Maternal health among Venezuelan women migrants at the border of Brazil

BACKGROUND

Guaranteeing the sexual and reproductive health and rights (SRHR) of populations living in fragile and humanitarian settings is essential and constitutes a basic human right. Compounded by the inherent vulnerabilities of women in crises, substantial complications are directly associated with increased risks of poor SRHR outcomes for displaced populations. The migration of Venezuelans, displaced due to current economic circumstances, is one of the largest in Latin America's history. This study aims to provide an overview of the sexual and reproductive health (SRH) issues affecting migrant Venezuelan women in the state of Roraima, Brazil.

METHODS

Face-to-face interviews were conducted from 24 to 30 November 2019. Data collection covered various issues involving access to and use of SRH services by 405 migrant Venezuelan women aged 18-49 years. The Minimum Initial Service Package readiness assessment tools, available from the Inter-Agency Working Group on Reproductive Health in Crises, were used in the data collection.

RESULTS

Most commonly, the women reported unmet family planning needs. Of these, a significant proportion reported being unable to obtain contraceptive methods, particularly long-acting reversible contraceptives, either due to the woman's inability to access them or their unavailability at healthcare centres. Although a significant proportion of women were largely satisfied with the attention received at the maternity hospital, both before and during childbirth, 24.0% of pregnant or postpartum women failed to receive any prenatal or postnatal care.

CONCLUSION

Meeting the essential SRHR needs of migrant Venezuelan women in Roraima, Brazil is a challenge that has yet to be fully addressed. Given the size of this migrant population, the Brazilian healthcare system has failed to adapt sufficiently to meet their needs; however, problems with healthcare provision are similar for migrants and Brazilian citizens. Efforts need to be encouraged not only in governmental health sectors, but also with academic, non-governmental and international organisations, including a coordinated approach to ensure a comprehensive SRHR response. Given the current high risks associated with the SARS-CoV-2 pandemic, meeting the SRHR needs of migrant populations has become more critical than ever.

DNA methylation reprogramming, TE derepression, and postzygotic isolation of nascent animal species

The genomic shock hypothesis stipulates that the stress associated with divergent genome admixture can cause transposable element (TE) derepression, which could act as a postzygotic isolation mechanism. TEs affect gene structure, expression patterns, and chromosome organization and may have deleterious consequences when released. For these reasons, they are silenced by heterochromatin formation, which includes DNA methylation. Here, we show that a significant proportion of TEs are differentially methylated between the "dwarf" (limnetic) and the "normal" (benthic) whitefish, two nascent species that diverged some 15,000 generations ago within the Coregonus clupeaformis species complex. Moreover, TEs are overrepresented among loci that were demethylated in hybrids, indicative of their transcriptional derepression. These results are consistent with earlier studies in this system that revealed TE transcriptional derepression causes abnormal embryonic development and death of hybrids. Hence, this supports a role of DNA methylation reprogramming and TE derepression in postzygotic isolation of nascent animal species.

The role of ecotype-environment interactions in intraspecific trophic niche partitioning subsequent to stocking

Worldwide, stocking of fish represents a valuable tool for conservation and maintenance of species exploited by recreational fishing. Releases of hatchery-reared fish are more and more recognized to have numerous demographic, ecological, and genetic impacts on wild populations. However, consequences on intraspecific trophic relationships have rarely been investigated. In this study, we assessed the impacts of supplementation stocking and resulting introgressive hybridization on the trophic niches occupied by stocked, local, and hybrid lake trout (Salvelinus namaycush) within populations of piscivorous and planktivorous ecotypes stocked from a wild piscivorous source population. We compared trophic niches using stable isotope analysis (δ¹³ C and δ¹⁵ N) and trophic position among the three genetic origins. Putative genetic effects were tested with phenotype-genotype association of "life history" ecological traits (body size, growth rate, condition index, and trophic niche) and genotypes (RADseq SNP markers) using redundant discriminant analysis (RDA). Results showed that sympatry resulting from the stocking of contrasting ecotypes is a risk factor for niche partitioning. Planktivorous populations are more susceptible to niche partitioning, by competitive exclusion of the local fish from a littoral niche to an alternative pelagic/profundal niche. Observed niche partitioning is probably a manifestation of competitive interactions between ecotypes. Our results emphasize that ecotypic variation should be considered for more efficient management and conservation practices and in order to mitigate negative impact of supplementation stocking.

