164 DEVELOPMENT OF MURINE EMBRYOS AFTER INJECTION OF UNCOATED GOLD AND SILVER NANOPARTICLES

Novel techniques such as ultrashort pulsed laser technology to produce in situ bio-conjugated nanoparticles (NP) as biomarkers for optical imaging and intervention hold great potential to observe dynamic processes in gametes and embryos without affecting their developmental potential. With regard to toxicology, current preliminary evidence is mainly based on specific cell lines and suggests low toxicity for gold NP (GNP), but a higher toxicity for silver NP (SNP), which also possess a considerable antibacterial effect. Little is known about their impact on sensitive biological systems as early mammalian embryos. The present study investigated the potential toxicity of GNP and SNP in murine embryos for the first time. Since the NP were laser-generated, they formed a stable dispersion in water without the need of surface coating, which might have caused additional toxic effects. Approximately 10 pL of a NP díspersion (average NP diameter of 15 nm) containing 50 μg mL-1 of either GNP or SNP were injected into 1 blastomere of 2-cell-stage embryos (n = 93 or 75, respectively), derived from superovulated NMRI mice. Embryos injected with water alone (n = 79) served as controls. Untreated embryos (n = 92) were run as a handling control. Successful NP injection was confirmed using laser scanning confocal microscopy. After treatment, embryos were cultured for 72 h at 37°C and 5% CO2 in KSOM plus 1% BSA. Embryo development was assessed on a daily basis. No abnormal development was observed. The handling controls reached a blastocyst rate of 77.2%. A total of 66.2% of the water-injected embryos developed to blastocysts, compared to 62.4% and 56.0% after injection of GNP and SNP, respectively. Neither 1-way ANOVA nor an additional chi-square test indicated significant differences between treatment groups. In conclusion, these preliminary data indicate that intracytoplasmatic injection of GNP and SNP had no significant impact on embryo development. Further tests, including qRT-PCR of development-relevant genes in blastocysts and transfer of injected embryos into recipient animals to study potential long-term effects, are underway to gain a better understanding of GNP and SNP embryo toxicology. We gratefully acknowledge the support of the Masterrind GmbH Verden and the NBank Niedersachsen.

Family history of pilonidal sinus predisposes to earlier onset of disease and a 50% long-term recurrence rate

PURPOSE

It has long been suspected that a family history of pilonidal sinus disease may predispose to higher disease incidence. The influence of family history on recurrence rate has not been investigated. The purpose of this study was to evaluate the recurrence rate in patients with both a personal and a family history of pilonidal sinus disease.

METHODS

A standardized telephone interview was used to retrospectively study 578 patients who underwent primary surgery between 1980 and 1996. Differences concerning the long-term recurrence rate between patients with a positive or negative family history were analyzed using Kaplan-Meier statistics.

RESULTS

Sixty-eight of 578 patients (12%) had a positive family history with first-degree relatives, in which 28 brothers and 25 fathers were similarly involved. The long-term recurrence rate was significantly elevated when family history was positive (35% vs. 22% after 15 years and 52% vs. 28% after 25 years; P = 0.02). The long-term recurrence rate was elevated if surgery was needed at a younger age (P = 0.03). The body mass index measured at time of admission for surgery did not seem to have any negative influence on recurrence rates (P = 0.31). Although a positive family history predisposes a person to earlier onset of disease, recurrences occur within 5.1 +/- 6.2 years (mean +/- standard deviation) in patients with a positive family history and within 5.3 +/- 5.2 years in patients with a negative family history (P = 0.95).

CONCLUSION

Patients with a positive family history need closer surgical monitoring because primary disease will manifest earlier. A remarkable long-term recurrence rate exceeding 50% after 25 years places a much higher disease burden on patients with a positive family history. All available interventions known to reduce recurrence rate should be applied to this group of patients.

Selective cognitive deficits and reduced hippocampal brain-derived neurotrophic factor mRNA expression in small-conductance calcium-activated K+ channel deficient mice

Small-conductance calcium-activated K(+) channels 1-3 (SK1-3) are important for neuronal firing regulation and are considered putative CNS drug targets. For instance non-selective SK blockers improve performance in animal models of cognition. The SK subtype(s) involved herein awaits identification and the question is difficult to address pharmacologically due to the lack of subtype-selective SK-channel modulators. In this study, we used doxycycline-induced conditional SK3-deficient (T/T) mice to address the cognitive consequences of selective SK3 deficiency. In T/T mice SK3 protein is near-eliminated from the brain following doxycycline treatment. We tested T/T and wild type (WT) littermate mice in five distinct learning and memory paradigms. In Y-maze spontaneous alternations and five-trial inhibitory avoidance the performance of T/T mice was markedly inferior to WT mice. In contrast, T/T and WT mice performed equally well in passive avoidance, object recognition and the Morris water maze. Thus, some aspects of working/short-term memory are disrupted in T/T mice. Using in situ hybridization, we further found the cognitive deficits in T/T mice to be paralleled by reduced brain-derived neurotrophic factor (BDNF) mRNA expression in the dentate gyrus and CA3 of the hippocampus. BDNF mRNA levels in the frontal cortex were not affected. BDNF has been crucially implicated in many cognitive processes. Hence, the biological substrate for the cognitive impairments in T/T mice could conceivably entail reduced trophic support of the hippocampus.

