Pharmaceutical active compounds in sewage sludge: Degradation improvement and conversion into an organic amendment by bioaugmentation-composting processes

Around 143,000 chemicals find their fate in wastewater treatment plants in the European Union. Low efficiency on their removal at lab-based studies and even poorer performance at large scale experiments have been reported. Here, a coupled biological technology (bioaugmentation and composting) is proposed and proved for pharmaceutical active compounds degradation and toxicity reduction. The optimization was conducted through in situ inoculation of Penicillium oxalicum XD 3.1 and an enriched consortium (obtained from non-digested sewage sludge), into pilot scale piles of sewage sludge under real conditions. This bioaugmentation-composting system allowed a better performance of micropollutants degradation (21 % from the total pharmaceuticals detected at the beginning of the experiment) than a traditional composting process. Particularly, inoculation with P. oxalicum allowed the degradation of some recalcitrant compounds like carbamazepine, cotinine and methadone, and also produced better stabilization features in the mature compost (significant passivation of copper and zinc, higher macronutrients value, adequate physicochemical conditions for soil direct application and less toxic effect on germination) compared to the control and the enriched culture. These findings provide a feasible, alternative strategy to obtain a safer mature compost and a better removal of micropollutants performance at large scale.

(13)C metabolic flux analysis shows that resistin impairs the metabolic response to insulin in L6E9 myotubes

Background

It has been suggested that the adipokine resistin links obesity and insulin resistance, although how resistin acts on muscle metabolism is controversial. We aimed to quantitatively analyse the effects of resistin on the glucose metabolic flux profile and on insulin response in L6E9 myotubes at the metabolic level using a tracer-based metabolomic approach and our in-house developed software, Isodyn.

Results

Resistin significantly increased glucose uptake and glycolysis, altering pyruvate utilisation by the cell. In the presence of resistin, insulin only slightly increased glucose uptake and glycolysis, and did not alter the flux profile around pyruvate induced by resistin. Resistin prevented the increase in gene expression in pyruvate dehydrogenase-E1 and the sharp decrease in gene expression in cytosolic phosphoenolpyruvate carboxykinase-1 induced by insulin.

Conclusions

These data suggest that resistin impairs the metabolic activation of insulin. This impairment cannot be explained by the activity of a single enzyme, but instead due to reorganisation of the whole metabolic flux distribution.

Melatonin exerts direct inhibitory actions on ACTH responses in the human adrenal gland

In nonhuman primates and rodents, melatonin acting directly on the adrenal gland, inhibits glucocorticoid response to ACTH. In these species, an intrinsic adrenal circadian clock is involved in ACTH-stimulated glucocorticoid production. We investigated whether these findings apply to the human adrenal gland by determining i) expression of clock genes in vivo and ii) direct effects of melatonin in ACTH-stimulated adrenal explants over a) expression of the clock genes PER1 (Period 1) mRNA and BMAL1 [Brain-Muscle (ARNT)-like] protein, ACTH-induced steroidogenic acute regulatory protein (StAR), and 3β-hydroxysteroid dehydrogenase (3β-HSD) and b) over cortisol and progesterone production. Adrenal tissue was obtained from 6 renal cancer patients undergoing unilateral nephrectomy-adrenalectomy. Expression of the clock genes PER1, PER2, CRY2 (Cryptochrome 2), CLOCK (Circadian Locomotor Output Cycles Kaput) and BMAL1, was investigated by RT-PCR in a normal adrenal and in an adenoma. In independent experiments, explants from 4 normal adrenals were preincubated in culture medium (6 h) followed by 12 h in: medium alone; ACTH (100 nM); ACTH plus melatonin (100 nM); and melatonin alone. The explants' content of PER1 mRNA (real-time PCR) and StAR, 3β-HSD, BMAL1 (immuno slot-blot), and their cortisol and progesterone production (RIA) were measured. The human adrenal gland expresses the clock genes PER1, PER2, CRY2, CLOCK, and BMAL1. ACTH increased PER1 mRNA, BMAL1, StAR, and 3β-HSD protein levels, and cortisol and progesterone production. Melatonin inhibited these ACTH effects. Our study demonstrates, for the first time, direct inhibitory effects of melatonin upon several ACTH responses in the human adrenal gland.

The initial rise method extended to multiple trapping levels in thermoluminescent materials

The well known Initial Rise Method (IR) is commonly used to determine the activation energy when only one glow peak is presented and analysed in the phosphor materials. However, when the glow peak is more complex, a wide peak and some holders appear in the structure. The application of the Initial Rise Method is not valid because multiple trapping levels are considered and then the thermoluminescent analysis becomes difficult to perform. This paper shows the case of a complex glow curve structure as an example and shows that the calculation is also possible using the IR method. The aim of the paper is to extend the well known Initial Rise Method (IR) to the case of multiple trapping levels. The IR method is applied to minerals extracted from Nopal cactus and Oregano spices because the thermoluminescent glow curve's shape suggests a trap distribution instead of a single trapping level.

Gastrojejunal anastomotic stricture after Roux-en-Y gastric bypass: ambulatory management with the Savary-Gilliard dilator

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is currently one of the most frequently performed procedures for the surgical treatment of morbid obesity. The success of this procedure's restrictive component requires a small gastrojejunostomy (GJ), which occasionally results in stenosis. The treatment of choice for this complication is balloon dilation. This study aimed to evaluate the feasibility and safety of ambulatory management for stenosis of the GJ using endoscopically guided Savary-Gilliard dilators.

