Treatment of postoperative ileus with choline citrate--results of a prospective, randomised, placebo-controlled, double-blind multicentre trial

OBJECTIVES

This was a prospective, randomised, placebo-controlled, double-blind multicentre trial to analyse the efficacy of choline citrate in patients with postoperative ileus (POI) after elective colorectal surgery.

METHODS

From October 2005 until June 2008, 122 patients with POI were randomised to receive choline citrate or placebo. One hundred twenty patients were evaluable for tolerability and 107 patients were evaluable for efficacy. The treatment group, 47% (50/107), received 300.2 mg choline citrate intravenously, while the placebo group, 53% (57/107), received sodium chloride. Injections were performed every 12 h until defecation.

RESULTS

Demographic data analysis did not show clinically differences between both groups. Operative procedures included 40% (43/107) hemicolectomy, 38% (41/107) sigmoid resection and 22% (23/107) other colorectal resections. Defecation occurred after an average of 91.8 ± 26.6 h postoperatively in the treatment group, vs. 96.7 ± 35.2 h in the placebo group (p = 0.805). After laparoscopy, defecation occurred after 78.7 ± 25.3 h, vs. 99.2 ± 31.6 h after laparotomy (p = 0.001). Serious adverse effects occurred in 2% (1/60) in the treatment group, vs. 3% (2/60) in the placebo group. None of the events have been assessed as related to the study medication.

CONCLUSION

An efficacy of choline citrate in the treatment of POI after elective colorectal surgery could not be verified. The problem of POI requiring drug treatment seems to be less frequent than suggested by the literature. With technical advances in surgery, especially laparoscopic and fast track surgery, the frequency of POI will further decrease in the future.

Evidence-based German guidelines for surgery for obesity

BACKGROUND

The young field of obesity surgery (bariatric surgery) in Germany expands as a consequence of the rapid increase of overweight and obesity. New surgical methods, minimal access techniques, and the enormous increase of scientific studies and evidence, all contribute to the success of bariatric surgery, which is the only realistic chance of permanent weight loss and regression of secondary diseases in many cases.

METHODS

A systematic literature review, classification of evidence, graded recommendations, and interdisciplinary consensus.

RESULTS

Obesity surgery is an integral component of the multimodal treatment of obesity, which consists of multidisciplinary evaluation and preparation, conservative and surgical treatment elements, and a life-long follow-up. The guideline confirms the body mass index (BMI)-based spectrum of indications (BMI > 40 kg/m(2) or >35 kg/m(2) with secondary diseases) and extends it through elimination of all age restrictions (>18 years and <60 years) and most of the contraindications. Precondition for surgery is the failure of a structured conservative program of 6-12 months or the expected futility of it. Type II diabetes mellitus becomes an independent indication criterion for BMI < 35 kg/m(2) (metabolic surgery). The standard techniques are gastric balloon, gastric banding, gastric bypass, gastric sleeve, and biliopancreatic diversion. The choice of procedure is based on profound knowledge of results, long-term effects, complications, and patient-specific circumstances. The after-care should be structured and organized long term.

CONCLUSION

The S3-guidelines contain evidence-based recommendations for the indication, selection of procedure, technique, and follow-up. Patient care should improve after implementation of these guidelines in clinical practice. Compliance by decision makers and health insurers is warranted.

Prevention of lamivudine-resistant hepatitis B recurrence after liver transplantation with entecavir plus tenofovir combination therapy and perioperative hepatitis B immunoglobulin only

Combination therapy with antivirals plus hepatitis B immunoglobulin (HBIg) has become the standard treatment for prevention of post-liver transplant hepatitis B virus (HBV) recurrence. However, HBIg therapy is inconvenient and expensive. Alternative therapeutic approaches with modern nucleos(t)ide analogues are limited so far. The present case report describes prevention of HBV recurrence with entecavir and tenofovir. A 48-year-old male patient with hepatitis B-induced decompensated liver cirrhosis initially improved on lamivudine (LAM) until LAM resistance (rtL180M and rtM204V) emerged followed by renewed decompensation. Therefore, tenofovir was added to LAM leading to undetectable HBV DNA (<200 copies/mL). Six months later, low-level viremia (479 copies/mL) was detected. Treatment was escalated to tenofovir plus entecavir. HBV DNA became negative again, and the patient underwent orthotopic liver transplantation. HBIg was administered during transplantation (10,000 IU) and on the second and third postoperative days (total dose 26,000 IU). Subsequently, the anti-hepatitis B surface (HBs) titer rose to 1477 IU/L at day 4 post transplantation. Although HBIg should have been continued, the patient remained on combination therapy with tenofovir plus entecavir only. The anti-HBs titer decreased and became negative 4 months later. However, under continued combination therapy with oral antivirals, HBV DNA and hepatitis B surface antigen remained negative during the entire follow-up of 21 months after liver transplantation. Combination therapy with entecavir plus tenofovir may prevent post-liver transplant hepatitis B recurrence even without HBIg maintenance therapy. This case illustrates that combination oral antiviral therapy might substitute for HBIg as indefinite prophylactic regimen due to profound antiviral efficacy and low risk of viral resistance. Efficacy and safety must be further investigated in randomized controlled trials.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI))