Shape plasticity in response to water velocity in the freshwater blenny Salaria fluviatilis

A non-random association between an environmental factor and a given trait could be explained by directional selection (genetic determinism) and by phenotypic plasticity (environmental determinism). A previous study showed a significant relationship between morphology and water velocity in Salaria fluviatilis that conformed to functional expectations. The objective of this study was to test whether this relationship could be explained by phenotypic plasticity. Salaria fluviatilis from a Corsican stream were placed in four experimental channels with different water velocities (0, 10, 20 and 30 cm s(-1)) to test whether there was a morphological response associated with this environmental factor. After 28 days, fish shape changed in response to water velocity without any significant growth. Fish in higher water velocities exhibited a more slender body shape and longer anal and caudal fins. These results indicate a high degree of morphological plasticity in riverine populations of S. fluviatilis and suggest that the previous relationship between morphology and water velocity observed in the field may largely be due to an environmental determinism.

Percutaneous neuromodulation of the posterior tibial nerve for the treatment of faecal incontinence - mid-term results: is retreatment required?

AIM

Posterior tibial nerve stimulation (PTNS) has emerged in recent years as a therapy for faecal incontinence. Its long-term effectiveness is yet to be established, along with what the form of retreatment should be in the event of loss of effectiveness. The present study aimed to establish the mid-term results to identify the proportion of patients who may need further treatment, and if so when.

METHOD

A prospective study including 30 patients was conducted at an academic hospital. The patients underwent 12 weekly outpatient treatment sessions, each lasting 30 min (first PTNS phase). Neuromodulation was discontinued in those patients who did not have a 40% decrease in their pretreatment Wexner score. Patients having a better than 40% response were offered another 12-week course of complete treatment (second PTNS phase), following which they received no further PTNS treatment (phase without PTNS) but were assessed at 6 months and 2 years.

RESULTS

All patients finished the first phase and 22/30 patients continued to the second phase. During this phase 11 patients showed an improved Wexner score (baseline/first phase/second phase: 14.3 ± 4.2 vs 9.9 ± 5.4 vs 6.8 ± 5.4). After a 6-month period without any treatment, the score was still improved in 11/30 patients (9.1 ± 6.2). At 2 years there was improvement in 16/30 patients (8.8 ± 7.1). There was a significant improvement in three variables of the quality of life questionnaire: lifestyle, coping behaviour and embarrassment.

CONCLUSION

The response to first and second phase PTNS was maintained for up to 2 years. Retreatment was not required in about half of patients, even when they had finished the treatment 6 months or 2 years previously.

Abstract PD4-4: Whole exome sequencing of aggressive rare breast cancers histologic subtypes reveals novel pathway for breast cancer progression

Background: Rare cancers sometimes present clonal evolution. Genomic characterisation of these rare entities could lead to identify new genes involved in the progression of more frequent cancers. In the present study, we have performed whole exome sequencing of three rare and aggressive histological subtypes in order to identify new targets that could subsequently be validated in common breast cancers.

Methods: Whole exome sequencing was applied in ten pleiomorphic lobular carcinoma, seven micropapillary BC and eight metaplastic BC. Each cancer sample was matched with normal DNA from the same patient. Overall 50 samples were therefore sequenced. Tumor samples were selected to present >30% cancer cells. Histological diagnosis was confirmed by a BC pathologist. Whole exome sequencing (WES) was performed by BGI (Bejing Genomic Institute, Hong-Kong, China) using the Illumina Hiseq2000 platform (90bp paired-end reads, depth ≥80x). Genes recurrently mutated (with somatic mutations in >2 cases) were selected for validation. The validation by IonTorrent target sequencing was performed on additional formalin-fixed paraffin-embedded (FFPE) tumor samples (>30% of tumor cells).

Results: Complete results of both WES and targeted resequencing validation are available for pleiomorphic lobular carcinoma. Nine of the 10 DNA pairs were eligible for WES. Genes already implicated in BC were significantly mutated: PIK3CA (3/9), TP53 (3/9) and CDH1 (3/9). Novel significantly mutated genes were identified: PYGM (2/9), EMR1 (2/9), ALDH1A2 (2/9), and DCLK1 (2/9). The validation using target gene sequencing was performed on the same 9 cases and on 19 additional confirmed pleiomorphic lobular BC cases (n = 28). For 8 out of the 9 cases with WES data, the results were reproducible on FFPE samples. Validation set confirmed recurrent mutations on PYGM genes (25%). PYGM is involved in glycogen metabolism. Further analyses on gene expression array revealed that PYGM is downregulated in most of the common BC samples, as compared to normal tissue, suggesting a role for this gene in the metabolism of common BC.