METHODS

Between January 1998 and October 2003, 769 patients underwent RYGBP. The mean age of these patients was 38 +/- 12 years, and their mean body mass index (BMI) was 43 +/- 6 kg/m2. Of these 769 patients, 520 (68%) underwent open surgery and 249 (32%) underwent laparoscopic RYGBP. Patients suspected of GJ stenosis were referred for upper gastrointestinal endoscopy. Those who presented with stenosis were managed endoscopically with Savary-Gilliard dilators.

RESULTS

Stenosis at the GJ was confirmed in 53 patients (6.9%). A total of 71 dilations were performed for these patients, resulting in a mean of 1.3 dilations per patient. One dilation was needed for 41 patients (75.5%), two dilations for 9 patients (16.9%), three dilations for 3 patients (5.7%), and four dilations 1 patient (1.9%). The patients subjected to open RYGBP required a mean of 1.57 dilations, and those who had laparoscopic RYGBP required mean of 1.08 dilations. The mean time for the first dilation was 51 +/- 28 days after surgery (range, 20-178 days). All the dilations were performed in ambulatory settings. One patient (1.9%) was admitted after GJ dilation for pain. He was discharged without symptoms after 2 days with no need for invasive procedures.

CONCLUSIONS

The management and treatment of GJ stenosis after RYGBP can be effectively accomplished in ambulatory settings using endoscopically guided Savary-Gilliard dilators, with good and safe results.

Severe tophaceous gout. Characterization of low socioeconomic level patients from México

OBJECTIVE

To describe a group of patients with frequent tophaceous gout, the variables associated with severe tophaceous gout and to compare them with other patients with gout described elsewhere.

METHODS

We looked for 65 demographic clinical and paraclinical variables from patients with gout who attended our gout clinic from 1995-2000 and were evaluated by the same group of physicians.

RESULTS

Three hundred and sixteen patients were included, 98% males, 82% live in México city, the mean age at onset, educational level and disease duration were 37.5 +/- 12.4, 6.3 +/- 3.9 and 12.6 +/- 10.3 years respectively. Tophaceous gout was present in 62% of the patients with a mean tophi number of 4.7 +/- 6.3 and mean HAQ score 0.13 +/- 0.37. Severe tophaceous gout (>or= 5 tophi) was found in 34% and these patients had significantly: earlier age at onset, longer duration of the disease, lesser frequency of obesity and higher frequency of: intradermal tophi, HAQ > 0.5, hospitalizations, radiographic score III/IV, uric acid under-excretion, renal function impairment and previous (oral and parenteral) auto-prescribed chronic glucocorticoid treatment compared with patients with non-severe tophaceous gout. In the multiple logistic regression the significant variables were renal function impairment (p = 0.000) and previous chronic parenteral glucocorticoid treatment (p = 0.011) .

CONCLUSION

Our patients compared with those from other countries who have earlier age at onset, very low frequency of gout among females, frequent tophaceous gout and severe tophaceous gout. Severe tophaceous gout in this group is associated with renal function impairment and previous chronic parenteral glucocorticoid treatment.

Risk progression to chronic Chagas cardiomyopathy: influence of male sex and of parasitaemia detected by polymerase chain reaction

BACKGROUND

Polymerase chain reaction (PCR) allows detection of Trypanosoma cruzi in blood throughout the course of Chagas' disease.

OBJECTIVE

To determine whether T cruzi DNA detected by PCR is associated with progression to chronic Chagas cardiomyopathy.

DESIGN

Prospective cohort study.

SETTING

A tertiary care centre in Argentina.

PATIENTS

56 consecutive patients with chronic T cruzi infection.

METHODS

Clinical examination, ECG, and Doppler echocardiography were carried out at baseline and at the end of the follow up. Detection of T cruzi DNA by PCR amplifying a nuclear sequence was undertaken in all patients at baseline.

MAIN OUTCOME MEASURES

Progression was defined as death from chronic cardiomyopathy or the presence of a new ECG or left ventricular echocardiographic abnormality at the end of follow up.

RESULTS

The 56 patients (21 male, 35 female; mean (SD) age, 56.0 (11.3) years) were followed for a mean 936.3 (244.39) days. Progression to cardiomyopathy was detected in 12 patients (21.4%). Three of these patients died after baseline evaluation. Univariate analysis showed that a positive PCR (relative risk 4.09, 95% confidence interval (CI) 1.60 to 9.85) and male sex (5.00, 95% CI 1.65 to 15.73) were associated with progression. Multivariable logistic regression indicated that both sex and PCR were independent variables affecting the outcome.

CONCLUSIONS

In a cohort of seropositive individuals, patients with T cruzi DNA detected by PCR and male patients were at higher risk of progression. These results highlight the importance of T cruzi in the pathophysiology of chronic cardiomyopathy.

Anti-inflammatory and immunomodulatory activities of polysaccharide from Chlorella stigmatophora and Phaeodactylum tricornutum

Crude polysaccharide extracts were obtained from aqueous extracts of the microalgae Chlorella stigmatophora and Phaeodactylum tricornutum. The crude extracts were fractionated by ion-exchange chromatography on DEAE-cellulose columns. The molecular weights of the polysaccharides in each fraction were estimated by gel filtration on Sephacryl columns. The crude polysaccharide extracts of both microalgae showed anti-inflammatory activity in the carrageenan-induced paw edema test. In assays of effects on the delayed hyper-sensitivity response, and on phagocytic activity assayed in vivo and in vitro, the C. stigmatophora extract showed immunosuppressant effects, while the P. tricornutum extract showed immunostimulatory effects.

Antiinflammatory, analgesic and free radical scavenging activities of the marine microalgae Chlorella stigmatophora and Phaeodactylum tricornutum

A pharmacological study of hydrosoluble and liposoluble extracts of the marine microalgae Chlorella stigmatophora and Phaeodactylum tricornutum indicated that hydrosoluble components of both species show significant antiinflammatory, analgesic and free radical scavenging activity. These activities were not detected in the liposoluble fractions.