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1^st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

Functioning and health in patients with cancer on home-parenteral nutrition: a qualitative study

Background

Malnutrition is a common problem in patients with cancer. One possible strategy to prevent malnutrition and further deterioration is to administer home-parenteral nutrition (HPN). While the effect on survival is still not clear, HPN presumably improves functioning and quality of life. Thus, patients' experiences concerning functioning and quality of life need to be considered when deciding on the provision of HPN. Currently used quality of life measures hardly reflect patients' perspectives and experiences. The objective of our study was to investigate the perspectives of patients with cancer on their experience of functioning and health in relation to HPN in order to get an item pool to develop a comprehensive measure to assess the impact of HPN in this population.

Methods

We conducted a series of qualitative semi-structured interviews. The interviews were analysed to identify categories of the International Classification of Functioning, Disability and Health (ICF) addressed by patients' statements. Patients were consecutively included in the study until an additional patient did not yield any new information.

Results

We extracted 94 different ICF-categories from 16 interviews representing patient-relevant aspects of functioning and health (32 categories from the ICF component 'Body Functions', 10 from 'Body Structures', 32 from 'Activities & Participation', 18 from 'Environmental Factors'). About 8% of the concepts derived from the interviews could not be linked to specific ICF categories because they were either too general, disease-specific or pertained to 'Personal Factors'. Patients referred to 22 different aspects of functioning improving due to HPN; mainly activities of daily living, mobility, sleep and emotional functions.

Conclusions

The ICF proved to be a satisfactory framework to standardize the response of patients with cancer on HPN. For most aspects reported by the patients, a matching concept and ICF category could be found. The development of categories of the component 'Personal Factors' should be promoted to close the existing gap when analyzing interviews using the ICF. The identification and standardization of concepts derived from individual interviews was the first step towards creating new measures based on patients' preferences and experiences which both catch the most relevant aspects of functioning and are sensitive enough to monitor change associated to an intervention such as HPN in a vulnerable population with cancer.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60–80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

Consequences of low birthweight on urinary excretion of DNA markers of oxidative stress in young men

OBJECTIVE

Low birthweight (LBW) has been associated with an increased risk of development of type 2 diabetes in adult life. Both type 1 and type 2 diabetes mellitus are characterized by increased oxidative stress. The purpose of this study was to investigate whether young healthy adults born with LBW showed differences in oxidative stress under normal conditions and during the added challenge of a physiological Intralipid infusion.

MATERIAL AND METHODS

Urinary excretion of DNA markers of oxidative stress were analyzed by LC-MS/MS in 19 men (aged 19 years) with LBW and in 19 age matched, normal birthweight (NBW) controls pre- and post a 3-fold increase of plasma free fatty acids.

RESULTS

Mean excretion rates of 8-oxo-guanine (8oxoGua), 8-oxo-guanosine (8oxoGuo), 8-oxo-2'deoxyguanosine (8oxodG), and 1,N6-ethenodeoxyadenosine (epsilon dA) did not statistically differ between subjects with LBW and NBW (66.9 versus 73.9 nmol/15 h, 17.8 versus 18.5 nmol/15 h, 11.9 versus 14.4 nmol/15 h and 44.0 versus 43.2 pmol/15 h, respectively). Furthermore, Intralipid infusion did not affect excretion of DNA adducts in LBW or NBW subjects. Statistically significant correlations were found between body mass index and urinary excretion of 8oxoGua (r = 0.64, p = 0.003) and 8oxoGuo (r = 0.64, p = 0.003) in the LBW group only.

CONCLUSIONS

These findings suggest that oxidative stress may be a consequence of diabetes and is not, or at least only partly, involved in the early pathogenesis of type 2 diabetes.

Serum peptidome profiling revealed platelet factor 4 as a potential discriminating Peptide associated with pancreatic cancer

PURPOSE

Mass spectrometry-based serum peptidome profiling is a promising tool to identify novel disease-associated biomarkers, but is limited by preanalytic factors and the intricacies of complex data processing. Therefore, we investigated whether standardized sample protocols and new bioinformatic tools combined with external data validation improve the validity of peptidome profiling for the discovery of pancreatic cancer-associated serum markers.

