers. The suspended particles showed high concentrations (in mg kg(-1)) of zinc (62 600) and aluminium (559 000), while vegetation samples collected near rivers were heavily contaminated with iron (7680). The fishes examined were contaminated with chromium (1.5 mg kg(-1)). In general, the concentrations of nitrite, nitrate, chloride, phosphate and BOD in river water were lower than the maximum values established by the Brazilian Environmental Standards.

[Subclinical thyroid disease in institutionalised healthy geriatric population]

BACKGROUND

Our aim was to determine the prevalence of subclinical thyroid disease in a healthy institutionalised geriatric population.

PATIENTS AND METHOD

We determined TSH, free T4 and antithyroid antibodies from 242 healthy elderly subjects living in Andalusian public nursing homes.

RESULTS

Subclinical hypothyroidism was detected in 3.71% of cases; clinical hypothyroidism in 1.65%; subclinical hyperthyroidism in 0.82%,and autoimmune disease in 10.33%.

CONCLUSIONS

There is a high rate of clinically undetected thyroid dysfunction among the healthy institutionalised geriatric population. Therefore, a hormonal screening may be justified in this population.

The impact of delirium on the circadian distribution of breakthrough analgesia in advanced cancer patients

Most cancer patients will experience pain requiring opioid therapy during their illness. Standard opioid therapy includes fixed scheduled doses and so-called "rescue" doses for breakthrough pain. Circadian rhythms seem to influence the expression of pain and the responsiveness to analgesic medication. Delirium is a common complication in advanced cancer patients and it also may modify the expression of pain and the use of analgesic medication. We reviewed the circadian distribution of breakthrough analgesia (BTA) doses in 104 advanced cancer patients who were part of a prospective study of the occurrence of delirium. We found that the circadian distribution of BTA is significantly different from a random distribution in the case of patients with and without delirium. Patients without delirium tended to use more BTA (P < 0.001) in the morning, whereas patients with delirium tended to use more BTA in the evening and at night (P = 0.02). We conclude that delirium is associated with changes in the circadian distribution of BTA, which is possibly related to reversal of the normal circadian rhythm.

Effects of minor constituents (non-glyceride compounds) of virgin olive oil on plasma lipid concentrations in male Wistar rats

We aimed to assess the effects of minor constituents (MC) from virgin olive oil upon the plasma lipid profile of experimental animals. Therefore, 32 Wistar rats were fed for 6 weeks with one of four different diets with a similar fatty acid composition but different MC: high-oleic sunflower oil (HOSO), virgin olive oil (VOO), 400%-MC enriched olive oil (EOO) and MC poor (impoverished) olive oil (IOO). At the end of the week 6 of dietary treatment, blood samples were obtained for analysis of lipid composition. A statistically significant influence was observed upon both total HDL (1.593+/-0.4, 1.204+/-0.212, 0.991+/-0.244 and 0.827+/-0.279 mmol/L for EOO, HOSO, VOO and IOO, respectively, Kruskal-Wallis test, P<0.05) and HDL(2)cholesterol levels (1.16+/-0.26, 0.576+/-0.191, 0.585+/-0.216 and 0.583+/-0.207 mmol/L for EOO, HOSO, VOO and IOO, respectively, Kruskal-Wallis test, P<0.05). No statistically significant effect was observed upon LDL-cholesterol or triglycerides. Thus, MC supplementation has beneficial effects on HDL concentrations in Wistar rats.

[Oral nutritional supplements. Are they useful?]

Oral nutritional supplements are products included in enteral nutrition, preferably used in hospital settings, although their use in the community is gradually increasing and in the United Kingdom has doubled in the last seven years, with prescriptions covering a wide range of the population from children to the elderly, and different pathologies affecting their nutritional status. There is, however, no consensus on the usefulness of oral nutritional supplements among these patients, so we do not have any recommendations for use. In this paper we have reviewed the various studies available in the literature in order to clarify the usefulness of these supplements in different contexts or pathologies.