Intervención educativa comunitaria sobre la diabetes en el ámbito de la atención primaria

OBJECTIVE

To offer an educational alternative on diabetes, with the participation of patients with type 2 diabetes, their family members, and health care providers, adapted to local conditions and to these person's felt needs.

METHODS

Focused on the primary-care level, this program was carried out in the health area of El Guarco, which is in the province of Cartago, Costa Rica. The first stage of the project included a qualitative study of the knowledge and practices of both patients and health care providers, looking at diabetes prevention and control and the local availability of foods. Based on those results, an educational methodology was developed, educational manuals were written, and courses for health care providers, patients, and patients' families were implemented. Other strategies were developed to make the effort sustainable.

RESULTS

We found that patients did not associate family history or obesity with diabetes and that those persons were also confused about the symptoms of diabetes. Patients also received inconsistent nutrition messages from health care providers. Using the diabetes education manual as a base, the providers increased their knowledge of diabetes prevention, treatment, and education by an average of 85%. The diabetic patients who received educational training (mean age, 57.0 years, with a standard deviation of 8.9 years; 92% women) improved their glycemic control. Blood glucose levels decreased from 189 +/- 79 mg/dL (average and standard deviation) to 157 +/- 48 mg/dL (P < 0.05), and glycosylated hemoglobin (HbA1c) went from 11.3% +/- 2.4% to 9.7% +/- 2.3% (P = 0.05). There were no significant changes in body weight or lipid profile, except for triglycerides, which declined (P < 0.05).

CONCLUSIONS

This educational program was successfully incorporated into the regular activities of the El Guarco-area health centers. The primary-care level is ideal for carrying out educational programs for diabetes treatment and early detection that are directed at patients, their families, and health care providers.

[Change in metabolic risk factors in obese patients in treatment]

BACKGROUND

Obesity is a threat to health due to its association with cardiovascular risk factors.

AIM

To assess the change in metabolic risk factors after weight reduction in obese patients.

PATIENTS AND METHODS

A retrospective analysis of 277 obese patients (198 female) aged 39.5 +/- 12 years old, that completed a six month treatment period, consisting in a calorie restricted diet (800-1200 Kcal/day), physical activity, education and group psychological counseling. At the beginning and at the end of the program, weight, waist circumference, resting energy expenditure (REE), serum lipid profile, plasma glucose and plasma insulin levels were measured.

RESULTS

During the treatment period, body mass index decreased from 38 +/- 7 to 33.2 +/- 6.4 kg/m2 with a weight loss of 11.7 kg, waist circumference decreased from 106.6 +/- 14.6 to 93.9 +/- 13.5 cm, REE decreased from 1774 +/- 383 to 1585 +/- 267 Kcal/day, blood glucose fell by 5.8%, plasma insulin fell by 40.4%, total cholesterol fell by 7.5%, LDL cholesterol fell by 8.7%, triglycerides fell by 26.6%, and total cholesterol/HDL ratio fell by 12.2%.

CONCLUSIONS

Weight loss was associated with improvement in metabolic cardiovascular risk factors in obese patients.

[Indication of gastrojejunostomy in unresectable pancreatic cancer]

BACKGROUND

Up to 20% of patients with pancreatic carcinoma subjected to a bilio digestive diversion, develop a delayed gastric emptying due to duodenal infiltration. However the role of prophylactic gastrojejunoanastomosis is not well defined.

AIM

To compare the effects of gastrojejunoanastomosis performed as prophylaxis or as treatment for duodenal infiltration, in patients with unresectable pancreatic carcinoma.

PATIENTS AND METHODS

Between 1983 and 1994, 44 gastrojejunoanastomosis were performed in patients with pancreatic carcinoma. In 24 patients the procedure was done as prophylaxis and in 20 as treatment of duodenal infiltration. Of these, three had been subjected previously to a bilio digestive diversion. Postoperative outcome and mortality of both groups of patients were compared.

RESULTS

Both groups of patients had similar sex and age. Operative morbidity and mortality were 33% and 0% in the group with the prophylactic procedure and 35 and 10% in the group with duodenal infiltration. Oral feeding was started 6.5 and 6.9 days after operation, and hospital stay was 10.7 and 11.4 days in either group. At the moment of the analysis, 95.5% of patients had died. Survival was significantly longer in the group with the prophylactic procedure (337.2 and 116.9 days respectively, p < 0.01). Thirty eight percent of patients required a further admission to the hospital, but only 4.8% due to gastric retention.

CONCLUSIONS

Gastrojejunoanastomosis is a good palliative procedure in patients with unresectable pancreatic carcinoma. It should be performed in every such patient who is subjected to a bilio digestive diversion and in whom a survival of some months can be predicted.

New melampolides from Schkuhria schkuhrioides

The novel melampolides (11R)-11,13-dihydro-schkuhriolide (7), (11S)-11,13-dihydro-schkuhriolide (8), and schkuhrioidiol (11), along with the known constituents, frutescin (1), schkuhriolide (2), frutescinic acid (4), allo-schkuhriolide (5), and epoxyschkuhriolide (6) were isolated from the aerial parts of Schkuhria schkuhrioides. The structures of the new compounds were determined by spectroscopic methods. Compounds 1, 2, 4, 5, and 6 displayed no significant cytotoxic or antimicrobial activities.

[Negative appendectomy: experience at a university hospital]

BACKGROUND

Acute appendicitis still constitutes a difficult diagnostic problem.

AIM

To assess the experience of an University Hospital in the diagnosis of acute appendicitis and to determine the rates of negative appendectomies.