The possible relation between postpartum exacerbation of hyperthyroidism and neonatal thyrotoxicosis

Hyperthyroidism is generally considered to be ameliorated during pregnancy, and there appears to be a high incidence of postpartum exacerbation. These phenomena have to our knowledge not been related to neonatal thyrotoxicosis, a transient hyperthyroidism seen only in newborns of previous or current hyperthyroid mothers. The first of two siblings of a previously thyrotoxic mother had marked symptoms of neonatal thyrotoxicosis and high levels of thyroid hormones. The mother had not received antithyroid treatment during her first pregnancy. During her next pregnancy she was treated with propylthiouracil from the second trimester. This infant had only minimal thyrotoxic signs but almost as high levels of thyroid hormones during the neonatal period as the elder. The mother had no signs of postpartum exacerbation but her thyroid hormones were significantly elevated in the postpartum period analogous to the infants. Neither the mother nor the infants presented any increase in thyroid-stimulation hormone and long-acting thyroid stimulator during the hyperthyroid periods. The possibility is discussed, that postpartum exacerbation of hyperthyroidism and neonatal thyrotoxicosis may be related. They could be the result of a changed balance between a thyroid stimulator and an inhibitor after birth.

Long-term effects of postoperative razor epilation in pilonidal sinus disease

PURPOSE

To study potential benefits of postoperative epilation after pilonidal sinus surgery, the long-term effect of hair removal on pilonidal recurrence was investigated.

METHODS

A total of 1,960 patients with pilonidal sinus treated surgically from 1980 to 1996 in three hospitals of the Deutsche Bundeswehr were eligible for the study. Regular hair removal with a razor was recommended for all patients after surgery. A randomly selected sample of 504 patients was contacted for a follow-up telephone interview.

RESULTS

The mean follow-up time was 11.3 (standard deviation, 6.4) years. Overall, pilonidal sinus disease recurred in 111 (22 percent) of the 504 patients. A total of 113 patients followed the recommendation to perform epilation (mean duration, 7.5 months), and 391 patients did not. Recurrence was observed in 30.1 percent (34/113) of patients who performed postoperative epilation and in 19.7 percent (77/391) of patients who did not perform postoperative epilation (P = 0.01).

CONCLUSIONS

Razor hair removal increases the rate of long-term recurrence after surgery for pilonidal sinus disease and therefore should not be recommended. However, the rationale for hair removal in pilonidal sinus disease is compelling. Other epilation techniques such as laser hair removal should be investigated in appropriate studies.

Time and rate of sinus formation in pilonidal sinus disease

BACKGROUND

and aims To elicit mechanisms and timing of sinus development, the role of age at onset of symptoms, symptomatic disease duration, and consecutive number of sinuses were investigated.

MATERIALS AND METHODS

Analysis of 1,962 medical records of patients admitted for primary surgical pilonidal sinus treatment.

RESULTS

Sinus number ranged from 1 to 16 (median 2), with chronic pilonidal disease showing more sinuses than acute disease (mean 2.6 vs 2.1 sinuses; p < 0.0001; Kolmogorov-Smirnov). Disease duration in chronic pilonidal disease was not linked to sinus formation (p = 0.98; Spearman). In acute pilonidal disease, duration was linked to the development of six sinuses per 1,000 symptomatic disease years (p = 0.0001; Spearman). A larger sinus number correlated with earlier onset of symptoms (p = 0.009; Spearman).

CONCLUSION

Long-standing chronic disease does not produce sinus per se. As sinus does not substantially arise during the course of symptomatic disease, there must be a time before the start of symptomatic disease when the sinus originates. These findings suggest that sinus can only be acquired up to a certain age, even if occupational exposure continues.

Timeline of recurrence after primary and secondary pilonidal sinus surgery

PURPOSE

This study was designed to evaluate the timeline of recurrence of pilonidal sinus disease after primary vs. multiple surgery. Data of medical military service in Germany were reviewed.

METHODS

Telephone interview of 205 patients after pilonidal sinus disease surgery after median interval of 14.8 (standard deviation +/-3.9) years was conducted. A total of 345 patient charts with pilonidal sinus disease recurrence and fully documented previous surgery history were analyzed.