EXPERIMENTAL DESIGN

For the discovery study, two sets of sera from patients with pancreatic cancer (n = 40) and healthy controls (n = 40) were obtained from two different clinical centers. For external data validation, we collected an independent set of samples from patients (n = 20) and healthy controls (n = 20). Magnetic beads with different surface functionalities were used for peptidome fractionation followed by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS). Data evaluation was carried out by comparing two different bioinformatic strategies. Following proteome database search, the matching candidate peptide was verified by MALDI-TOF MS after specific antibody-based immunoaffinity chromatography and independently confirmed by an ELISA assay.

RESULTS

Two significant peaks (m/z 3884; 5959) achieved a sensitivity of 86.3% and a specificity of 97.6% for the discrimination of patients and healthy controls in the external validation set. Adding peak m/z 3884 to conventional clinical tumor markers (CA 19-9 and CEA) improved sensitivity and specificity, as shown by receiver operator characteristics curve analysis (AUROC(combined) = 1.00). Mass spectrometry-based m/z 3884 peak identification and following immunologic quantitation revealed platelet factor 4 as the corresponding peptide.

CONCLUSIONS

MALDI-TOF MS-based serum peptidome profiling allowed the discovery and validation of platelet factor 4 as a new discriminating marker in pancreatic cancer.

ESPEN Guidelines on Parenteral Nutrition: surgery

In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.

Central venous catheter complications during home parenteral nutrition: a prospective pilot study of 481 patients with more than 30,000 catheter days

BACKGROUND

Home parenteral nutrition (HPN) has been shown to delay deterioration in cancer patients with malnutrition. Its risk-benefit ratio, however, is determined by the threat of central venous catheter (CVC) complications. Only few prospective studies on this subject exist, most of them based on small samples. The objective of this study was to provide reliable estimates of incidence rates of CVC complications in everyday HPN patient care in Germany.

PATIENTS AND METHODS

Aiming for a large prospective cohort study, we cooperated with a service provider caring for HPN patients nationwide. Between July 1 and November 30, 2006, all consecutive adult patients with more than 10 infusion days and no previous history of HPN were recruited. Follow-up ended on January 31, 2007. Data were collected in a standardised way by the provider's staff. To prevent underreporting, we used computer-assisted telephone interviews with medical caregivers as a provider-independent data source.

RESULTS

481 patients met the inclusion criteria, contributing a total of 31,337 catheter days. 52 patients experienced a total of 63 CVC complications, resulting in an incidence rate of 2.01 CVC complications per 1,000 catheter days including 1.02 CVC infections per 1,000 catheter days.

CONCLUSION

HPN administration can be safely performed with a relatively low rate of CVC complications.

Impaired erythropoiesis after haemorrhagic shock in mice is associated with erythroid progenitor apoptosis in vivo

OBJECTIVE

Multiply traumatised patients often suffer from blood loss and from subsequent therapy-resistant anaemia, possibly mediated by apoptosis, necrosis, or humoral factors. Therefore, the underlying mechanisms were investigated in bone marrow (BM) and peripheral blood in a murine resuscitated haemorrhagic shock (HS) model.

METHODS

In healthy male mice, pressure-controlled HS was induced for 60 min. The BM was analysed for Annexin-V, 7-amino-actinomycin D, apoptotic enzymes (caspases-3/7, -8, and -9), expression of death receptors (CD120a, CD95), mitochondrial proteins (Bax, Bcl-2, Bcl-x), as well as erythropoietin (EPO) receptor (EPO-R). Blood cell count, peripheral EPO, and tumour necrosis factor-alpha response were additionally monitored.

RESULTS

Twenty-four and 72 h after HS, EPO and EPO-R were strongly up-regulated in peripheral blood and BM, respectively. Decreasing numbers of erythroid progenitors in BM after HS correlated with significant apoptotic changes confirmed by increased caspases-3/7, -8, -9 activity in total BM, death receptor CD95 and CD120a expression on erythroid progenitors, and down-regulated mitochondrial Bcl-2 expression in total BM. Erythroid progenitors in peripheral blood were found to be increased after 72 h.

CONCLUSION

Despite the massive EPO response and up-regulation of EPO-R, BM erythroblasts (EBs) decreased. This could be due to deficient maturation of erythroid progenitors. Furthermore, the increased intrinsic and extrinsic apoptosis activation suggests programmed death of erythroid progenitors. We propose that both apoptosis and negatively regulated erythropoiesis contribute to BM dysfunction, while erythroid progenitor egress plays an additional role.

Gene expression in endoprosthesis loosening: chitinase activity for early diagnosis?