WES data are available for micropapillary and metaplastic BC. HSPA8 (coding for a Heat shock protein) was found mutated in 3/7 of micropapillary samples. Validation on additional FFPE samples is ongoing and will be presented. WES of metaplastic BC revealed a high frequency of TP53 and PIK3CA mutations (50% in both cases).

Conclusions: A novel mutated gene was identified in PLBC. PYGM is a gene involved in glycogen metabolism and was found downregulated in most of the common breast cancer. WES of micropapillary cancers suggests mutations on HSPA8, a gene encoding for a chaperon protein. Validation is ongoing. Deeper sequencing is ongoing for metaplastic BC that may help identifying new mutated genes in this multiclonal disease. Results will be presented.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD4-4.

[Interest of immunohistochemic markers (Ki67, HMB45, p53) in risk analysis of congenital naevi of little and middle size]

The risk to develop melanoma from small or medium size congenital naevus remain controversial. The main goal of the present study was to determine the interest of three immunohistochemical markers (Ki67, HMB45 and p53) in predicting malignant transformation of these congenital naevi and to see if a specific immunohistochemical profile of such transformed naevi can be identified. The markers (Ki67, HMB45 and p53) have been used retrospectively on sections of small or medium size congenital naevi (group NC, n = 15), of melanoma developed on small or medium size congenital naevi (group MNC, n = 15) and of melanoma developed on acquired naevi (group MNA, n = 15). The labelled cells have been counted in different cutaneous layers: junction, superficial dermal layer and deep dermal layer. No reactivity was observed for the three markers in group NC. The percentage of labelled cells was significantly different for the three markers between the group NC and the groups MNC and MNA. There was no difference between the groups MNC and MNA. In the groups MNC and MNA, a gradient in the percentage of labelled cells was observed between superficial and deep layers. These three markers do not differentiate melanoma developed from congenital naevi of small or medium size and melanoma developed from acquired naevi. Moreover, the results suggest that these three markers are useless in predicting the risk of malignant transformation of small or medium size congenital naevi.

CDKN2A mutations in melanoma families from Uruguay

BACKGROUND

Familial melanoma, a cluster of several cases within a single family, accounts for approximately 10% of cases of melanoma. Hereditary melanoma is defined as two or more first-degree relatives having melanoma. A member of a melanoma-prone family has a 35-70-fold increased relative risk of developing a melanoma. Genetic susceptibility is linked to the major susceptibility genes CDKN2A and CDK4, and the minor susceptibility gene MC1R.

OBJECTIVES

To determine the clinical and genetic characteristics of cutaneous melanoma in melanoma-prone families from Uruguay.

METHODS

We studied 13 individuals from six melanoma-prone families living in Uruguay. Phenotype, familial and personal history were recorded. Molecular screening of CDKN2A and CDK4 was done by polymerase chain reaction-single strand conformational polymorphism analysis. The MC1R gene was sequenced.

RESULTS

Mutations in CDKN2A were detected in five of six families: c.-34G>T, p.G101W and p.E88X. A novel germline mutation p.E88X, associated with hereditary melanoma in two unrelated families, is described. We hypothesize that a founder effect occurred probably in the Mediterranean region. No mutations in CDK4 were detected. Six different MC1R variants, all previously reported, were present in Uruguayan families.

CONCLUSIONS

The overall rate of deleterious CDKN2A mutations in our familial melanoma pedigrees, even though the sample size is small, was considerably higher (83%) than the often quoted range.

Predictive factors for conversion in laparoscopic colorectal surgery

BACKGROUND

Although laparoscopic colon and rectal surgery can be safely performed in the hands of well-trained surgeons, criteria for patient selection should be further developed in order to decrease the conversion rate. The main objective of this study was to identify predictive factors for conversion of laparoscopic colorectal surgery to an open procedure based on statistical analysis.

METHODS

A retrospective survey was performed using data collected from 400 patients who underwent laparoscopic colorectal surgery between March 2000 and December 2006. As potential predictive factors for conversion, we considered demographic characteristics, surgery-related variables and disease-related variables. Univariable analysis was performed to identify individual predictive risk factors for conversion. Factors with p values below 0.05 were included in a regression model.

RESULTS

Conversion to open surgery was required in 51 patients (12.7%). Age (>65 years) was the only independent predictive demographic factor (OR=2.3; 95% CI, 1.25-4.46). Low anterior resection (OR=3.9; 95% CI, 1.64-9-18) and complicated diverticulitis (OR=3.9; 95% CI, 1.64-9.18) were also predictive factors. The only predictive factor evidenced in the multivariate analysis was complicated diverticulitis (OR=159.99; 95% CI, 41.02-624.02). Indications for conversion were: adhesions in 53% of the patients, technical problems in 18%, bleeding in 1%, and other indications for the remaining 28%.