RESULTS

Pilonidal sinus disease recurred in 41 of 205 patients (20 percent; actuarial survival 22 percent) after first surgery. Median recurrence-free-interval was 1.8 (range, 0.1-16.5) years. Twenty-nine of 41 of all recurrences (71 percent) were observed within four years after primary surgery. Fifteen of 50 patients (30 percent) treated by primary closure had recurrent disease after a median recurrence-free interval of 2.7 (range, 0.2-13.5) years compared with 24 of 144 patients (17 percent), who experienced recurrence after rhomboid excision and open wound treatment after a median of 1.8 (range 0.1-16.5) years (P = 0.081, long-rank-test). Analysis of 345 recurrent disease charts revealed that recurrence time decreased for multiple recurrences compared with first recurrence (R1 vs. R2: P = 0.07; R2 vs. R3: P = 0.03, Mann-Whitney U test).

CONCLUSIONS

Long-term recurrence rate was 22 percent and thus higher than previously reported. This may be attributed to the long follow-up interval. Recurrences up to 20 years after surgery were seen. Our data provide evidence that follow-up after first to the third pilonidal sinus surgery should complete or exceed five years, because the majority of recurrences occur during this postoperative interval. Nevertheless, even a five-year follow-up will still miss 25 percent of recurrences.

Radiation-induced sequelae affecting the continence organ: incidence, pathogenesis, and treatment

INTRODUCTION

Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians.

REVIEW

This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea.

CONCLUSION

Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option.

Short-term results of Karydakis flap for pilonidal sinus disease

BACKGROUND

Because of the higher quality of life that the Karydakis flap provides compared to excision-only treatment, it became a recommended closure technique for pilonidal sinus disease. This study aimed to evaluate whether Karydakis flap technique can be performed in potentially infected tissue if the surrounding cellulitis allows wound closure.

METHODS

188 patients with pilonidal sinus who underwent excision only (n=91, 48%) or the Karydakis-flap technique (n=97, 52%) were evaluated. The results were reviewed according to the degree of wound contamination, and the effects of closure technique were studied in terms of early wound complications and the duration of hospital stay.

RESULTS

In the excision-only group, one patient developed a hematoma (1%) and one patient had cellulitis of the surrounding tissue (1%), which resulted in a 2% complication rate this group. In the Karydakis flap group, wound abscesses were observed in 12 patients (12%). Additionally, four patients (4%) had hematomas, two patients had seromas (2%) and three had other complications. For the Karydakis group, the overall complication rate was 21%, significantly higher than that for the excision-only group (p<0.01). In the Karydakis group, no association was found between complications and the degree of contamination (p=0.36).

CONCLUSIONS

These data provide evidence that the Karydakis flap technique might be performed even in potentially infected tissue. Although a considerable number of wound-related complications was observed in the Karydakis flap group, the majority of patients had primary healing. Thus, from our viewpoint, the Karydakis flap seems to be a potential alternative to simple excision in infected pilonidal sinus disease.

Chirurgische Therapieoptionen beim Rektumprolaps - Indikation, Technik und Ergebnisse

Two different approaches can be distinguished in the surgical treatment of rectal prolapse, i. e. the transabdominal route and the perineal procedures. The following article deals with both operative options with a detailed discussion of the Delorme's operation and the perineal rectosigmoidectomy, also known as the Altemeier procedure for the perineal techniques. Regarding abdominal operations simple rectopexy is compared with operations including bowel resection including minimally invasive approaches. In general, perineal procedures for full-thickness rectal prolapse cause less morbidity compared with abdominal operations. They are especially indicated in the elderly and /or high-risk patients. Recurrences, on the other hand, are usually encountered more often following local techniques as compared with abdominal operations. It can be concluded that perineal as well as abdominal procedures remain important options in the surgical treatment of rectal prolapse and should be part of the armamentarium of colorectal surgeons.

Long-term trends and short-term variability of water quality in Skive Fjord, Denmark - nutrient load and mussels are the primary pressures and drivers that influence water quality

Nineteen years of monitoring data from the eutrophic Skive Fjord, Denmark were examined for linkages to external pressures and drivers, including nutrient inputs, meteorology and stocks of blue mussels. Linkages were examined by: 1) time-series analysis to document effects of nutrient reduction programs, 2) Pearson Rank correlations, 3) multivariate statistical analysis (PLS) to identify water quality variables with high predictability and their linkages to pressures, and 4) regression analysis to quantify relationships between pressures and water quality. Freshwater input, nitrogen load and phosphorus load showed decreasing trends through the period 1984-2002. The load reductions were only partially translated into trends in water quality: phosphorus decreased in most seasons, while total nitrogen decreased during winter and spring only. Phosphorus concentration had the highest predictability (explained by seasonal temperature variation) followed by transparency, silicate, tot-N, chlorophyll-a, primary productivity, phytoplankton diversity and phytoplankton turnover. The variation in pressures other than nutrient input confounded the relations between loads and water quality. High biomass of mussels led to reduced chlorophyll-a and increased transparency, while short-term variability in water column mixing led to changes in chlorophyll-a due to nutrient entrainment and coupling to benthic mussels.