PATIENTS AND METHODS

The charts of 1,075 patients operated with the diagnosis of acute appendicitis, between 1993 and 1995, were retrospectively reviewed. All resected appendices were pathologically examined. Those cases in whom pathology did not confirm the clinical diagnosis were considered as a negative appendectomy.

RESULTS

There was a 12.2% rate of negative appendectomies (18.9% in women and 6.2% in men). The difference between sexes disappears in patients over 40 years old. In 49% of patients, no abnormality was detected during the laparotomy. The most frequent differential diagnosis were gynecological illnesses or diseases of the colon.

DISCUSSION

The rate of negative appendectomies can be reduced with a close clinical observation of patients during their hospitalization and the judicious use of diagnostic laparoscopy.

[Occult gallbladder disease or microlithiasis in patients with acute pancreatitis: a frequent clinical event]

BACKGROUND

Patients with acute pancreatitis (AP) and a normal gallbladder by standard echographic evaluation may have "occult" gallbladder disease or microlithiasis with recurrent episodes of AP.

AIM

To conduct a prospective evaluation of patients with the diagnosis of non-biliary AP in order to detect "occult" gallbladder disease and to compare its clinical presentation with that of biliary AP.

PATIENTS AND METHODS

Patients admitted with the diagnosis of AP to a clinical hospital were included in the study. According to an abdominal ultrasound study, patients were classified as having or not cholelithiasis. A duodenal biliary drainage was performed in 15 patients with AP and without gallbladder stones.

RESULTS

Patients without cholelithiasis had recurrent AP more often than patients with biliary AP (53 and 3.3% respectively). Excessive alcohol ingestion did not rule out the possibility of biliary etiology. In 6 patients, the analysis of duodenal bile showed cholesterol crystals, and cholecystectomy confirmed the existence of gallbladder disease in 5. All of them remained asymptomatic during a follow-up period of four years. One patient refused surgery, with subsequent development of gallstones and recurrent episodes of AP. In other 4 patients, gallbladder disease was confirmed by percutaneous gallbladder puncture or during cholecystectomy. No recurrence of AP were observed during the follow-up

CONCLUSIONS

Microlithiasis or "occult" gallbladder disease accounts for at least 67% of the original "non-biliary" AP. Duodenal bile analysis is a useful and necessary technique for the evaluation of patients with "non-biliary" acute pancreatitis. Careful clinical and echographic follow-up of this subgroup of patients with AP is mandatory.

Neuropeptide Y Y1 receptors are involved in the vasoconstriction caused by human sympathetic nerve stimulation

Neuropeptide Y, a novel neurotransmitter, interacts with selective membrane receptors to cause vasoconstriction. Frequency- and concentration-dependent isometric contractions were observed in human inferior mesenteric artery and vein mounted rings that were stimulated with either electrical pulses (70 V, 0.5 ms, 2.5-20 Hz) or noradrenaline. The antagonism elicited by 100 nM tetrodotoxin and 1 microM guanethidine confirmed the neuronal and sympathetic origins of the vasomotor response. Incubation with BIBP 3226 ((R)-N2-(di-phenacetyl)-N-(4-hydroxyphenyl)-methyl-D-arginineam ide), a selective neuropeptide Y Y1 receptor antagonist, significantly reduced the vasoconstriction. The incomplete antagonist activity of BIBP 3226 tends to support the hypothesis of sympathetic co-transmission involving neuropeptide Y, adenosine 5'-triphosphate and noradrenaline. These findings were confirmed in parallel studies using rat superior mesenteric artery and vein ring preparations.

[The assessment of nutritional status in patients over 60 with arteriopathy]

The nutritional status of patients older than 60 years affected by arteriopathy, who were admitted in a scheduled manner to a Vascular Surgery Department, have been studied. The nutritional status was evaluated upon admittance to the hospital and again upon release from the same, to determine whether this changes during the hospital stay. A total of 93 patients (80 men males and 13 females), with a mean age of 71 years, who were admitted to the hospital during a one year period, were studied prospectively. Among the present risk factors, active smokers or ex-smokers (83.87%), diabetics (32.25%), and the consumption of more than 40 g of alcohol/day (21.5%), should be noted. Upon admittance to the hospital, 43.5% of the studied cases presented mild malnutrition. During the hospital stay, which lasted 26.4 +/- 13.8 days, the nutritional status of these patients was ot modified. It should be noted that the delayed type sensitivity skin tests showed anergy in all cases, which suggests that this parameter is not a good nutritional marker for individuals over 60. Finally, we observe that the lean body mass index did not correlate with the rest of the anthropometric parameters used, which could indicate that age affects the lean body mass more than it does the other body components.

[Non Hodgkin lymphoma of the stomach: evaluation of surgical treatment in 24 patients]

This is a retrospective review of 24 patients with Non Hodgkin Lymphoma of the stomach operated between 1959 and 1991. The diagnosis was reached with a radiological study in 12 of 15 (80%) patients and with endoscopy in 11 of 16 (69%) of patients. Eleven of 14 (78%) preoperative biopsies available at the moment of the revision were positive for non Hodgkin Lymphoma. Clinical staging was performed using Ann Arbor Classification and the histological type was defined according to the Working Formulation. Diffuse large cell lymphoma (intermediate grade) was the most frequent histological subtype. Eleven patients were in clinical stage I, 10 patients in stage II and 3 in stage IV. Eight total gastrectomies and 16 subtotal gastrectomies were performed. Twenty one percent of patients had a postoperative complication and operative mortality was 12%. Stage I patients were treated exclusively with surgery and no recurrences were observed. Stage II patients received adjuvant chemotherapy, the tumor recurred in three and two died due to disease progression. Five years disease free survival was 64%. It is concluded that surgical treatment achieves a good disease control in stage I patients but must be complemented with chemotherapy in stage II tumors.