CONCLUSION

Complicated diverticulitis or cancer of the rectum treated by low anterior resection have higher probabilities of conversion.

Skin biopsies in DC vaccines for stage III-IV melanoma patients: role of neutrophils?

Dendritic cell (DC) vaccines are used for the induction of anti-tumor T cell reaction in melanoma patients. DC are generated in vitro, pulsed with antigen and matured prior to injection. They are supposed to migrate to lymph nodes and to present the processed antigen to naive T cells allowing activation of tumor-specific lymphocytes. It has been suggested that intradermal injection allows a superior migration to the lymph node. Eight HLA-A2 positive patients with stage III or IV melanomas expressing NA 17 antigen were collected. They were included in a pilot trial of vaccination in which they received IL3/INFb DC presenting the NA17 A2 antigen. In each patient, a skin biopsy was performed at the injection site, 24 h after inoculation. The striking features of the biopsies were the presence of a perivascular CD3+/CD8+ T cell infiltrate with a slight population of CD4+ cells and the presence of a massive neutrophilic infiltrate associated with the injected DC still present, realizing a suppurative granuloma. The persistence of DC 24 h after the injection suggests that migration in the lymph node is not necessary for the induction of the immune response. The skin itself could be the location of a reaction starting with a massive recruitment of neutrophils.

[The strategy of prevention and early detection of cutaneous melanoma]

Dermatology, and more specifically cutaneous oncology, has evolved from a descriptive science concept towards multifaceted medico-surgical medicine which is nowadays based not only on observation. In this view, the importance of prevention and early detection of skin cancers including cutaneous melanoma has been recognized and has created a new challenge. Thanks to this proactive approach, the improvement in the prognosis of newly diagnosed melanomas has been demonstrated, but many efforts have to be brought to reduce the incidence and the mortality of this potentially aggressive tumor.

Colorimetric analysis of pigmented skin lesions: a pilot study with the Visi-Chroma VC-100 device

BACKGROUND

Definition of the colour of pigmented skin lesions (PSLs) with the naked eye remains subjective and may be influenced by lighting. This problem underlines the usefulness of instrumental assessments such as epiluminescence microscopy and colorimetric devices.

OBJECTIVE AND METHODS

We describe here a new method of colour analysis of PSLs with the Visi-Chroma VC-100 device, which illuminates the surface of the skin with white light-emitting diodes (LEDs) and analyses the reflected light by a red-green-blue (RGB) charge-coupled device (CCD) colour camera. Twenty-one PSLs to be excised for cosmetic or medical reasons were analysed by this device with clinicopathological correlation.

CONCLUSIONS

This method is feasible and might be useful to assess the colour of PSLs and allow comparisons for changes over time. Further studies are needed to determine the usefulness of this device in clinical practice.

Evaluation of extensive initial staging procedure in intermediate/high-risk melanoma patients

INTRODUCTION

Early diagnosis and treatment of metastases have been shown to improve overall survival of melanoma patients. The purpose of this study was to evaluate the impact of extensive initial staging, including positron emission tomography (PET) scan on the management of melanoma patients.

PATIENTS AND METHODS

Forty-three patients with intermediate/poor prognosis primary melanoma benefited from complementary excision and sentinel lymph node biopsy (SLB) after clinical and paraclinical staging (computed tomography, nuclear magnetic resonance and whole body fluorodeoxyglucose PET scan).

RESULTS

No systemic metastases were demonstrated, while the SLB procedure emphasized the presence of regional lymph node metastases in 10 patients as suggested by the PET scan in four patients (sensitivity of the PET scan 40%). These 10 patients with early diagnosed lymph node involvement benefited from early surgery and were included in adjuvant treatment protocols. A secondary primary cancer was fortuitously diagnosed and treated early in two patients.

CONCLUSIONS

The development of new adjuvant therapies and therapeutic procedures (specific and non-specific immunotherapy, gamma-knife radiosurgery, etc.) now raises the relevance of extensive staging in intermediate/poor prognosis melanoma patients. We confirm in our series that PET scan is not useful to detect micrometastasis and cannot replace SLB in initial regional staging. However, we show in our study that 12 of 43 patients were treated early or were included early in treatment protocols thanks to the extensive staging procedure. Nevertheless, it seems important to evaluate through larger prospective trials the real impact of these early diagnoses and new treatments on overall survival before defining new diagnostic and therapeutic guidelines.