Comparison of a new composite index based on midlatency auditory evoked potentials and electroencephalographic parameters with bispectral index (BIS) during moderate propofol sedation

BACKGROUND AND OBJECTIVE

Derived parameters of the electroencephalogram and auditory evoked potentials can be used to determine depth of anaesthesia and sedation. However, it is not known whether any parameter can identify the occurrence of awareness in individual patients. We have compared the performance of bispectral index and a new composite index derived from auditory evoked potentials and the electroencephalogram (AAI 1.61) in predicting consciousness, explicit and implicit memory during moderate sedation with propofol.

METHODS

Twenty-one patients with spinal anaesthesia received intraoperatively propofol at the age-corrected C(50) for loss of consciousness and were presented test words via headphones. Bispectral index and AAI 1.61 (auditory evoked potentials, AEP-Monitor2) were recorded in parallel as well as the Observer's Assessment of Alertness/Sedation-score. Postoperatively, testing for explicit and implicit memory formation was performed.

RESULTS

Bispectral index and AAI 1.61 correlated well with loss of consciousness defined by an Observer's Assessment of Alertness/Sedation-score of 2 (identical P(K) of 0.87), but did not allow a prediction of postoperative explicit or implicit recall.

CONCLUSIONS

Both bispectral index and AAI may be indices of depth of sedation rather than indicators of memory formation, which persists during propofol sedation even after loss of consciousness.

Reliability of verbal descriptors of dyspnea and their relationship with perceived intensity and unpleasantness

Verbal descriptors of dyspnea have been suggested as being useful in providing information on the underlying pathophysiology. However, little is known about the reliability of these descriptors. The present study examined the reliability of a German language list of respiratory symptom descriptors and studied the association of these descriptors with the intensity and unpleasantness of perceived dyspnea. Fourteen healthy volunteers performed cycle-ergometer exercise and voluntary breath-holding during which they rated the perceived intensity (VAS-I) and unpleasantness (VAS-U) of dyspnea on visual analog scales. Following this, they judged their sensations of dyspnea using the list of symptom descriptors. Both conditions were repeated in reverse order on a subsequent occasion 10 days apart. Ventilatory measures, heart rate, blood lactate, VAS-I and VAS-U during cycle-exercise as well as breath-holding time, VAS-I and VAS-U during breath-holding showed no differences between both occasions. Separate hierarchical cluster analyses identified four clusters of verbal descriptors of dyspnea which were widely comparable between both occasions: effort, speed, obstruction and suffocation. Separate multidimensional scaling analyses (MDS) confirmed these four clusters for each occasion. On both days, perceived unpleasantness of dyspnea was correlated with all four clusters during cycle-exercise, while perceived intensity showed only correlations with effort or speed, respectively. No such correlations were obtained for breath-holding. The results suggest that separable clusters of German language descriptors of dyspnea are reliably used by healthy volunteers. The obtained clusters are widely comparable to previously described clusters in other languages and are differently related to the intensity and unpleasantness of perceived dyspnea.

Cost of cardiovascular diseases in the United Kingdom

OBJECTIVE

To estimate the economic burden of cardiovascular disease (CVD) in the United Kingdom, including health and non-healthcare costs, and the proportion of total CVD cost due to coronary heart disease (CHD) and cerebrovascular disease.

DESIGN AND SETTING

Prevalence-based approach to assess CVD-related costs from a societal perspective.

PATIENTS

All UK residents in 2004 with CVD (International classification of diseases, 10th revision (ICD-10) codes I00-I99) and subgroups with CHD (ICD-10 codes I20-I25) or cerebrovascular disease (ICD-10 codes I60-I69).

MAIN OUTCOME MEASURES

Healthcare costs were estimated from expenditure on community health and social services, accident and emergency care, hospital care, rehabilitation and drugs. Non-healthcare costs were estimated from data on informal care and from productivity losses arising from morbidity and premature death.

RESULTS

CVD cost the UK economy 29.1 billion pound in 2004, with CHD and cerebrovascular disease accounting for 29% (8.5 billion pound) and 27% (8.0 billion pound) of the total, respectively. The major cost component of CVD was health care, which accounted for 60% of the cost, followed by productivity losses due to mortality and morbidity, accounting for 23%, with the remaining 17% due to informal care-related costs.

CONCLUSIONS

CVD is a leading public health problem in the UK measured by the economic burden of disease. This study identified the size and main components of that burden, and will help to inform decisions about research priorities and to monitor the impact of policy initiatives.

Is surgery-only the adequate treatment approach for T2N0 rectal cancer?

BACKGROUND AND OBJECTIVES

Resection combined with standard lymphadenectomy is generally recommended for T2N0 rectal cancer. In order to evaluate the outcome of this specific tumor category, our own data were reviewed.

METHODS

To evaluate the results of patients with curative resected T2N0 rectal carcinoma, we reviewed data of 164 consecutive patients with adenocarcinoma of the rectum between 1981 and 2003 in our department. In addition, patient characteristics were stratified according to the position of the rectal tumor with respect to the anal verge.