Canine distemper in a genet (Gennetta gennetta), associated with endogenous lipid pneumonia

This report describes the histological and immunohistochemical findings in an adult male genet (Gennetta gennetta) which died a few hours after being found lying in a forest in Lugo (north-western Spain). Subpleural, yellowish, firm foci were found in the lung. Histopathological examination confirmed a diagnosis of endogenous lipid pneumonia. Microscopical lesions that gave rise to a suspicion of canine distemper virus (CDV) infection included lymphoid depletion, non-suppurative encephalitis and demyelination in the central nervous system, and the presence of inclusion bodies in renal tubules. Immunohistochemical examination was performed with the streptavidin-biotin-complex method and a monoclonal antibody against the nucleocapsid protein (NP) of CDV. Antigen was detected in epithelial, nervous and lymphoid cells in several organs. This would appear to be the first report of distemper-like infection in a genet.

Internet usage among women with breast cancer: an exploratory study

An increasing number of breast cancer patients are accessing the Internet for medical information. A survey was administered to breast cancer patients and their families attending follow-up outpatient clinics in a comprehensive cancer care center to explore their frequency of Internet use, their motivation for online activity, the type of information they sought, and the perceived impact of the information they found on the Internet on their medical care. The survey was conducted over a 4-month period. A total of 107 surveys were returned. Seventy-nine of these (74%) were from patients while 28 (26%) were from family members and friends. Thirty-four of the patient responses (43%) indicated that the patient had used the Internet to look for cancer-related information. Patients who had used the Internet to access cancer-related information were significantly younger (P = 0.007), better educated (P = 0.027), and less satisfied with the amount of treatment-related information given by caregivers than those patients who had not used the Internet to access cancer-related information (P = 0.032). The majority of patient Internet users desired more information on their cancer and its treatment (91%), looked up information that was presented to them by their clinicians (66%), researched other treatment options (63%), and obtained more information on "alternative treatments" (63%). Patient Internet users generally found the cancer-related information on the Internet to be useful, and the majority discussed Internet-derived information with their health care providers and perceived that clinicians listened to such information. However, 53% were undecided about the trustworthiness of the medical information obtained via the Internet. Internet nonusers commonly lacked Internet access (53%) or were unfamiliar with the Internet (33%), but few (13%) distrusted Internet-derived information. This exploratory study underscores the need for more research in this area, specifically with the aims of identifying and verifying factors that lead patients to use the Internet and the impact of their online activities on their medical care.

Clinical utility, factor analysis, and further validation of the memorial delirium assessment scale in patients with advanced cancer: Assessing delirium in advanced cancer

BACKGROUND

Delirium is a common neuropsychiatric complication in patients with advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a recently developed 10-item severity rating instrument. The purpose of the current prospective study was to further assess the clinical utility, factor structure, and validity of the MDAS in a relatively homogeneous population of patients with advanced cancer.

METHODS

Study entry of 104 patients occurred on their consecutive admission to a tertiary-level, acute palliative care unit in a university-affiliated teaching hospital. Patients underwent regular cognitive screening using the Mini-Mental State Examination, and serial monitoring of delirium using standardized semistructured interviews and MDAS ratings, up to the study endpoints of either patient discharge or death.

RESULTS

Seventy-one patients met Diagnostic and Statistical Manual (of Mental Disorders)-IV criteria for a first episode of delirium. In 15 of 71 (21%) patients with a first episode of delirium, the first MDAS ratings were prorated because of dyspnea, fatigue, or profound delirium. In the remaining 56 patients (79%), the first MDAS ratings were rated fully and therefore evaluable. Correlations among the scale items ranged from moderate to low (correlation coefficient [r] = 0.68-0.02). Analysis of the pattern of factor loadings identified two primary correlated factors: global cognitive (Factor I) and neurobehavioral (Factor II) (r = 0.33). Cronbach alpha coefficients for Factors I and II were 0.8 and 0.66, respectively, indicating a relatively high level of correlation for items within each. The Cronbach alpha coefficient for all 10 items was 0.78, suggesting a general underlying factor. In a larger sample of complete MDAS ratings (n = 330) a cutoff total MDAS score of 7 of 30 yielded the highest sensitivity (98%) and specificity (96%) for delirium diagnosis. The MDAS was correlated moderately with the Mini-Mental State Examination (r = 0.55).

CONCLUSIONS

The authors concluded that the MDAS structure is representative of the many features of delirium, broadly grouped as global cognitive and neurobehavioral dimensions. Prorating item scores is necessary in approximately 20% of advanced cancer patients with delirium. This poses potential limitations on the applicability of the MDAS in research. Conversely, the ability to prorate item scores confers a clinical advantage to the instrument when assessing delirium in a patient population with advanced cancer.

Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study

CONTEXT

Delirium impedes communication and contributes to symptom distress in patients with advanced cancer. There are few prospective data on the reversal of delirium in this population.

OBJECTIVES

To evaluate the occurrence, precipitating factors, and reversibility of delirium in patients with advanced cancer.

DESIGN

Prospective serial assessment in a consecutive cohort of 113 patients with advanced cancer. Precipitating factors were examined using standardized criteria; 104 patients met eligibility criteria.

SETTING

Acute palliative care unit in a university-affiliated teaching hospital.

MAIN OUTCOME MEASURES

Delirium occurrence and reversal rates, duration, and patient survival. Strengths of association of various precipitating factors with reversal were expressed as hazard ratios (HRs) in univariate and multivariate analyses.

RESULTS

On admission, delirium was diagnosed in 44 patients (42%), and of the remaining 60, delirium developed in 27 (45%). Reversal of delirium occurred in 46 (49%) of 94 episodes in 71 patients. Terminal delirium occurred in 46 (88%) of the 52 deaths. In univariate analysis, psychoactive medications, predominantly opioids (HR, 8.85; 95% confidence interval [CI], 2.13-36.74), and dehydration (HR, 2.35; 95% CI, 1.20-4.62) were associated with reversibility. Hypoxic encephalopathy (HR, 0.39; 95% CI, 0.19-0.80) and metabolic factors (HR, 0.44; 95% CI, 0.21-0.91) were associated with nonreversibility. In mulitivariate analysis, psychoactive medications (HR, 6.65; 95% CI, 1.49-29.62), hypoxic encephalopathy (HR, 0.32; 95% CI, 0.15-0.70), and nonrespiratory infection (HR, 0.23; 95% CI, 0.08-0.64) had independent associations. Patients with delirium had poorer survival rates than controls (P<.001).

CONCLUSIONS

Delirium is a frequent, multifactorial complication in advanced cancer. Despite its terminal presentation in most patients, delirium is reversible in approximately 50% of episodes. Delirium precipitated by opioids and other psychoactive medications and dehydration is frequently reversible with change of opioid or dose reduction, discontinuation of unnecessary psychoactive medication, or hydration, respectively.

[Artificial nutrition in the home. Annual information 1996.Group NADYA-SENPE]

Using a simplified questionnaire from the NADYA group, data referring to age, sex, diagnosis, access route, duration, form of administration, complications, and quality of life have been gathered from 1,400 patients (57% male, 43% female) who receive home enteral nutrition, and from 38 patients (20% male and 18% female) who receive home parenteral nutrition. All of these patients come from the 1996 national registry. The most common indication for home enteral nutrition are neoplasias (39%) followed by neurological alterations (33%). The most common access route is oral (48%), followed by a nasogastric tube in 34%, PEG in 10% and surgical ostomies in 7%. The average treatment duration is 6 months. There is an index of 0.74 complications/patient-year (gastrointestinal 0.28 and mechanical alterations 0.19). At the end of the year 58% of the patients continued to use at home enteral nutrition, with a death rate of 17%. The majority of the treated patients presented a severe social disability (28%) or was bed-ridden (22%). The most common indications for home parenteral nutrition are: neoplasia (42%), Crohn_s disease (10%), and mesenteric ischemia (10%). AIDS (8%), radical enteritis (5%), and motility disorders (5%) are less common. In 42% of the cases tunneled catheters are used, and port-a-cath are used in 53%. The average treatment duration is 6.9 months. 1.06 hospitalizations/patient-year have been registered in relation to the nutritional treatment (mainly catheter sepsis). A mortality of 29% is registered, and there is recovery of the oral route in 7.9% of the cases. 50% of the patients present a severe social disability.

Linkage analysis in Rett syndrome families suggests that there may be a critical region at Xq28

A whole X chromosome study of families in which Rett syndrome had been diagnosed in more than one member indicated that the region between Xq27 and Xqter was the most likely region to harbour a gene which may be involved in the aetiology of the disease. Further, more detailed studies of Xq28 detected weak linkage and a higher than expected sharing of maternally inherited alleles. It is suggested that there may be more than one gene involved in the aetiology of this syndrome, particularly as the very rare families in which more than one girl is affected often show variable clinical symptoms.