[Topical photodynamic therapy in cutaneous oncology]

Photodynamic therapy (PDT) or photodynamic chemotherapy is a new therapeutic two-step procedure consisting of an administration of a photosensitizer followed by light irradiation. PDT has been used for the treatment of cutaneous malignancies and offers the advantage over surgery of being a selective and non-invasive approach. The authors present a review of Medline-indexed experiences and trials of topical PDT in cutaneous oncology, and, by the way, remind anatomoclinical features of non-melanoma skin cancers. Complete response rates and cosmetic outcome after topical PDT with 5-aminolevulinic acid are encouraging and enable from now to consider this promising procedure as a new effective approach to manage skin cancers, particularily superficial and extensive lesions including actinic keratoses, superficial basocellular carcinomas and Bowen's disease.

Engineering plants for elevated CO(2): a relationship between starch degradation and sugar sensing

In the future, plants will have additional CO(2) for photosynthesis. However, plants do not take maximal advantage of this additional CO(2) and it has been hypothesized that end product synthesis limitations and sugar sensing mechanisms are important in regulating plant responses to increasing CO(2). Attempts to increase end product synthesis capacity by engineering increased sucrose-phosphate synthase activity have been generally, but not universally, successful. It was found that plants benefited from a two- to three-fold increase in SPS activity but a 10-fold increase did not increase yield. Despite the success in increasing yield, increasing SPS did not increase photosynthesis. However, carbon export from chloroplasts was increased during the day and reduced at night (when starch provides carbon for sucrose synthesis. We develop here a hypothesis that starch degradation is closely sensed by hexokinase because a newly discovered pathway required for starch to sucrose conversion that involves maltose is one of few metabolic pathways that requires hexokinase activity.

[Neurotropic metastasis of squamous cell carcinoma]

INTRODUCTION

Epidermoid skin carcinoma is the second most frequent skin cancer. It is rarely considered as aggressive. Other than its extension through the blood of lymph circulation, perineural invasion is also a significant form of tumoral invasion. We report a case of recurrent epidermoid skin carcinoma beginning with a neurological symptomatology.

OBSERVATION

A 77 year-old man with a history of right fronto-temporal epidermoid skin carcinoma turned up at our clinic with a ptosis of the right eyelid and hypoesthesia in the nerve VI area. He later developed pain in the arch of the eyebrow and diplopia. Five weeks later, two subcutaneous nodules appeared. Histology revealed a neuro-invasive epidermoid carcinoma explaining the clinical picture. Re-loading of the histological sections of the first injury confirmed the clearly differentiated invasive epidermoid carcinoma. However, renewed classified sections revealed neoplastic cells surrounding the nerve branches in the deep dermis.

DISCUSSION

Other than the extension through the blood or lymph circulation, epidermoid cutaneous cancers exhibit varying invasion of the nerve structures. Neurotropism is an aggressiveness marker. Only the pathologico-anatomic investigation enables an early diagnosis. In the case of recurrence, neurological symptomatology can precede skin injuries and make diagnosis difficult. The follow-up of the carriers of this type of tumor must include a neurological examination.

[Molecular markers associated to prognosis of melanoma]

Melanoma prognosis is based on histological criteria such as tumor thickness (measured by Breslow index), level of invasion (Clarck's level), presence of ulceration and number of mitoses per mm2. However, these parameters do not provide a precise prognosis in all cases: thin melanomas may develop metastases and thick melanomas may remain focalized for many years. For these reasons, the search for other prognostic factors is still ongoing. Many molecules play a part in the invasiveness and metastatic dissemination of melanoma have now been identified. Expression of these molecules has been studied in primary melanoma and correlated with prognosis. An increase in the number of cells positive for Ki67 (detected by Mib1), cycline A, cycline D, p35, MMp-2, beta1 and beta3 integrins, osteonectin, the presence of an intense inflammatory infiltrate and capillary invasion are considered as factors of poor prognosis as well as the decrease in p16, p27, Melan A and nm23. The significance of CD44 modifications is still controversial. Only a small number of these different proteins has a prognostic value independent of tumor thickness. These results need to be confirmed on larger series of patients. Additional hope is given to new techniques such as the analysis of the genes implied in tumor progression by microarray technique in such a way as to provide a molecular map of each tumor.

Spread of melanoma after lymphatic drainage: relaunching the debate

Secondary lymphoedema of the leg can result in disruption of lymphatic vessels following lymph node surgery. Evidence supports the use of complex decongestive physiotherapy (CDP) in such cases, despite the possibility of tumour recurrence due to this therapy in cancer patients. We present the case of a 52-year-old woman who developed in-transit metastases and systemic evaluable disease one month after starting CDP for secondary lymphoedema of the leg.