RESULTS

One hundred ten patients (67.1%) underwent anterior resection and 54 patients (32.9%) received abdominoperineal amputation. The follow-up revealed 6 local recurrences (3.7%); in 10 patients (10.0%), metastases were discovered. Regarding the tumor localization nearly no local recurrence or distant metastases were observed in the middle or the upper rectum. However, in the lower rectum the actuarial 5-year recurrence rate was 16.2%.

CONCLUSIONS

Although T2N0 rectal carcinomas are considered as low risk tumors, we found a considerable local recurrence rate of 3.7%. The question arises whether this result can be improved by adjuvant treatment modalities without being compromised by the toxicity of an adjuvant treatment.

Stapled transanal rectal resection under laparoscopic surveillance for rectocele and concomitant enterocele

PURPOSE

Stapled transanal rectal resection recently became a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential threat to structures located in front of the anterior rectal wall. We decided to perform a combined procedure of transanal rectal resection with a simultaneous laparoscopy for patients with obstructed defecation syndrome and an enterocele.

METHODS

Between November 2002 and May 2005 a total of 41 patients were treated surgically for obstructed defecation syndrome. Four patients with concomitant enterocele underwent stapled transanal rectal resection under laparoscopic surveillance. Before surgery all patients underwent preoperative assessment, including clinical examination, colonoscopy, conventional video defecography, dynamic magnetic resonance imaging defecography, gynecology examinations, and psychologic evaluation.

RESULTS

The mean operative time was 50 (+/-16.5) minutes for the conventional stapled transanal rectal resection and 67 (+/-14.1) minutes for combined laparoscopy and stapled transanal rectal resection (P < 0.01). Three major complications were observed: two had bleeding in the staple line (one from each group) and one had a late abscess in the staple line.

CONCLUSIONS

The combination of the stapled transanal rectal resection procedure and laparoscopy provides the opportunity to perform transanal rectal resection without the threat of intra-abdominal lesions caused by enterocele.

Chromosomal imbalances in brain metastases of solid tumors

Metastases account for approximately 50% of the malignant tumors in the brain. In order to identify structural alterations that are associated with tumor dissemination into the central nervous system we used Comparative Genomic Hybridization (CGH) to investigate 42 brain metastases and 3 primary tumors of 40 patients. The metastases originated from lung cancer (14 cases), melanomas (7), carcinomas of breast (5), colon (5), kidney (5), adrenal gland (1) and thyroid (1). In addition, tumors of initially unknown primaries were assessed in 3 cases. The highest incidence of DNA gains were observed for the chromosomal regions 1q23, 8q24, 17q24-q25, 20q13 (>80% of cases) followed by the gain on 7p12 (77%). DNA losses were slightly less frequent with 4q22, 4q26, 5q21, 9p21 being affected in at least 70% of the cases followed by deletions at 17p12, 4q32q34, 10q21, 10q23-q24 and 18q21-q22 in 67.5% of cases. Two unusual narrow regional peaks were observed for the gain on 17q24-q25 and loss on 17p12. The incidence at individual loci can be viewed at our CGH online tumor database at http:// amba.charite.de/cgh/. The metastases of each tumor type showed a recurrent pattern of changes. In those cases with primary tumor and metastases available, the CGH pattern exhibited a high degree of conformity. In conclusion, our data suggests that specific genetic lesions are associated with tumor dissemination into the nervous system and that CGH analysis may be a useful supplementary tool for classification of metastases with unknown origin.

Botulinum toxin in dermatology - beyond wrinkles and sweat

Botulinum toxin (BTX) types A and B have been used with success in cosmetic dermatology and hyperhidrosis treatment. The present review focuses on other uses of BTX in dermatology. Discussed in particular are the available data on BTX in inflammatory diseases, proctology, and some other indications. From studies in various types of eczema, it seems that BTX-A not only acts as a potent inhibitor of acetylcholine but also as an inhibitor of substance P and of glutamate as well. By those mechanisms, BTX-A may be antipruritic, which may help explain the benefits of BTX-A in lichen simplex and dyshidrotic hand eczema. In Hailey-Hailey disease, facial eccrine hidrocystomas, salivary fistulas, and intrinsic rhinitis, BTX-A blocks the secretion of sweat/saliva/mucus. BTX-A has important applications in proctology where it has become the most powerful nonsurgical therapy for anal fissures. In proctalgia fugax and after hemorrhoidectomy, BTX-A is analgesic. Current treatment applications of BTX-A and its limitations are reviewed in this paper.

Intravenous indometacin in preterm infants with symptomatic patent ductus arteriosus. A population pharmacokinetic study

AIMS

To characterize the population pharmacokinetics of indometacin in preterm infants with symptomatic patent ductus arteriosus and to investigate the influence of various factors on the response to treatment.