Efficacy of the Komesaroff anaesthetic machine for delivering isoflurane to dogs

The Komesaroff machine is a low-flow, closed-circle circuit with a low resistance vaporiser, of the Goldman type, in circuit. This trial assessed the mechanical consistency of the delivery of isoflurane by the vaporisers, and used six dogs to compare the in vivo cardiorespiratory effects of the anaesthetic agent delivered by the Komesaroff machine with the effects of a circle system with high flows in the semi-closed mode. The delivery of isoflurane was constant for each vaporiser setting and no potentially dangerous concentrations of isoflurane were observed. The mean (sem) percentages of isoflurane were 0.18 (0.019) at setting I, 1.46 (0.055) at setting II, 3.12 (0.066) at setting III and 3.01 (0.047) at setting IV. There were no significant differences between the two types of circuit in vivo, and the measured haemodynamic variables were satisfactory throughout the experiments.

Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases

We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.

[Artificial nutrition in the home. 1995 yearly report. NADYA-SENPE Group (Natiional Registry of Patient-Spanish Society for Parnteral and Enterlal Nutrition]

By means of a simplified questionnaire, the NADYA group has gathered and analyzed data with regard to the age, sex, diagnosis, access route, duration, form of administration, complications, and quality of life, in 812 patients (62% male; 37% female) with At Home Enteral Nutrition (AHEN), and 19 patients (42% male; 57% female) with At Home Parenteral Nutrition (AHPN) corresponding the National Registry of 1995. The most frequent indication of AHEN was a neoplasm (41%), followed by neurological alterations (33%). The most common access route is the NGT (37%) followed by oral administration in 37%, PEG in 13% and surgical ostomics in 8%. The mean treatment time is 8 months. The index of complications/patient-year is 0.50 (gasterointestinal 0.17, and mechanical alterations 0.9). At the end of the study, 63% of the patients continued to receive AHEN, showing a mortality rate of 70%. The majority of the patients undergoing treatment presented a sever social disability (20%) or were bed ridden (18%). The most common indications for the AHPN are: radical enteritis (26%), Crohn's disease (21%), and mesenteric ischemia (16%). AIDS, motility alterations, and neoplasic diseases are scantly represented (10%). Tunneled catheters are used in 58% of the cases, and Port-a-Cath in 31%). The mean duration for the treatment was 7.9 months. An index of 0.47 hospitalization/patient-year was seen in relation to the nutritional treatment (mainly due to catheter septicemia). A mortality of 16% is noted, and 21% show a recovery of the oral route. 42% of the patients did not present an assessable social disability.

Squamous cell carcinoma in an immature common stork (Ciconia ciconia)

An immature common stork (Ciconia ciconia) was referred from the Wildlife Recovering Center to the Department of Surgery for evaluation. Physical examination revealed a partially ulcerated, necrotic mass on the left surface of the upper beak. The mass was surgically removed and classified histologically as a squamous cell carcinoma. Postsurgically, the bird recovered uneventfully and proceeded to mature normally. During this growth period, no tumor recurrence or metastasis was detected, and no local bone alteration to the beak was found. The stork was ringed and released back into its natural environment.

[Percutaneous endoscopic gastrostomy and gastrojejunostomy. Experience and its role in domiciliary enteral nutrition]

Percutaneous Endoscopic Gastrostomy (PEG) and its variation Percutaneous Endoscopic Gastrojejunostomy (PEGJ), has become the method of choice to achieve an enteral access route in patients who require long term enteral nutrition, especially in the area of the At Home Enteral Nutrition (AHEN). We present our experience on the first PEG's and PEGJ's carried out in our hospital.

MATERIAL

We studied 48 patients (14 women and 34 men) in whom a PEG/Percutaneous Endoscopic Gastrojejunostomy (PEGJ) was indicated, as they required enteral nutrition for prolonged periods of time (> 4 weeks) and/or they presented obstructive dysphagia, neuromotor dysphagia, or incorrigible vomiting in the two cases in whom PEGJ was carried out. 34 patients underwent the Ponsky-Gauderer technique, 6 patients underwent the Sacks-Vine technique, and 2 patients underwent a PEGJ. 24 hours after the PEGJ enteral nutrition (EN) was begun in a progressive manner. During the hospitalization period there was a daily follow up of the patient. In those cases in which At Home Enteral Nutrition was programmed, the patients/families were trained in the techniques and the care of the PEG and the EN, and the control was carried out through the Nutrition out patient department.