[The dermatology department]

The department of dermatology has developed a broad clinical activity with a particular expertise in oncology, allergology, psoriasis and gynecological dermatology. Research has also been developed in these areas.

Validity and reliability of simple nutrition screening tools adapted to the elderly population in healthcare facilities

This study was conducted to assess the validity and the reliability of simple tools to screen the protein-energy malnutrition (PEM) risk among the elderly population in healthcare facilities. An initial screening tool, made up of nine PEM risk factors, was previously developed to be validated. This tool was quite complex and showed low validity results. A stepwise regression analysis determined significant risk factors (P < or = 0.05) among those included in the initial tool. These were the foundation to develop two simplified screening tools. One included Body Mass Index (BMI) and % weight loss over time. The second included BMI and albumin. Both tools classified subjects in low or high PEM risk levels. In the present study, the simple tools were assessed in a sample of 142 elderly subjects divided into two categories: acute care elderly (ACE, n=72) and long-term care elderly (LTCE, n=70). The simple tools were administered by a dietetic technician and a nurse with the purpose of assessing inter-rater and test-retest reliabilities. The criterion validity of the simple tools were assessed in comparison to in-depth nutritional assessments carried out by a dietitian. The validity results were ranked between 60.5% and 91.7%. The reliability scores showed levels of agreement of 70.8% to 93.1% and kappa coefficients ranking between 0.59(+/-0.07) and 0.79(+/-0.05). Simple tools are now available for efficiently screening the PEM risk among the elderly population on a healthcare facility-wide basis.

Nondetection of sentinel lymph node with lymphoscintigraphy as a result of massive malignant invasion shown by positron emission tomography

PURPOSE

The authors report the complementary roles of lymphoscintigraphy in sentinel node mapping and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) in a massively invaded sentinel node.

MATERIALS AND METHODS

A 49-year-old woman was referred to the authors' institution after the resection of a malignant melanoma (Clark IV, Breslow 5.25) of the right buttock. No evidence of regional or distant organ metastases was observed on bone scintigraphy or thoracoabdominal or cerebral computed tomographs. Preoperative lymphoscintigraphy showed drainage around a circular structure, without any node detected. F-18 FDG PET imaging detected an area of focal, markedly hypermetabolic activity at the same location.

RESULTS

The focal, markedly hypermetabolic activity detected by F-18 FDG PET corresponded to a massively invaded sentinel node not shown by lymphoscintigraphy but found and removed at the time of surgery. Radical regional lymphadenectomy showed only one small additional lymph node micrometastasis detected after immunohistochemical staining for S-100 protein and HMB45 antigen.

CONCLUSIONS

This case emphasizes the complementary roles of lymphoscintigraphy sentinel node mapping and F-18 FDG PET. Indeed, a massively invaded sentinel node may be detected by PET but missed by lymphoscintigraphy.

Effects of hemorrhage on gastrointestinal oxygenation

OBJECTIVES

(1) To demonstrate that metabolic parameters are better indicators of tissue hypoxia than regional and whole oxygen consumption (VO(2)). (2) To compare intramucosal pH (pHi) in different gastrointestinal segments.

DESIGN

Prospective, interventional study.

SETTING

Research laboratory at a university center.

SUBJECTS

Fourteen anesthetized, mechanically ventilated dogs.

INTERVENTIONS

Twenty milliliters per kilogram bleeding.

MEASUREMENTS AND MAIN RESULTS

We placed pulmonary, aortic and mesenteric venous catheters, and an electromagnetic flow probe in the superior mesenteric artery, and gastric, jejunal and ileal tonometers to measure flows, arterial and venous blood gases and lactate, and intramucosal PCO(2). We calculated systemic and intestinal oxygen transport (DO(2)) and consumption (VO(2)), pHi and arterial minus intramucosal PCO(2) (DeltaPCO(2)). Then, we bled the dogs and repeated the measurements after 30 min. Systemic and intestinal DO(2) fell (26.0+/-7.3 versus 8.9+/-2.6 and 71.9+/-17.3 versus 24.6+/-9.6 ml/min per kg, respectively, p<0.0001). Systemic and intestinal VO(2) remained unchanged (5.5+/-1.3 versus 5.4+/-1.3 and 15.7+/-5.0 versus 14.9+/-5.3 ml/min per kg, respectively). Gastric, jejunal and ileal pHi (7.13+/-0.11 versus 6.96+/-0.17, 7.18+/-0.06 versus 6.97+/-0.15, 7.12+/-0.11 versus 6.94+/-0.14, p<0.05) and DeltaPCO(2) (21+/-13 versus 35+/-23, 15+/-5 versus 33+/-16, 23+/-17 versus 38+/-20, p<0.05) changed accordingly. Arterial and mesenteric venous lactate and their difference, rose significantly (1.7+/-0.9 versus 3.7+/-1.4 and 1.8+/-0.8 versus 4.3+/-1.5 mmol/l, 0.1+/-0.6 versus 0.6+/-0.7 mmol/l, p<0.05).