METHODS

Data were collected from 35 infants (gestational age 25-34 weeks; postnatal age 1-77 days) in neonatal units in Belfast and Copenhagen. Infants received an initial course of up to three doses of intravenous indometacin (0.1-0.2 mg kg(-1)) as considered appropriate by the treating physician. For those infants who did not respond to therapy or in whom the ductus reopened, a second course was sometimes given. Population analysis of the 185 plasma concentrations obtained was conducted using NONMEM and pharmacokinetic and demographic differences between responders and nonresponders were compared.

RESULTS

The concentration-time course of indometacin was best described by a one-compartment model. The final population parameter estimates of clearance (CL) and volume of distribution (V) (standardized to the median weight of 1.17 kg) were 0.00711 l h(-1) and 0.266 l, respectively. CL increased from birth by approximately 3.38% per day and V by approximately 1.47% per day. Concomitant digoxin therapy resulted in a 30% decrease in V. Interindividual variability in CL and V was 41% and 21%, respectively. Interoccasion variability for CL was 43%. Residual variability corresponded to a standard deviation of 0.148 mg l(-1). Closure occurred in 75% of infants with a plasma concentration > or = 0.4 mg l(-1) 24 h after the last dose.

CONCLUSIONS

Dosing regimens for indometacin should take into account the weight and postnatal age of the infant and any concomitant digoxin therapy. The population estimates can be used to determine typical values of CL and V allowing the prediction of individualized doses of indometacin that should increase the probability of achieving a 24 h plasma concentration > or = 0.4 mg l(-1). Although the pharmacokinetic estimates will be affected by both interindividual and within-individual variation, it is anticipated that this approach will decrease the variability of exposure and optimize treatment outcome.

Ventral Rectus Fascia Closure on Top of Mesh Hernia Repair in the Sublay Technique

Sublay prosthetic herniorrhaphy has become a widely accepted procedure for incisional hernias. To evaluate the effect of fascia closure on top of mesh repair on infection, and the recurrence rate, the authors reviewed their data regarding herniorrhaphy in the sublay technique. This study was a retrospective analysis of 175 consecutive patients who underwent hernia repair by implantation of prostheses by means of the Stoppa-Rives technique from December of 1994 to December of 2001. All 175 patients had the mesh implanted in the subfascial plane, 130 received a light-weight or heavy-weight polypropylene mesh (Vypro or Prolene) (74 percent), eight had a polyester mesh (Mersilene) (5 percent), and 37 had an expanded polytetrafluoroethylene patch (Gore-Tex) (21 percent). After sublay mesh positioning, the mesh could not be covered by the fascia in 50 cases; in 31 of these cases, a second mesh was placed into the fascial defect. To evaluate the influence of the fascia closing procedure on top of the sublay mesh, three groups were differentiated: initial fascia closure (n = 125), no fascia closure and concomitant mesh interposition (n = 31), and no fascia closure without mesh interposition (n = 19). After a mean follow-up of 20 months, 11 deep prosthetic infections (8 percent) and 15 hernia recurrences (9 percent) were observed. There was an increased risk of mesh infection when the fascia could not be closed, but there was no influence of fascia closure on hernia recurrence. When the fascia was left open, the placement of a second mesh inlay technique reduced mesh infection. The authors' data give evidence that closing the ventral fascia after mesh repair in the sublay position is beneficial. When the edges of the hernia defect could not be approximated, the suturing of a second mesh into the fascia defect was a useful tool for reducing the prosthetic infection rate; however, no significant influence on hernia recurrence was observed.

Two single nucleotide polymorphisms in the CYP17 and COMT Genes--relation to bone mass and longitudinal bone changes in postmenopausal women with or without hormone replacement therapy. The Danish Osteoporosis Prevention Study

Sex steroids are important physiologic regulators of bone mass, and genes regulating sex steroid production and metabolism are obvious as candidate genes for osteoporosis susceptibility. We present data from a study of 1795 recent postmenopausal women, assigned to either hormone replacement therapy (HRT) or no treatment and followed for 5 years. The association between bone mass measurements and two single nucleotide polymorphisms, a T (A1) to C (A2) transition in the 5'-UTR of the cytochrome P450c17alpha (CYP17) gene and a G (Val) to A (Met) transition in exon 4 of the catechol- O-methyltransferase (COMT) gene, was evaluated. Association with CYP17 genotype was modified by body mass index (BMI). In lean women, individuals homozygous for the CYP17 A2 allele were 1 cm shorter and had lower baseline BMD (bone mineral density), BMC, and CSA (cross sectional area) in the spine and femoral neck than did other women (BMD spine A2A2: 0.975 g/cm2 versus 1.011 g/cm2 in A1A1 + A1A2, P = 0.002). Conversely, an adverse association with A2A2 and bone loss over 5 years seemed present only in overweight women, but differences were small. Response to HRT was not dependent on CYP17 genotype. COMT genotype was not associated with bone mass at baseline, bone loss in untreated women, or response to HRT. In conclusion, the A2 allele of the CYP17 T(27)-C polymorphism is associated with reduced bone mass and bone size in lean perimenopausal women, whereas high BMI protects against this negative association. The COMT G(1947)-A polymorphism is not associated with bone parameters in this study.