The aim of the study was to identify markers for the early diagnosis of endoprosthesis loosening, for the differentiation between wear particle-induced and septic loosening and to gather new insights into the pathogenesis of endoprosthesis loosening. Gene expression profiles were generated from five periprosthetic membranes of wear particle-induced and five of infectious (septic) type using Affymetrix HG U133A oligonucleotide microarrays. The results of selected differentially expressed genes were validated by RT-PCR (n = 30). The enzyme activity and the genotype of chitinase-1 were assessed in serum samples from 313 consecutive patients hospitalized for endoprosthesis loosening (n = 54) or for other reasons, serving as control subjects (n = 259). Eight hundred twenty-four genes were differentially expressed with a fold change greater than 2 (data sets on http://www.ncbi.nlm.nih.gov/geo/ GSE 7103). Among these were chitinase 1, CD52, calpain 3, apolipoprotein, CD18, lysyl oxidase, cathepsin D, E-cadherin, VE-cadherin, nidogen, angiopoietin 1, and thrombospondin 2. Their differential expression levels were validated by RT-PCR. The chitinase activity was significantly higher in the blood from patients with wear particle-induced prosthesis loosening (p = 0.001). However, chitinase activity as a marker for early diagnosis has a specificity of 83% and a sensitivity of 52%, due to a high variability both in the disease and in the control group.

Reticulocytes and their immature fraction do not detect acute rejection after kidney transplantation

BACKGROUND

Early detection of an acute rejection episode is an important problem in monitoring transplant patients. Erythropoietin (EPO) production is diminished in patients suffering from chronic renal insufficiency or acute rejection. Therefore, a decrease of reticulocyte counts and of young reticulocytes might indicate the emergence of an acute rejection episode. This pilot study examined the value of reticulocyte parameters as indicators of acute rejection episodes.

PATIENTS AND METHODS

Reticulocyte parameters were examined in 25 renal transplant patients. Initial immunosuppressants therapy was based on a combination of methylprednisolone, mycophenolatmofetil, cyclosporine and antithymocyte globulin or basiliximab, CellCept, cyclosporine, and ATG or Simulect. During the first 3 weeks after the procedure, blood samples were collected three times per week. Complete blood counts were performed on XE-2100 analyzers (Sysmex). Acute rejection was biopsy-proven.

RESULTS

Acute rejection episodes were not accompanied by significantly altered reticulocyte parameters. During the first weeks, the reticulocyte count or the immature fraction, respectively, did not differ between patients with delayed versus immediate onset of renal function: reticulocyte count 1.70 +/- 1.06% vs 1.58 +/- 1.10% and ratio of immature (high fluorescent) reticulocytes 22.8 +/- 7.9% vs 17.6 +/- 9.4%).

CONCLUSION

Reticulocyte counts and determination of the immature reticulocyte fraction were not significantly altered by an acute rejection episode. Various influences modulate the release of EPO and reaction of erythropoiesis upon an EPO stimulus.

Multiple gastrointestinale Stromatumoren bei Neurofibromatose Typ 1

BACKGROUND

Gastrointestinal stromal tumors (GIST) are generally rare, but appear more frequently in patients with neurofibromatosis type 1. Mostly asymptomatic, GIST can also cause relevant clinical appearances such as gastrointestinal bleeding, obstruction, or invagination. In recent years, a significant expert knowledge was gained in biology and treatment of these tumors.

CASE REPORT

The case of a 50-year-old man with a history of neurofibromatosis type 1 and acute gastrointestinal bleeding is described. In the index upper endoscopy an ulcerated tumor of the proximal small bowel was found. The histopathologic examination showed a GIST. Segmental small bowel resection was carried out. Over the course of 1 year, there has been no evidence of a recurrence, metastases, or metachronous GIST.

CONCLUSION

Considering the distinct biology of GIST in patients with neurofibromatosis type 1, the recommendation for a generous endoscopic examination or a routine endoscopy in this population is discussed.

Metabolic effects of caffeine ingestion and physical work in 75-year old citizens. A randomized, double-blind, placebo-controlled, cross-over study

OBJECTIVE

Whereas caffeine has been demonstrated to impact substantially on the metabolic response to exercise in healthy young subjects, this issue remains to be addressed in healthy elderly subjects.

DESIGN AND PATIENTS

The metabolic response to caffeine ingestion (6 mg/kg) and exercise in healthy elderly citizens at 70 years was examined in a randomized, double-blind, placebo-controlled, cross-over study. We included 30 subjects attending for driver license renewal at their general practitioner. Participants abstained from caffeinated drinks and food for 48 h and were randomized to receive placebo-caffeine or caffeine-placebo with 1 week between sessions.

MEASUREMENTS

A cycling endurance test at 65% of the expected maximal heart rate was performed 1 h after intervention. Blood samples were taken before intervention, before cycling, after 5 min of cycling, and at exhaustion. Analysis was by intention-to-treat and P < 0.05 was regarded as significant.