[Pyogenic liver abscess. Experience with 50 cases]

During the last years the diagnosis and treatment of pyogenic liver abscess has changed substantially. The aim of this work is to report a retrospective analysis of 50 patients aged 24 to 87 years old, that presented with a pyogenic liver abscess and were treated in the last 13 years. The sensitivity for diagnosis of ultrasound examination, CAT scan and angiography was 68, 89 and 75% respectively. The origin of the abscess was detected at the biliary tree in 46% and remained unknown in 38%. Thirty one patients were operated, 13 were subjected to percutaneous drainage and 5 were treated only with antimicrobials. Forty percent of patients had a septic complication and 4 (8%) died. Mean hospital stay was 31 days for operated patients and 21 for the rest. The abscess recurred in seven patients and two of these had a gallbladder carcinoma. It is concluded that percutaneous drainage is an alternative to surgical treatment that must be accompanied by a careful diagnostic workup.

[Choledochocele. Report of a case and review of the literature]

We report a 29 years old man with a choledochocele or type III choledochal cyst, an extremely rare condition. This was found during a cholecystectomy using a transcystic intra operative cholangiogram. A transduodenal sphincteroplasty was performed. The cyst diameter was 1.5 cm approximately and two 1-2 mm stones were extracted from its lumen. The chemical composition of these was different from those located in the gallbladder. The postoperative period was uneventful and the patient remains asymptomatic.

[Gastrointestinal bleeding of unknown origin. Experience in 31 cases]

Thirty one patients with GI bleeding of obscure origin, defined as those with normal upper endoscopy and colonoscopy, were studied to know the yield of different diagnostic procedures. Seventeen patients consulted for hematochezia and bleeding less than 10 days of evolution in 71%. Small bowel X ray examination was performed in 14 cases with a diagnostic effectiveness (number of diagnosis/number or examination) of 14%, angiography was performed in 12 cases with an effectiveness 33%, radiolabeled erythrocyte scanning in 12 cases with an effectiveness of 75%, scintigraphy with pertechnetate in 6 cases with an effectiveness of 17% and intraoperatory endoscopy in 2 cases with an effectiveness of 50%. A definitive diagnosis was reached in 8 patients during the first admission and in 6 during the second admission. The principal etiologies were small bowel tumors in 3 cases, cecal ulcers in 2 and ileal diverticula in 2. Ten subjects were subjected to surgical and 2 to endoscopic treatment. Five patients with recurrent bleeding remain without diagnosis. It is concluded that radiolabeled erythrocyte scanning and angiography are effective examinations that should follow upper and lower endoscopies in the diagnosis of a concealed GI bleeding. When a diagnosis is not reached in the first admission, patients should be following with repeated diagnostic procedures.

[Variability of measured energy expenditure in patients with acute pancreatitis: is it possible to obtain a reliable pathology factor for these cases?]

Energy expenditure was measured in 55 patients with acute pancreatitis, during variable periods ranging from 1 to 5 weeks and it was compared with estimated energy expenditure according to Harris Benedict equations. Patients with severe pancreatitis had similar measured and measured/estimated energy expenditure rations, compared to those with mild pancreatitis (1678 +/- 349.6 kcal/day and 1.1 +/- 0.19 vs 1632 +/- 383 kcal/day and 1.06 +/- 0.19). There was a high dispersion of measured/estimated rations (0.67 - 1.7) that precluded the calculation of a reliable energy expenditure correction factor for this disease. It is concluded that energy expenditure must be measured and not estimated, when planning an adequate nutritional support in patients with acute pancreatitis.

[Hemangiopericytoma: report of 4 cases]

Hemangiopericytoma is an infrequent tumor of vascular origin derived from Zimmermann's pericyte cells. It is generally seen in adults of both sexes and its major risk is late recurrence, that occurs in up to 50% of cases. Its spread pattern is principally hematogenous. The management of the disease is similar to that of other sarcomas. Surgical treatment alone controls the disease in less than 30% of cases and the association of surgery and radiation therapy decrease the risk of local and distant recurrence. We report four cases of hemangiopericytomas, located in the prostate, retroperitoneum, supraclavicular space and lung. The four patients were treated with surgery and radiation therapy, three of them have had no evidence of recurrence after 1.5 to 6 years of follow up and the patient with the tumor located in the lung died one year after the operation.

[Colorectal cancer. Study of survival and surgical results]

The aim of this study was to assess the progress in the surgical treatment of colorectal carcinoma in a 15 years period at the Catholic University Clinical Hospital. The medical records of 397 patients were retrospectively analyzed. Two hundred eighty four patients (164 male) aged 24 to 90 years old, subjected to elective and curative interventions, were selected for the study and separated in two groups: 132 subjects operated between 1975 and 1984 (group A) and 152 operated between 1985 and 1989 (group B). Group B patients were older (66.7 vs 61.3 years old), had a higher proportion of Dukes A tumors (11 vs 18%) and a lower proportion of lesions localized in the rectum (37 vs 49%). Rectal operations had higher morbidity than colonic interventions (35 vs 17.5%). Operative mortality was 0.7% in group A and 0.6% in group B. Ninety one percent of patients had a mean follow up of 38 months. Five years actuarial survival was 52% in group A and 69% in group B and 58, 74 and 46% for tumors Dukes A, B and C respectively.