Severe intra-abdominal bleeding following stapled mucosectomy due to enterocele: report of a case

Stapled rectal mucosectomy (SRM) became a widely accepted surgical procedure for haemorrhoids. One of the rare complications is severe bleeding. We report the case of a patient who underwent SRM for thirddegree haemorrhoids. In addition, he suffered symptoms of outlet obstruction, although defecography showed no serious disease. One day after SRM, the patient complained of abdominal pain and peritonitis. Computed tomography revealed blood in the abdomen. The patient underwent laparotomy, which revealed a deep enterocele that reached down to the level of the sphincteric muscle. The ventral part of the stapled ring was placed intraperitoneally, and a longitudinal defect of the rectal serosa was observed. The serosa defect was sutured and a diverting sigmoid stoma was carried out. The patient left the hospital 10 days later. We emphasize vigilance for undetected enteroceles in mucosal prolapse syndrome combined with defecation problems.

Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids

Background

Within the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events.

Methods

A retrospective analysis of 419 consecutive patients, which underwent SRM from December 1998 to August 2003 was performed. Only patients with at least one follow-up check were evaluated, thus the analysis includes 289 patients with a mean follow-up of 281 days (±18 days).

For statistic analysis the groups with and without stenosis were evaluated using the Chi-Square Test, using the Kaplan-Meier statistic the actuarial incidence for rectal stenosis was plotted.

Results

Rectal stenosis was observed in 9 patients (3.1%), eight of these stenoses were detected within the first 100 days after surgery; the median time to stenosis was 95 days. Only one patient had a rectal stenosis after more than one year. 8 of the 9 patients had no obstructive symptoms, however the remaining patients complained of obstructive defecation and underwent surgery for transanal strictureplasty with electrocautery. A statistical analysis revealed that patients with stenosis had significantly more often prior treatment for hemorrhoids (p < 0.01). According to the SRM only severe postoperative pain was significantly associated with stenoses (p < 0.01). Other factors, such as gender (p = 0.11), surgical technique (p = 0.25), revision (p = 0.79) or histological evidence of squamous skin (p = 0.69) showed no significance.

Conclusion

Rectal stenosis is an uncommon event after SRM. Early stenosis will occur within the first three months after surgery. The majority of the stenoses are without clinical relevance. Only one of nine patients had to undergo surgery for a relevant stenosis. The predictive factor for stenosis in the patient-characteristics is previous interventions for hemorrhoids, severe postoperative pain might also predict rectal stenosis.

Polymorphisms in the CYP19 and AR genes--relation to bone mass and longitudinal bone changes in postmenopausal women with or without hormone replacement therapy: The Danish Osteoporosis Prevention Study

Polymorphisms in the androgen receptor ( AR) gene and genes encoding enzymes involved in synthesis of sex steroids (e.g., the CYP19 gene encoding aromatase) have recently received attention in osteoporosis research. In the Danish Osteoporosis Prevention Study, recent postmenopausal women were allocated to either hormone replacement therapy (HRT) or no treatment. We genotyped 1792 women for the CYP19 (TTTA)(n) repeat [short (TTTA)(n <or= 7) or long (TTTA)(n > 7)] the CYP19 C(1558)-T, and the AR (CAG)(n) repeat polymorphism [short (CAG)(n < 22), long (CAG)(n >or= 22)], and investigated associations with bone mineral density (BMD) and 5-year change in BMD. The CYP19 polymorphisms were in strong linkage disequilibrium. Perimenopausal bone mass or bone loss in untreated women was not associated with the CYP19 polymorphisms. In hormone-treated women, BMD increase in the femoral neck was highest (+0.3%/year) for long CYP19 alleles, lowest (-0.09%/year) for short alleles, and intermediate (-0.002%/year) in heterozygous women, P = 0.015. Differences were also significant in the lumbar spine, total hip, and ultradistal forearm. The C(1558)-T T-allele was associated with a more pronounced response to HRT ( P = 0.04, total hip). AR genotype was not related to BMD, but a modifying effect of sex hormone-binding globulin (SHBG) was present. In the highest SHBG quartile (SHBG > 95 nmol/1, n = 222), AR genotype was associated with baseline BMD (femoral neck: P < 0.001, total hip: P = 0.008), but without a clear gene dosage effect. We have demonstrated that polymorphisms in the CYP19 gene are associated with the magnitude of bone gain in response to HRT and that the (CAG)(n) repeat polymorphism in the AR gene is associated with bone mass in women with high levels of SHBG. These findings emphasize the complexity of the genetics of bone mass and bone loss.