RESULTS

PEG was successfully carried out in 42 patients (88%). 35 patients had previously been given EN through a naso-gastric tube (NGT), while in 7 cases the PEG was the first enteral access route. The average duration of the PEG was 212 days, and 27 patients (64%) needed the PEG for more than 3 months. The mean caloric supply was 1921 +/- 200 kcal/day. The mode of administration was by means of an intermittent infusion by gravity in 31 cases, and by continuous infusion using a volumetric pump in 11 patients. Two patients with pregnancy induced hyperemesis underwent a PEGJ in the 3rd and the 4th month of pregnancy, with the pregnancy being successfully brought to term and ending in vaginal deliveries. Carrying out a PEG permitted release from hospital and the programming of At Home Enteral Nutrition in 30 patients. With respect to the evolution of the patients, 22 patients have died during the course of the study. 18 patients remain in follow up in an ambulatory Enteral Nutrition program, and in the two patients with pregnancy induced hyperemesis, the PEGJ was removed after the pregnancy was successfully ended. There were no complications of any kind in 21 patients. The most common complication was the infection of the gastrostomy, which occurred in 13 patients. There was an accidental removal of the gastrostomy tube in 3 patients. In 3 cases there was an eversion of the gastric mucosa through the ostomy within the first 24-hours, and 20 days after the PEG respectively. In 2 cases there was an incarceration of the gastrostomy tube in the abdominal wall. Only two patients showed an important reflux of the gastric contents. There were no deaths as a result of PEG complications.

CONCLUSION

From our experience we can conclude the advantages of PEG as a long term nutritional support, showing a low incidence of complications, and the endoscopic technique has a zero mortality.

Hepatitis G virus (GBV-C) infection among Brazilian patients with chronic liver disease and blood donors

BACKGROUND

The recently discovered hepatitis G virus (HGV) belongs, as hepatitis C virus (HCV), to the Flaviviridae family. HGV has been isolated from the serum of patients with non A-E hepatitis. However, the association of HGV with hepatitis is uncertain.

OBJECTIVE

To determine the HGV prevalence in blood donors and in patients with liver disease and to evaluate a possible correlation between HGV infection and liver disease.

STUDY DESIGN

Sera from a total of 113 consecutive patients with chronic liver disease were submitted to a series of liver enzymes and function tests and analyzed for the presence of HBsAg, anti-HBs, anti-HBc, anti-HCV, HCV RNA and HGV RNA. Prevalence of HGV RNA was determined in a group of 87 blood donors.

RESULTS

Nine (10%) sera from blood donors and 15 (13%) sera from patients with chronic liver disease were HGV RNA positive. Some 28 (25%) patients were HCV RNA positive, with genotypes 1a, 1b and 3 present in 10, 12 and 5 patients, respectively. A total of 20 (18%) patients were HBsAg carriers. Five (4%) patients were double infected (one with HBV + HCV, one with HBV + HGV and three with HCV + HGV).

CONCLUSION

The proportion (10%) of HGV-infected blood donors was very high when compared with other countries. The results did not allow to establish HGV as an etiologic agent for chronic liver disease. The parenteral route was the presumed means of HGV transmission for only one-third of the patients.

Chromium contamination in sediment, vegetation and fish caused by tanneries in the state of Minas Gerais, Brazil

In order to evaluate the chromium contamination from tannery discharges into rivers in the State of Minas Gerais, Brazil, samples of fluvial sediment, vegetation and fish were collected and submitted to chemical analysis. The chromium content in the samples was measured by atomic absorption spectrophotometry. Metal inputs were related to effluent discharges into the rivers. High concentrations of chromium were found in samples when compared with controls. Sediment investigations indicated strong enrichment and high geoaccumulation indices, while chromium concentrations in the analyzed vegetation were higher than those normally found in these materials. Chromium levels in fish exceeded 35 times the Brazilian recommendation value for human intake.