[The effectiveness of endoscopic retrograde cholangiopancreatography in the etiological diagnosis of postcholecystectomy syndrome]

A retrospective study of 249 with symptoms and signs of postcholecystectomy syndrome was made to evaluate the usefulness of endoscopic retrograde cholangiopancreatography (ER CP) in its etiological diagnosis. From 1693 ERCP evaluated, 1108 were checked and from these 249 patients showed symptoms and signs after the cholecystectomy. So they were selected to practice a diagnostic ERCP. 204 patients were females and its principal symptom was jaundice. Lesions found in most of the cases were: stones in the bile ducts (45.78%), benign biliary stenosis (8.3%), stenosis of vater's papilla (7.22%) and biliary fistula (7.22%). It can be conclude that biliary stones is the most frequent pathology in those patients with clinical suspicion of biliary-pancreatic organicity and that ERCP is the principal method of diagnosis in these patients.

[Budd-Chiari syndrome. Report of 2 surgical cases]

Two female patients with Budd-Chiari syndrome and suffering of Polycythemia Vera are reported. Both patients were operated performing a central spleno renal shunt with preservation of the spleen and ligation of the splenic artery. The patients are well 6 and 24 months after the operation respectively. The principal features and therapeutic alternatives of this condition are reviewed briefly.

[Disseminated histoplasmosis in a patient with acquired immunodeficiency syndrome]

A twenty nine year old male homosexual presented with malaise, weight loss, fever and profuse sweating. An ill defined abdominal mass was found during physical examination in the right lower quadrant and chest X rays disclosed a pleural effusion. HIV antibodies and hepatitis B surface antigen were positive and immunological parameters were altered. Light and electron microscopic examination of operative biopsies of the abdominal mass revealed the presence of Histoplasma capsulatum. Treatment with Amphotericin B was started with a favorable response and the patient was discharged. He was readmitted with a septic shock and died. Necropsy showed pulmonary histoplasmosis. This is the first case of disseminated histoplasmosis in a patient with AIDS described in Chile.

[Respiratory complications in severe acute pancreatitis]

Respiratory complications are important causes of mortality in severe acute pancreatitis. We analyzed the pleuropulmonary complications that occurred in a series f 63 patients with severe acute pancreatitis. The most frequent were respiratory failure (52.4%) and bronchopulmonary infection (33.3%), both associated with sepsis and a high mortality rate. The initial laboratory workup included serial arterial blood gases and chest roentgenogram within the first 24 hours. The latter was useful to predict mortality. The tracheobronchial cultures isolated only enteral bacteriae. We conclude that pleuropulmonary complications are clearly related to the outcome of severe acute pancreatitis, specially when associated to sepsis.

[Acalculous acute cholecystitis caused by Cryptosporidium in a patient with AIDS]

We report a patient with the acquired immunodeficiency syndrome who developed acute cholecystitis. Removal of the gallbladder revealed infection by Cryptosporidium spp. The clinical course after cholecystectomy was favourable. The pathogenesis and therapy of this complication in patients with AIDS is discussed.

[Treatment of non-variceal upper digestive hemorrhage with endoscopic thermocoagulation]

Over a year period, 60 of 172 patients presenting with upper gastrointestinal bleeding were treated by endoscopic thermocoagulation. Entry criteria included active bleeding (pulsatile or oozing), a visible vessel, sentinel clot or the presence of a pigmented protuberance at the ulcer crater. Hemostatic therapy was performed using the heat probe. The physical status and risk of the patients was estimated according to the ASA classification. Hemostasis was obtained in 17 of 21 patients with pulsatile bleeding (81%), 30 of 30 patients with oozing (100%) and 18 of 18 patients with a visible vessel or a pigmented protuberance in the lesion (100%). Three patients, older than 70 years of age, died. All had pulsatile bleeding from a deep ulcer located at the posterior-inferior wall of the duodenal bulb. They were classified as ASA III (n = 1) or IV (n = 2) with significant concomitant illness. These results suggest that endoscopic thermocoagulation is an effective treatment of active upper gastrointestinal bleeding, especially useful in a group of high risk patients.

[Duodenal villous adenoma. Report of 2 cases]

The case history, diagnosis and management of 2 pts with villous adenoma of the duodenum are reported. Both were operated on with good results, with no relapse at 12 and 18 months of observation. This tumor which is more frequently located in the vicinity of the Vater Ampullae, has a low incidence. One third of them have malignant elements raising an issue on therapeutic options. Literature is reviewed with special emphasis on the type of surgical resection to be used.

[Incipient and intermediate gastric cancer II. Anatomo-pathological and surgical aspects. Cooperative study in 13 hospitals]

Anatomic and surgical characteristics of 233 pts with early, and 120 with intermediate gastric cancer, from 13 hospitals in Chile are analyzed. 63% had depressed or excavated lesions. Most of the tumors were located in the inferior or middle third, while only 17% of the early carcinomas were found in the superior third of the stomach, specially in the lesser curvature. 5% had residual tumor in the gastric remanent. Histologically, tubular adenocarcinoma was the most common finding. According to Lauren's classification intestinal carcinoma was more frequent than the diffuse type. Surgeons underestimated lymphatic node involvement (macroscopic appreciation) in up to 58% of the cases when compared to the pathologists observation (microscopic appreciation). This was specially true in muscular carcinomas. The incidence of lymphatic metastases was 6% in mucous, 12% in submucous and 57% in muscular carcinoma. The need of complete lymph node dissection of all the lymphatic barriers is emphasized.

Malignant papillomatosis of the common bile duct. A case diagnosed by endoscopic retrograde cholangiopancreatography

Bile duct papillomatosis is a rare entity with a high risk of malignant change. We report the case of a 60-year-old man with malignant papillomatosis of the distal common bile duct and a separate carcinoma of ampulla of Vater. The patient had previously undergone surgery for acute cholecystitis and common bile duct calculi. Three months later the patient developed jaundice and fever. An endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects adherent to the wall of the distal common bile duct. Pancreatoduodenectomy was performed with complete resection of the extrahepatic bile duct. Histologic examination showed a multicentric papillary adenocarcinoma of the common bile duct associated with an adenocarcinoma of the ampulla of Vater. The resection margins were free of tumor.