CONCLUSIONS

During hemorrhage, systemic and intestinal VO(2) remained stable. However, hyperlactatemia and intramucosal acidosis evidenced anaerobic metabolism. pHi changes paralleled in the three intestinal segments.

Simple nutrition screening tools for healthcare facilities: development and validity assessment

The purpose of nutrition screening is to identify individuals at high nutritional risk. Given that dietitians cannot always carry out screening in health-care facilities, tools should be simple and based on data obtained from the nursing admission questionnaire. This study was conducted to develop timely and valid tools for screening protein-energy malnutrition (PEM). A dietetic technician administered an initial screening tool to 160 subjects recruited from two settings. This tool comprised nine PEM risk factors. The sample included 54 adults in acute care, 57 elderly adults in acute care, and 49 elderly adults in long-term care. Dietitians performed comprehensive nutritional assessments to determine the validity of this screening tool. Stepwise regression analysis revealed significant risk factors among those included in the initial screening. These risk factors were considered during development of the first simple screening tool, which encompassed body mass index (BMI) and percentage of weight loss, and classified subjects as having low or high PEM risk levels. A second tool using BMI and albumin level was tested in cases where an albumin measurement was available upon admission. These simple tools had validity indices of 75.9% or higher, except in adults in acute care; sensitivity was low in this group. The tools proved helpful in establishing dietitians' priorities for involvement and in initiating early nutritional care.

Transient expansion of peptide-specific lymphocytes producing IFN-gamma after vaccination with dendritic cells pulsed with MAGE peptides in patients with mage-A1/A3-positive tumors

Assessment of T-cell activation is pivotal for evaluation of cancer immunotherapy. We initiated a clinical trial in patients with MAGE-A1 and/or -A3 tumors using autologous DC pulsed with MAGE peptides aimed at analyzing T-cell-derived, IFN-gamma secretion by cytokine flow cytometry and ELISPOT. We also tested whether further KLH addition could influence this response favorably. Monocyte-derived DC were generated from leukapheresis products. They were pulsed with the relevant MAGE peptide(s) alone in group A (n=10 pts) and additionally with KLH in group B (n=16 pts). A specific but transient increase in the number of peripheral blood T lymphocytes secreting IFN-gamma in response to the vaccine peptide(s) was observed in 6/8 patients of group A and in 6/16 patients of group B. We conclude that anti-tumor vaccination using DC pulsed with MAGE peptides induces a potent but transient anti-MAGE, IFN-gamma secretion that is not influenced by the additional delivery of a nonspecific, T-cell help.

Melanoma screening: results of the first one-day campaign in Belgium ('melanoma Monday')

BACKGROUND

Although the incidence of melanoma is increasing and many informative campaigns have been organized. The general population is still little informed about this tumour.

AIMS

To organize a media campaign, with more relevant information and the opportunity for free skin inspections.

METHODS

A 'Task Force' organized a media campaign in April 1999 and convinced 65% of the Belgian dermatologists to give up 4 h of their time to do free skin examinations for skin cancer on Monday 26 April 1999; it was called 'Melanoma Monday'.

RESULTS

A total 2767 patients were screened. We found 25 melanomas and suspected 59 basal cell carcinomas. In the following 4 weeks another 141 melanomas were found. These 166 melanomas found in one month represent 15-20% of the total number of melanomas per year in Belgium.

SUMMARY

A media campaign with relevant information combined with screening opportunities can lead to the early detection of melanomas in a large number of patients and can continue to alert people at risk in the following weeks.

End-tidal CO2 pressure determinants during hemorrhagic shock

OBJECTIVES

To examine the relationship between end-tidal CO2 (PETCO2) and its physiological determinants, pulmonary blood flow (cardiac output, CO) and CO2 production (VCO2), in a model of hemorrhagic shock during fixed minute ventilation.

DESIGN AND SETTING

Prospective, observational study in a research laboratory at a university center.