RESULTS

Caffeine significantly increased the concentration of plasma epinephrine (by 42%, 39%, and 49%), serum-free fatty acids (by 53%, 44%, and 50%), and plasma lactate (by 46%, 36%, and 48%), and insulin resistance (homeostasis model assessment-IR) (by 21%, 26%, and 23%) during rest, after 5 min of cycling, and at exhaustion. At exhaustion, the concentration plasma norepinephrine was elevated by 29%. A decrease was seen with caffeine treatment in blood potassium after 5 min of cycling and at exhaustion (by 3% and 2%, respectively).

CONCLUSIONS

Caffeine treatment increased epinephrine, fatty acids, lactate and norepinephrine at different times during test session and led to insulin-resistance. Hence, caffeine ingestion elicits a similar metabolic response in elderly participants at 70 years old to that seen in younger subjects.

The German hospital malnutrition study

BACKGROUND & AIMS

Malnutrition is frequently observed in chronic and severe diseases and associated with impaired outcome. In Germany general data on prevalence and impact of hospital malnutrition are missing.

METHODS

Nutritional state was assessed by subjective global assessment (SGA) and by anthropometric measurements in 1,886 consecutively admitted patients in 13 hospitals (n=1,073, university hospitals; n=813, community or teaching hospitals). Risk factors for malnutrition and the impact of nutritional status on length of hospital stay were analyzed.

RESULTS

Malnutrition was diagnosed in 27.4% of patients according to SGA. A low arm muscle area and arm fat area were observed in 11.3% and 17.1%, respectively. Forty-three % of patients 70 years old were malnourished compared to only 7.8% of patients <30 years. The highest prevalence of malnutrition was observed in geriatric (56.2%), oncology (37.6%), and gastroenterology (32.6%) departments. Multivariate analysis revealed three independent risk factors: higher age, polypharmacy, and malignant disease (all P<0.01). Malnutrition was associated with an 43% increase of hospital stay (P<0.001).

CONCLUSIONS

In German hospitals every fourth patient is malnourished. Malnutrition is associated with increased length of hospital stay. Higher age, malignant disease and major comorbidity were found to be the main contributors to malnutrition. Adequate nutritional support should be initiated in order to optimize the clinical outcome of these patients.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Fit for surgery: an expert panel review on optmising patients prior to surgery, with a particular focus on nutrition

This article represents the views of an international group of surgeons on the need for pre-operative optimisation of patient's nutritional status prior to elective surgery as a means of reducing post-operative infective complications.

Feasibility and safety of needle catheter jejunostomy for enteral nutrition in surgically treated severe acute pancreatitis

BACKGROUND

The role of the gut in the development of septic complications and promising clinical results have led to a shift from the parenteral to the enteral route for nutrition support of patients with acute pancreatitis. In patients undergoing surgery for severe necrotizing pancreatitis, the application of a needle catheter jejunostomy might be useful. However, there is a shortage of clinical data on its feasibility and possible harmful effect.

METHODS

Between January 1999 and December 2002, 13 patients were operated for severe acute necrotizing pancreatitis. At the time of surgery, needle catheter jejunostomy was performed using a standard technique. Enteral nutrition was initiated without a strict protocol by feeding small amounts of a standard diet and carefully monitoring patient tolerance. As long as necessary, patients were also fed parenterally in order to achieve target caloric goals.

RESULTS

No major tube- or feeding-related complications were observed. A single case of tube dislodgement caused by manipulation during relaparotomy for lavage occurred and was rectified during the same operation.

CONCLUSIONS

In patients undergoing surgery for severe acute pancreatitis, needle catheter jejunostomy for long-term enteral nutrition can be applied with no additional risk.

["Shrinkage of cruciate ligaments"--a biomechanical study. Shrinkage of elongated cruciate ligaments using an application of radiofrequency energy]

The aim of this study was to evaluate structural properties of native and elongated bovine anterior cruciate ligaments after the application of bipolar radiofrequency. Using a material testing machine typical load-elongation curves were used to determine the initial strength of untreated (group 1, n = 20) and elongated cruciate ligaments (group 2, n = 20) after treatment with bipolar radiofrequency (ArthroCare). After the application of a cyclic loading protocol (1000 x 400 N) elongation, yield load, maximal load, and stiffness were determined. Native ligaments served as a control group (group 3, n = 20). In both groups 4 mm reduction in length was caused by the application of radiofrequency. Elongation was significantly higher; yield load, maximal load, and stiffness of cruciate ligaments treated with radiofrequency (groups 1 and 2) were significantly reduced after the application of a cyclic loading protocol in comparison to the control group (p < 0.05). Group 2 ligaments showed the lowest values. The application of radiofrequency weakens the biomechanical properties of native and elongated cruciate ligaments significantly. When radiofrequency energy is used to shrink elongated cruciate ligaments, a nonaggressive rehabilitation protocol should be applied.