Esophageal obstruction by solidification of the enteral feed: a complication to be prevented

We report three cases of esophageal obstruction due to solidification of enteral feed refluxed from the stomach in patients being fed through a nasogastric tube. All three patients were administered sucralfate continuously by tube. The few previous descriptions of this rare complication have also implicated sucralfate with its pathogenesis. Given its clinical importance and the growing use of long-term enteral nutrition, this adverse event needs to be considered.

[Evaluation of energy metabolism in burn patients: indirect calorimetry predictive equations]

INTRODUCTION

Knowing the most reliable method for measuring the metabolic energy use (MEU), is of great importance in patients with severe burns. For the calculation of the energetic requirements of large burn patients, several predictive equations (PE's) are used, based on weight, size, age, body surface area (BSA), and burned body surface (BBS). Previous studies note the tendency for over-or underestimating the MEU, depending on whether one or another PE is used, which is why it is considered necessary to calculate the energy requirements in the most exact manner possible, which can be done by means of indirect calorimetry (IC).

MATERIAL AND METHODS

18 patients (14 men and 4 women) who were admitted to the Burn Unit between 1994 and 1995, were included in the study, with the following inclusion criteria; age > 18 years and < 65 years, and who presented deep burns on are than 15% of the body surface. The MEU of the patients was evaluated by means of IC, using a Deltatrac il unit. The MEU calculated by means of IC was compared with that calculated by means of the four most commonly used PE's in literature: Long Formula: MEU = Basal energy use (BEU) x activity factor x aggression factor which is variable according to the BBS; Curreri Formula: MEU = (Weight x 25) + (total BBS x 40); MEU = 2000 x BSA. As statistical methods, one looked for the existence of correlation, by means of the Pearson method, and the "r" were compared by means of the Fischer conversion. The regression coefficient was found among the values obtained through the PE's and those measured by IC, as well as among those of IC and the percentage of deep burn and the total burned body surface.

RESULTS

All the formulate included overestimated the MEU measured between 30.6% and 43.8% with the 2 x MEU formula being the one which did so least (30.6%). In any of them, there is an important variation of the percentage of overestimation with respect to the average MEU in this group. All are correlated in an important way with the MEU. The reliability of these PE's is variable, as is shown by the slopes of the regression lines, with the most reliable PE being that of 2000 x BSA, and that of 2 x MEU, by Harris-Benedict. There is also correlation between the average MEU by IC and the deeply burned body surface.

CONCLUSION

This study proves the usefulness of the IC for knowing the EME in burn patients, to prevent their hypernutrition, as well as the relative value of the formulae usually used clinically to estimate this parameter.

Prevention of nonspecific reactions on reversed passive latex agglutination assay (RPLA) for detecting low amounts of staphylococcal enterotoxins

The SET-RPLA, from Denka Seiken Co. Ltd., Tokio, a commercial reversed passive latex agglutination test kit, has been recommended to establish the enterotoxicity capacity of some staphylococcal strains, implicated in food poisoning outbreaks that produce low levels of enterotoxins (SE). Despite the RPLA specificity, the occurrence of nonspecific reactions when testing low-SE-producing is common. In order to control these nonspecific reactions the addition of purified normal rabbit IgG purified was applied on approximately 350 staphylococcal isolates from human milk and anatomic sites of healthy dental student carriers. The results indicated that addition of 5% (v/v) of purified normal rabbit IgG (0.74 mg/mL) to the culture supernatant fluid is a simple and reliable tool for the controlling of nonspecific reactions in the RPLA assay.

[Decrease of the incidence of sepsis syndrome after early enteral nutrition of patients with severe burns]

The objective of this study was to evaluate the effect of early enteral nutrition on the incidence of the septic syndrome as well as its tolerance, in patients with severe burns. We retrospectively studied 64 patients older than 15 years of age, with a greater than 20% burned body surface area. They were divided into 2 groups as a function of the time elapsed between the beginning of Enteral Nutrition and the time of the burning: 23 patients were given Enteral Nutrition within 24 hours after the burn, and in 41 patients the enteral nutrition was started later than 24 hours after sustaining the thermal injury. Both groups were similar with respect to age, sex, percentage of 2nd and 3rd degree burns, incidence of inhalation, and deaths. All patients received the Enteral Nutrition through a nasogastric tube, with administration of a polymeric, hyperprotein and hypocaloric formula through a continuous infusion pump. In our study we saw a reduction of the incidence of the septic syndrome in the patients who received early enteral Nutrition (26%; 6 patients of a total of 23), with respect to those who did non receive early Enteral Nutrition (54%; 22 patients of a total of 41), with a statistical significance of p > 0.05. There were no differences between both groups with respect to the digestive tolerance to Enteral Nutrition. From our study we can deduce that early Enteral Nutrition reduces the incidence of septic complications, without this increasing the digestive intolerance to the same.