SUBJECTS AND INTERVENTIONS

Six anesthetized, intubated, and mechanically ventilated mongrel dogs. Progressive stepwise bleeding.

MEASUREMENTS AND RESULTS

We continuously measured PETCO2 with a capnograph, pulmonary artery blood flow with an electromagnetic flow probe, arterial oxygen saturation (SaO2) with a fiberoptic catheter, and oxygen consumption (VO2) and VCO2 by expired gases analysis. Oxygen delivery (DO2) was continuously calculated from pulmonary blood flow and SaO2. We studied the correlation of PETCO2 with CO and VCO2 in each individual experiment. We also calculated the critical point in the relationships PETCO2/ DO2 and VO2/DO2 by the polynomial method. As expected, PETCO2 was correlated with CO. The best fit was logarithmic in all experiments (median r2 = 0.90), showing that PETCO2 decrease is greater in lowest flow states. PETCO2 was correlated with VCO2, but the best fit was linear (median r2 = 0.77). Critical DO2 for PETCO2 and VO2 was 8.0 +/- 3.3 and 6.3 +/- 2.5 ml x min(-1) kg(-1), respectively (NS).

CONCLUSIONS

Our data reconfirm the relationship between PETCO2 and CO during hemorrhagic shock. The relatively greater decrease in PETCO2 at lowest CO levels could represent diminished CO2 production during the period of VO2 supply dependency.

Apoptosis in established and healing psoriasis

BACKGROUND

Previous studies have described apoptosis in the stratum granulosum and in the stratum corneum, but not in the germinative compartment in normal skin. In psoriasis, an increased epidermal apoptosis has been observed in the differentiated compartment, suggesting that apoptosis has a key role in the pathogenesis of psoriasis, as a counteracting factor to the overproduction of cells. Little is known on apoptosis in the germinative compartment.

METHODS

Apoptosis was studied on biopsies of normal skin, established lesions of psoriasis and PUVA-treated psoriasis using the transferase-mediated uridine nick end labelling method, which detects fragmented DNA, and electron microscopy. Counting of apoptotic cells was restricted to the germinative compartment as defined by Mib1 staining to evaluate the impact of cell loss on cell production and tissue architecture.

RESULTS

The apoptotic index was 0.12% in normal epidermis, 0.035% in established psoriasis and 0.31% in regressive psoriasis.

CONCLUSION

These results have three implications: (1) they show the physiological presence of apoptosis in the germinative compartment in normal epidermis; (2) they suggest that induction of apoptosis is involved in the regression of psoriatic hyperplasia after PUVA therapy; (3) the decrease of physiological apoptosis in the psoriatic lesion suggests that this phenomenon could play a role in the induction of psoriatic hyperplasia.

Sentinel lymph node mapping in the management of high risk malignant melanoma

In patients with malignant melanoma, the selective biopsy of the first draining lymph node, so-called the sentinel lymph node, allows to identify, with a low morbidity, the patients with nodal metastasis that require radical lymphadenectomy and adjuvant systemic chemotherapy. Herein, we report our initial experience in sentinel lymph node biopsy in 16 patients with malignant melanoma. The sentinel lymph node was localised using preoperative lymphoscintigraphy and injection of dye blue. Intraoperatively, the dissection was guided with a gamma probe and by the recognition of the blue nodes. In the 16 cases the sentinel lymph node was localised. In 50% of the cases, multiple sentinel nodes were demonstrated at lymphoscintigraphy and found during surgery. A limited postoperative morbidity was observed in three cases. Three patients presented nodal metastasis and underwent further radical lymphadenectomy. We conclude that sentinel lymph node mapping is a feasible and reproductive procedure. The preoperative lymphoscintigraphy is essential to identify multiple sentinel nodes and guide surgical dissection. The impact of this approach on the overall survival of patients with high-risk melanoma has still to be demonstrated in studies with a long follow-up.

Clinical characteristics of malignant melanoma

Malignant melanoma represents a major public health concern. Its incidence is rising throughout the world; in Europe particularly, 13-21 people/100.000 are affected annually. Although the aetiology is multifactorial, excessive UV exposure (UVB 290-320 min.) appears to be one of the most important predisposing agent. Genetic predisposition plays also a fundamental role. Chromosome 9p has been implicated in familial melanoma via the inhibition of a cyclin-dependent kinase 4 which interferes with cell cycle. The early detection and recognition of malignant melanoma is the key for possible cure. Technical aids like photography, computer based systems, epiluminescence or biopsy increase the sensitivity of formally trained clinicians.