Assessment of Sequential Enhancement Patterns of Focal Nodular Hyperplasia and Hepatocellular Carcinoma on Mangafodipir Trisodium Enhanced MR Imaging

RATIONALE AND OBJECTIVES

Sequential contrast changes of mangafodipir trisodium (Mn-DPDP)-enhanced magnetic resonance imaging (MRI) were evaluated in the differentiation of focal nodular hyperplasias (FNH) and hepatocellular carcinomas (HCC).

METHODS

Patients with FNH (n = 16) or HCC (n = 12) underwent MRI: T2-weighted fast spin echo before and T1-weighted gradient echo before and 1, 4, 14, and 22 hours after 5 micromol/kg Mn-DPDP. Homogeneity of enhancement and delineation of fibrous scars of FNHs were assessed qualitatively. Lesion-to-liver contrast changes of FNHs and HCCs were compared quantitatively (Mann-Whitney U).

RESULTS

Mn-DPDP improved detection of characteristic scars of FNHs from 50% before to 90% after contrast agent. Apart from fibrous tissue enhancement of FNHs was mostly homogeneous (90%). Time-dependent contrast changes were up to 20 times higher (after 4 hours) for FNHs than HCCs (P < 0.0001).

CONCLUSIONS

Mn-DPDP-enhanced MRI helps to delineate characteristic morphologic features of FNHs and can provide quantitative data differentiating FNH and HCC.

Immunonutrition in patients after multiple trauma

Severe trauma threatens the life of the victim, both directly and indirectly via immunological dysregulation during the subsequent clinical course. Inflammatory or infectious episodes may complicate the clinical course and ultimately result in sepsis and multiple organ failure, which have mortality rates of up to 80%. Immunomodulatory intervention aims to ameliorate the early hyperinflammatory phase (systemic inflammatory response syndrome, SIRS) to avoid the development of sepsis. One of the immunomodulation strategies is enteral feeding supplemented with specific nutrients, such as glutamine, n-3-polyunsaturated fatty acids, and nucleotides ('immunonutrition'), because changes in the GALT (gut-associated lymphoid tissue) immune response may contribute to intestinal dysfunction and increase susceptibility to post injury gut-derived sepsis. In a prospective, randomized, double-blind, controlled study in twenty-nine patients suffering severe trauma we were able to show that immunonutrition (arginine, n-3-fatty acids, and nucleotides) significantly reduces the number of SIRS days per patient, and also lowers the multiple organ failure (MOF) score on day 3 and days 8-11 (P<0.05). Other studies have reported a reduction in septic complications and MOF rates, shortened hospital stay, and reduction in the use of antibiotics in patients randomized to the immune-enhancing diet. This improved clinical outcome was reflected in a reduction in hospital costs. In the recovery period after trauma (1-72 h after injury) a limitation of the inflammatory response of immunocompetent cells must be achieved as quickly as possible (<72 h). The only strategy available to clinicians caring for trauma patients is immunonutrition, and this should be strongly considered as a rational approach improving immune function and reducing septic complications in critically ill or injured patients.

A study of kynurenine fragmentation using electrospray tandem mass spectrometry

A combination of accurate mass measurement and tandem mass spectrometry (both product ion and precursor ion scans) have been used to characterize the major fragment ions observed in the ESI mass spectrum of kynurenine. Kynurenine is a metabolite of tryptophan found in the human lens and is thought to play a role in protecting the retina from UV-induced damage. Three major fragmentation pathways were evident, following initial elimination either of ammonia, H2O and CO or the imine form of glycine. The latter is proposed to occur via the formation of an ion-molecule complex. In the case of loss of H2O and CO from deaminated kynurenine, there is evidence for an acylium ion intermediate, which is not observed for the loss of H2O and CO directly from protonated kynurenine. Product ion scans of deuterated kynurenine enabled the elucidation of structural rearrangements that were not evident in the spectra of the native compound. Since UV filter compounds can often only be isolated in small quantities from the lens, this study forms the basis for the characterization of novel UV filter compounds using mass spectrometry. The approach presented here may also be useful for the characterization of related classes of small molecules.

Measurement of 8-oxo-2'-deoxyguanosine and 8-oxo-2'-deoxyadenosine in DNA and human urine by high performance liquid chromatography-electrospray tandem mass spectrometry