[Acute severe pancreatitis. Analysis of mortality and morbidity]

Sixty-three patients with severe acute pancreatitis have been studied. Pancreatitis was associated with biliary tract disease in 23 patients (36.5%) and with alcoholism in 21 (33.3%). It occurred post-operatively in 9, and was associated with other conditions in 10. We evaluated the Ranson prognostic signs (RPS) with the appearance of complications. 36 patients (57.2%) had 3-4 RPS, 9 (30.2%) had 5-6 RPS and 8 (12.6%) had 7 or more RPS. Diagnostic laparotomy was performed in 11 patients (17.5%). 55 patients were operated one or more times due to failure of medical treatment and/or local and septic complications. The most frequent complications were pancreatic abscess (60.3%), sepsis (58.7%) and pulmonary insufficiency (52.4%). Renal failure occurred in 26 patients and 9 required dialysis. Of the patients with renal failure, 84.6% (22/26) had 4 or more RPS; 78.4% (29/37) of those with sepsis and 71.6% (27/38) of those with pancreatic abscess also had 4 or more RPS. The mean duration of hospitalization of survivors was 58 +/- 30 days. Overall mortality was 28.6%. We conclude that RPS are helpful to predict complications in patients with severe pancreatitis.

[Regeneration of gastric mucosa after endoscopic biopsy]

Eleven gastric mucosal defects produced by endoscopic biopsy in non-tumoral areas were histologically studied in gastrectomy specimens. The biopsies had been performed from one up to seven days before the operation. The base of each defect was formed by submucosa infiltrated by erythrocytes, fibrin and neutrophils, which were later replaced by small blood vessels, fibroblasts and collagen fibrils. The mucosa of the margins bowed down towards the base of the defect. This marginal mucosa showed dedifferentiation of the glandular epithelial cells, increased mitotic index and some cystic glandular structures lined by basophilic cells. The defect was progressively covered by a layer of flattened or cuboidal cells in which no mitoses were observed; their cytoplasm contained mucosubstances similar to those of the superficial epithelium of the remaining mucosa, either foveolar- or intestinal metaplastic-type. From this layer, simple gland-like invaginations to the underlying connective tissue were observed. The findings are consistent with the regenerative events described in experimental gastric ulcers in animals. The method employed may be useful to study specific aspects on the regeneration of the human gastric mucosa.

[Sudden unexpected nocturnal death: report of a case and review of the literature]

Sudden death usually affects individuals with severe heart disease. A more dramatic phenomenon is the sudden unexpected death of individuals with no evidence of heart disease. It has been described mainly in young healthy males under severe stress. We present a 32 year old man who presented ventricular fibrillation during sleep and was resuscitated by his wife. Recurrent episodes of VF occurred in the following hours. The study, including coronary angiography, revealed a normal heart. Endomyocardial biopsy showed minimal alterations with scarce areas of atrophy and fibrosis. Electrophysiologic evaluation showed an extremely short refractory period of the right ventricle, but the arrhythmia could not be induced by electrical stimulation. An internal cardioverter defibrillator was implanted since the risk of recurrent VF was high. A review of the literature concerning this unusual entity is offered.

[The medical treatment of intestinal obstruction due to adhesions and adherences]

Adhesions are the most common cause of intestinal obstruction. Medical treatment for those patients with no signs of vascular involvement has been successful in many cases. We reviewed the clinical records of 87 patients with intestinal obstruction due to adhesions, having a total of 122 episodes. Satisfactory follow up was obtained in 76% of patients for a mean of 29.6 months. 47% of episodes resolved without need for surgical intervention. Volume entrapment during the first hours was correlated with need for surgical treatment (p < 0.01). Recurrences were not different between medical and surgical patients (p = 0.28). Thus, medical treatment of this type of intestinal obstruction may be attempted in most patients, not only those who are poor surgical risks.

Catabolism of chylomicron remnants in patients with previous acute pancreatitis

A recent study reports that patients with previous acute pancreatitis commonly have an abnormal clearance of serum triglycerides after an oral fat load. This observation supports the hypothesis that patients with previous acute pancreatitis and normal fasting serum triglyceride levels may have a preexistent abnormality in the metabolism of chylomicrons. To test this hypothesis, the catabolism of chylomicrons and their remnants was studied in a series of 7 patients who had sustained an attack of pancreatitis (2, gallstone related; 2, alcohol ingestion; 1, hydatid cyst; and 3, no associated pathological condition) at least 18 mo earlier. All the patients had previously had abnormal oral-fat tolerance test results. These patients were compared with a series of 6 healthy volunteers. Chylomicrons were endogenously labeled with an oral dose of retinyl palmitate, and their plasma elimination half-life was calculated. The retinyl palmitate absorption rate constants were similar in control and pancreatitis patients. The chylomicron t1/2 were 2.3 +/- 0.8 (SD) h and 3.9 +/- 1.8 h in the control and pancreatitis groups, respectively (p = 0.07). The chylomicron remnant t1/2 was 2.7 +/- 1.1 h in the control group and 5.2 +/- 2.4 h in the pancreatitis group (p less than 0.05). This study supports the hypothesis that subjects with previous acute pancreatitis may have an abnormality in the catabolism of chylomicron particles. This abnormality may represent a preexistent genetic condition expressed in either the apoprotein composition of chylomicrons or in the hepatic apolipoprotein E-receptor activity.