[Long-acting and repeatable dose bromocriptine in the prolonged treatment of prolactinoma]

BACKGROUND

The presentations of intravenous or depot bromocriptine (bromocriptine LA or long acting, Pariodel LA and bromocriptine LAR or long acting repeatable, Pariodel LAR) have improved the efficacy and the tolerance of oral bromocriptine. In contrast to bromocriptine LA, bromocriptine LAR may be repeatedly administered intramuscularly.

METHODS

Five patients with macroprolactinoma and 4 with microprolactinoma were included in the study. A 50 mg bottle of bromocriptine LAR was administered intramuscularly every month, over a minimum period of 6 months. PRL was determined prior to the study, 1, 3, 7, 14, and 28 days following the initial dose of bromocriptine and thereafter with monthly periodicity.

RESULTS

The PRL values decreased in those patients with macroprolactinomas following the administration of bromocriptine LAR; in 2 patients the monthly doses of bromocriptine LAR was increased to 100 mg since the month after the initial dose PRL remained greater than 200 ng/ml with serum RPL normalizing in most of the patients at 6 months of treatment. In two of the three patients who presented visual changes a clear improvement was observed and in all the cases a reduction in the size of the macroprolactinoma was found upon CAT control at 6 months. The PRL values also decreased in the patients with microprolactinomas following administration of bromocriptine LAR, although the response was not as homogeneous as in the patients with macroprolactinomas due to that at 6 months 2 patients continued to have slightly elevated serum PRL levels. The microadenoma persisted in the control CAT at 6 months except in one case. Local and general tolerance to bromocriptine LAR was very good.

CONCLUSIONS

This study indicates good tolerance to bromocriptine LAR, being a therapeutic option in the treatment of macroprolactinomas.

[Neuronal ceroid-lipofuscinosis. Report of 4 cases with study by rectal histochemistry, conjunctiva electron microscopy and necropsy]

The authors present the neuropathological and clinical findings of four cases of ceroid lipofuscinosis or Batten's disease. In two cases the autopsy findings showed brain atrophy and nerve cells packed with cytoplasmic granules compatible with lipofuscin. One case was diagnosed by histochemical techniques in frozen sections of rectal biopsy which showed myoenteric ganglion cells with cytoplasmic acid phosphatase positive material as well as numerous macrophages filled with lipofuscin in the mucosae. The fourth case diagnosed by electron microscopy of conjunctival biopsy which showed cytoplasmic inclusions of membranous, curvilinear and fingerprint types.

[Insulin-like growth factor I as a marker of nutritional status in patients on enteral nutrition]

In order to appraise type 1 insulin growth factor (IGF-1) as nutritional state marker in comparison with other known markers, seric IGF-1 (RIA), albumin, prealbumin, transferrin and retinol-bound protein were determined weekly in 15 patients with oropharyngeal neoplasm and 7 in the burns unit, all being administered enteral nutrition. At the beginning of the study, IGF-1 seric levels were significantly lower in the burns group compared with the neoplasm group (82.28 +/- 23.36 vs 137.58 +/- 66.2 ng/ml, p < 0.01). IGF-1 values in the first group were initially significantly lower in comparison with those for the same group at the end of the study (82.28-23.36 vs 177.11 +/- 53.87 ng/ml, p < 0.01 for paired data). No significant change was demonstrated in IGF-1 seric levels in the neoplasm group. IGF-1 seric levels showed a significant multiple correlation with albumin, prealbumin, transferrin and retinol-bound protein in both the group with burns (r = 0.696, p < 0.001) and that with neoplasms (r = 0.615, p < 0.001). The nitrogen balance revealed a univariant and significant linear correlation with IGF-1 (r = 0.373, p < 0.05) and with prealbumin (r = 0.377, p < 0.05). According to the data obtained, seric IGF-1 has a significant correlation with other well-known nutritional markers. In the burns group, the hypercatabolism was accompanied by a significant increase in seric IGF-1 levels.