A method for the determination of 8-oxo-2'-deoxyguanosine and 8-oxo-2'-deoxyadenosine in DNA and urine by High Performance Liquid Chromatography (HPLC)-Tandem Mass Spectrometry is described. For the urine samples there is no sample preparation except for addition of buffer and internal standards followed by redissolvation of precipitate containing 8-oxo-2'-deoxyguanosine and a centrifugation step before the samples are injected onto the HPLC column. The detection limit for 8-oxo-2'-deoxyguanosine and 8-oxo-2'-deoxyadenosine is approximately 0.3 nM corresponding to 7.5 fmol injected. Long runs, that is, > 50 samples, can be analyzed with only minimal loss of sensitivity. The concentrations excreted into urine samples from humans are between 1 and 100 nM for 8-oxo-2'-deoxyguanosine and below 0.3 nM for 8-oxo-2'-deoxyadenosine. In calf thymus DNA levels down to about 1 oxidized guanosine and adenosine per 10(6) unmodified bases can be detected. High levels of 8-oxo-2'-deoxyguanosine were found, 30 per 10(6) 2'-deoxyguanosine, levels of 8-oxo-2'-deoxyadenosine are at or below the detection limit. These findings indicate that High Performance Liquid Chromatography-Tandem Mass Spectrometry is a highly sensitive and specific method for analysis of oxidative DNA modifications in tissue as well as for analysis of excretion of oxidized nucleotides into urine that ensures a minimum artifact formation.

Nutrition of liver transplant patients

Good cooperation between the hepatologist, surgeon and anesthesiologist is required to determine the appropriate perioperative nutritional management for the liver transplant patient. For preoperative risk stratification, nutritional assessment according to resting energy expenditure by indirect calorimetry, and body cell mass by bioelectrical impedence analysis, may be superior to anthropometric parameters. When considering impaired glucose tolerance in the early postoperative period, requirements of energy intake and macronutrients are no different from those established in major abdominal surgery. Preference should be made to use the enteral route whenever possible. Fat emulsions containing medium- and long-chain triglycerides have neither a negative impact on reticulo-endothelial system recovery of the graft, nor any obvious metabolic advantages. There is no evidence for the routine use of branched-chain amino acids. Even in the case of good graft function, long term dietary evaluation and counselling may be useful. Impaired glucose tolerance, hyperlipidemia and hypercholesterolemia should be considered carefully. The role of preoperative nutritional therapy using oral supplements and the value of immune-enhancing substrates should be evaluated with special regard to a decrease in postoperative septic complications and for possible impact on immune tolerance after transplantation.

Antioxidants, DNA damage and gene expression

Reactive oxygen species (ROS) are generated from incomplete reduction in the respiratory chain. On one hand they pose a serious threat of deleterious effects on important macromolecules, among which DNA is considered most important since it carries the genetic information and changes will be carried on to future generations, or will fundamentally change the behaviour of the cells. On the other hand, it is becoming evident that there are important changes in the cells in response to redox changes. This review summarises the genes, the intracellular signalling elements and molecules that presently are known to be regulated by oxidative stress. It is now clear that both oxidants and antioxidants can regulate a multitude of different cellular functions, signal transduction pathways and gene expression. However, the quantitative importance is unknown and as of yet there are no examples of regulation exclusively by oxidative stress. Also the response to oxidative stress is variable, can be up-regulation as well as down-regulation, and different responses to dose or magnitude of the oxidative stress can be demonstrated. The effect from supplementation with an antioxidant is difficult to predict, and ultimately must be assessed in clinical trials.

Retrospective analysis of prognostic factors after liver resection and transplantation for cholangiocellular carcinoma

BACKGROUND

Cholangiocellular carcinoma is an uncommon primary liver cancer, which may be mixed with hepatocellular carcinoma. A retrospective analysis was undertaken to evaluate the results of surgical treatment and to identify prognostic factors.

METHODS

Between 1978 and 1996, 162 patients underwent surgery for cholangiocellular carcinoma: liver resection (n = 95), liver transplantation (n = 24) and exploratory laparotomy with and without drainage (n = 43). Univariate and multivariate analyses of prognostic factors were performed.

RESULTS

Overall survival was 47 per cent at 1 year, 28 per cent at 2 years and 13 per cent at 5 years. Survival rates for patients with resectable tumours were 64, 43 and 21 per cent respectively, and for those who underwent liver transplantation 21, 8 per cent and zero respectively. Univariate analysis showed that the following variables had an effect on survival: age, jaundice, liver resection, T, N and M stage in the tumour node metastasis classification, Union Internacional Contra la Cancrum (UICC) tumour stage, tumour-free margins, vascular infiltration, tumour number, tumour size and serum level of carcinoembryonic antigen. Multivariate analysis identified jaundice, N and M category, and UICC tumour stage as independent prognostic factors.

CONCLUSION

The data underscore the importance and prognostic value of the UICC tumour classification for cholangiocellular carcinoma. The prognosis of mixed tumours is no different. Liver resection remains the treatment of choice; transplantation offers no solution for otherwise unresectable tumours.