[Abdominal actinomycosis: review apropos of 3 cases]

Actinomycosis is a chronic bacterial infectious disease, characterized by multiple abscesses, draining sinuses and abundant dense fibrous tissue. The intra-abdominal variety is rarely found and difficult to diagnose. We report three cases of intra-abdominal actinomycosis successfully treated by surgery and by longterm antibiotic therapy. One patient had a liver actinomycosis and two had ileo-caecal disease. Pertinent literature is reviewed.

[Duodenal obstruction caused by cholelithiasis (Bouverets' syndrome): a clinical case]

A 55 year old man presented with vomiting, abdominal pain, diarrhea, jaundice and choluria. An obstruction of the gastric outlet by a large gallstone located at the duodenum was demonstrated by radiologic, ultrasonographic and endoscopic examinations. The stone could not be removed through endoscopy and the patient was successfully operated on. A review of published reports is included.

[Gastric cancer: surgical results and survival]

From 1975 to 1984, 292 patients with gastric cancer were treated according to a prospective and standardized surgical protocol. This series included 195 men and 97 women, with an average age of 62.5 +/- 11 years (SD). In 20 patients (6.8%) surgery was not performed and 99 were considered unresectable at laparotomy. Gastric resection was performed in 173 (63.3%) (distal subtotal gastrectomy in 94 and total gastrectomy in 79). Operative mortality for subtotal gastrectomy was 3.1% and 6.3% for total gastrectomy. Early gastric cancer was found in 21 patients (none presented lymph node metastases). The cancer invaded the muscular layer in 18 (31% with lymph node metastases) and reached beyond the muscular layer in 134 patients (60.8% with lymph node metastases). The five year actuarial survival was 0% in patients who did not undergo gastric resection, 35.5% for those patients with tumor invading the serosal layer or beyond who were resected, 56.5% for those with invasion up to the muscular layer and 91.8% for patients with early gastric cancer. For those patients who underwent a curative resection, actuarial five year survival was 81%.

[Value of preoperative colonoscopy in colon-rectal neoplasms]

The surgical approach to treat colo-rectal carcinoma is usually based on the findings of barium enema. In 102 patients we reviewed the yield of pre-operative colonoscopy. Barium enema revealed the cancer in 76 of 84 patients (91%), whereas colonoscopy did so in 96 of 102 subjects (94%). In addition, 5 associated cancerous lesions were demonstrated by colonoscopy and none by barium enema. Associated benign lesions were seen in 14 patients. In 5 patients the surgical plan based on the barium enema was modified by the findings at colonoscopy. Eight false negatives to barium enema were correctly diagnosed by colonoscopy. We conclude that colonoscopy yields valuable information, beyond that of barium enema, in patients with colo-rectal cancer.

[Mesenteric vascular insufficiency caused by chronic occlusive disease: experience with the surgical management of 9 cases]

We report our experience in the surgical treatment of visceral arterial occlusive disease in 9 patients. The etiology was atherosclerosis in 7 cases and arteritis in 2. Four patients were admitted because of acute mesenteric ischemia, but only two had a previous history of intestinal angina. Four consulted because of chronic mesenteric angina and only 1 asymptomatic patient received prophylactic revascularization. The clinical picture of postprandial abdominal pain, weight loss, bowel habit disturbance, abdominal bruit or signs of occlusive disease elsewhere, should lead to clinical diagnosis. Angiographic evaluation is mandatory to plan the best surgical approach. In this series we revascularized 14 vessels in 9 patients using different technics. Two patients died (42 and 90 days) following revascularization and partial resection of the gut for extensive infarction. All survivors achieved symptom relief and or recovered or stabilized their weight.

[Colorectal cancer: follow-up after curative resection]

From Jan 1978 to Dec 1984, 128 patients had a curative resection of colorectal carcinoma. A program for early detection and surgical correction of recurrences was initiated in 88 patients with a mean age of 61 years (range 24 to 85). Seventy two patients complied with the program involving clinical examination, chest X-ray, alkaline phosphatase and CEA determinations and endoscopy at 6 month intervals. Mean follow up was 36 months (range 6 to 60). A total of 28 recurrences (32%) were detected: 4 local, 17 distant and 7 local and distant. Recurrences occurred in 46% of grade C, 19% of grade B and 0% of grade A lesions. Sixty eight% of recurrences were detected within 12 months and 93% within 36 months after surgery. Recurrences were detected by clinical examination in 71% of cases. CEA determination was sensitive (81% and specific (92%) for detection of recurrences in the remaining patients. Four patients (14%) were reoperated on with a survival of 3 to 26 months, all dying from disseminated disease. We conclude that this program did not help to improve the 5 year survival rate of colorectal carcinoma submitted to curative resection. CEA determination may be indicated at 2 month intervals during the period of increased recurrence risk.

[Acute pancreatitis and hypertriglyceridemia]

The etiology and pathogenesis of acute pancreatitis are unknown in the majority of patients. However, it is well known that there are several relevant clinical conditions associated to acute pancreatitis such as, gallstone disease, alcoholism and hypertriglyceridemia. The possible pathogenic relationships between acute pancreatitis and hypertriglyceridemia are discussed in this article. It has recently been shown that a significant proportion of patients with a history of acute pancreatitis have an abnormal clearance of exogenous triglycerides, indicating the presence of a preexistent metabolic abnormality in this population. This observation supports the hypothesis of a possible genetic heterogeneity related to either an abnormal apoprotein profile of chylomicrons, or hepatic receptor mechanism of chylomicron remnants uptake in the liver. If this hypothesis proves to be correct, then a genetic marker may be available to identify the subjects at high risk for acute pancreatitis.