Importance of guanine nitration and hydroxylation in DNA in vitro and in vivo

Guanine (Gua) modification by nitrating and hydroxylating systems was investigated in DNA. In isolated calf thymus DNA, 8-NO(2)-Gua and 8-oxo-Gua were dose-dependently formed with peroxynitrite, and 8-NO(2)-Gua was released in substantial amounts. Myeloperoxidase (MPO) with H(2)O(2) and NO(2)(-) reacted with calf thymus DNA to form 8-NO(2)-Gua dose dependently without release of 8-NO(2)-Gua. The frequency of strand breaks was higher than the sum of 8-NO(2)-Gua and 8-oxo-Gua, particularly in the MPO-treated DNA, indicating the importance of other types of damage. The activation of human neutrophils and lymphocytes with phorbol ester did not induce 8-NO(2)-Gua and 8-oxo-Gua in their nuclear DNA. However, 8-NO(2)-Gua was found in calf thymus DNA co-incubated with activated neutrophils in the presence of NO(2)(-). No significant formation of 8-NO(2)-Gua was found in liver DNA from mice treated with Escherichia coli lipopolysaccharide. The incubation of peroxynitrite or MPO-H(2)O(2)-NO(2)(-)-treated DNA with formamidopyrimidine glycosylase (Fpg) released 8-oxo-Gua, but not 8-NO(2)-Gua, indicating that 8-NO(2)-Gua is not a substrate for Fpg. Although 8-NO(2)-Gua was generated in isolated DNA by different nitrating systems, other types of damage were formed in abundance, and the lesion could not be found reliably in nuclear DNA, suggesting that the biological importance is limited.

Structural analysis of drug-DNA adducts by tandem mass spectrometry

The utility of electrospray ionisation (ESI) tandem mass spectrometry (MS/MS) for the characterisation of ligand-oligonucleotide adducts is demonstrated with adducts formed between the oligonucleotide 5'-CACGTG-3' and both a platinating agent, cis-diamminedichloroplatinum(II) (cisplatin), and an alkylating ligand, n-bromohexylphenanthridinium bromide (phenC6Br). We have demonstrated previously that negative ion MS/MS spectra of alkylated oligonucleotides show a highly specific fragmentation pathway that enables the site of binding of the ligand to be readily identified. In comparison, the positive ion ESI-MS/MS spectra reported here also show a single major fragmentation pathway, but the dominant ion is the protonated ligand-base adduct. MS/MS of this ion confirms the site on binding of the ligand to the guanine base. MS/MS spectra of cisplatin adducts show much less specific fragmentation than alkylated adducts, particularly in the negative ion mode. This suggests that the ESI-MS/MS spectra of ligand-DNA adducts are strongly influenced by the extent to which the ligand weakens the glycosidic bond in the residue to which it is bound. For platinating agents, which do not labilise the glycosidic bond, additional experiments involving MS/MS of source-generated product ions were required to enable isomeric adducts to be distinguished.

Methods to detect DNA damage by free radicals: relation to exercise

Epidemiological investigations repeatedly show decreased morbidity from regular exercise compared with sedentary life. A large number of investigations have demonstrated increased oxidation of important cellular macromolecules, whereas other investigators have found no effects or even signs of lowering of oxidation of macromolecules. In particular, extreme and long-duration strenuous exercise appears to lead to deleterious oxidation of cellular macromolecules. The oxidation of DNA is important because the oxidative modifications of DNA bases, particularly the 8-hydroxylation of guanine, are mutagenic and have been implicated in a variety of diseases such as ageing and cancer. The methodologies for further investigation of the relationship between DNA oxidation and exercise are available. The preferred methods rely on HPLC or GC-mass spectrometry; whereas the theoretically-attractive liquid chromatography-tandem mass spectrometry is being developed. Caution should be taken to avoid artifacts because of the six orders of magnitude of difference between oxidized and non-oxidized DNA bases in tissues. The methods can be used to estimate tissue levels, i.e. a local concentration of oxidized DNA, or to estimate the rate of body DNA oxidation by the urinary output of repair products, the latter being a method that is independent of repair. During exercise there appears to be a shifting of dietary-dependent antioxidant, e.g. vitamin C and vitamin E, from muscle to plasma, and an increased oxidation in plasma of these antioxidants. Supplementation trials with antioxidants have not been able to increase exercise performance; however, optimum nutrition with antioxidants and possibly supplementation, could be important in the prevention of diseases in the long term. The pattern from these observations appears to be quite consistent; immediately after exercise, regardless of how intense, there do not appear to be any signs of oxidative damage to DNA. Acute or prolonged moderate exercise does not produce signs of oxidative DNA damage and might even be associated with lowering of the levels of oxidation of tissue DNA; however, after long-duration and intense exercise an increase in oxidative DNA modifications is apparent. We suggest as a hypothesis that the relationship between exercise and health is U-shaped. This hypothesis needs to be tested in detail in order to establish the maximum beneficial exercise level with regard to oxidative DNA modification, and also the level that could be deleterious and might even increase the risk for cancer and other diseases.