New targets for the modulation of radiation response--selective inhibition of the enzyme cyclooxygenase 2

The development of new chemotherapeutic agents and concepts of radiation therapy has led to new perspectives in cancer therapy. Recently developed novel agents interfere with molecular mechanisms that are altered in cancer cells. Cyclooxygenase-2 (COX-2) is an enzyme induced by a variety of factors including tumor promoters, cytokines, growth factors and hypoxia. It is involved in the metabolic conversion of arachidonic acid to prostanoids, primarily in inflammatory states and tumors. In normal tissues, prostanoids are synthesized by COX-1, and they exert numerous homeostatic physiological functions. COX-2 overexpression is linked to carcinogenesis, maintenance of progressive tumor growth and metastatic spread. COX-2 and its products may act as protectors against cell damage by ionizing radiation. In this context, the treatment with selective COX-2 inhibitors became of interest for radiation oncology within the last years. In this review we focus on the effects of COX-2 in the modulation of the radiation response and the potential clinical application as cancer preventive drug or as novel agents in adjuvant clinical settings. The experimental data available suggest that COX-2 inhibitors can enhance the radiation response in tumors without serious side effects to the normal tissue. In conclusion COX-2 might be a useful tool for cancer prevention and represents a potential molecular target for improving cancer treatment in combination with radiotherapy.

Increasing prevalence of overweight in young schoolchildren in Umeå, Sweden, from 1986 to 2001

AIM

To investigate the current prevalence and trend of overweight in young schoolchildren in Umeå, Sweden.

METHODS

Two cross-sectional samples of children were studied: 1115 randomly selected children from preschool class to grade 6 (aged 6-13 y) attending school in 2001 and a matched sample of 507 schoolchildren from grades 0, 1 and 4 (aged 6-11 y) attending school in 1986. Overweight was defined according to age- and gender-specific body mass index (BMI) cut-off values, corresponding to BMI values of 25 kg/m2 (level 1) and 30 kg/m2 (level 2) at late adolescence.

RESULTS

In the population from 2001, the prevalence of overweight was 23% (18% at level 1, 5% at level 2). The prevalence differed with age, with a higher prevalence at the ages of 6 and 13 y. Comparing children from grades 0, 1 and 4, attending school in 1986 and 2001, respectively, the total prevalence of overweight was twice as high in 2001 as in 1986. Regarding severe overweight (level 2), the difference was even larger (five times). In the 1986 sample, the prevalence of overweight did not differ between girls and boys, while significantly more girls than boys were overweight in 2001.

CONCLUSION

In this sample of young children from Sweden, the prevalence of overweight doubled over the past 15 y and severe overweight increased even more, suggesting a need for intensified preventive efforts in young schoolchildren.

Potentiation of prelimbic field potentials during and seconds after trains of excitations in the rat hippocampo-prefrontal pathway

Field potentials were recorded in the prelimbic cortex of anaesthetized rats after excitations of the hippocampo-prefrontal pathway. Stimuli were delivered to the hippocampal CA1 region and short-term changes of field potential amplitudes were observed in two situations. (1) Amplitudes were monitored during trains of stimulations given at frequencies between 1 and 20 Hz. Within trains, potentiation was followed by depression. Both types of changes were frequency dependent. (2) The time course of recovery from within-train plasticity was obtained from field potentials evoked at varying intervals after trains. This revealed a post-train potentiation having a maximum after 2-4 s and lasting for approximately 10 s. The maximal post-train potentiation was nearly independent of the frequency of the preceding train.

Sublay prosthetic repair for incisional hernia of the flank

PURPOSE

A large hernia after flank incision for nephrectomy is a challenging problem in hernia surgery. In recent decades preperitoneal prosthetic herniorrhaphy became a widely accepted procedure for hernias of the abdominal wall. To evaluate the outcome of mesh hernia repair of the flank we reviewed our data on all patients who underwent preperitoneal mesh repair.

MATERIALS AND METHODS

We identified 4 patients who underwent prosthesis repair after incisional hernia of the flank within the last 6 years. The primary reason for surgery was nephrectomy in 2 cases, pyeloplasty in 1 and complicated kidney cyst resection in 1. Mean followup time was 33 months.

RESULTS

In a mean operative time +/- SD of 208 +/- 55 minutes the patients underwent incisional hernia repair with prosthesis implantation in the sublay position. In 3 patients an expanded polytetrafluoroethylene patch was used and in 1 polypropylene mesh was implanted. Mean prosthesis size was 25 x 38 cm. (950 +/- 300 cm. ). There were no postoperative complications. Patients were discharged from the hospital after a mean of 15 +/- 2 days. Followup revealed that none of the 4 patients with flank incision had recurrent hernia. Pain persisted in 3 patients after flank incision. However, no regular analgesic drug prescription was necessary.

CONCLUSIONS

Mesh repair for incisional flank hernia provides reinforcement of the hernia. However, the flank remains paralyzed with a muscle bulge and some patients have persistent discomfort.

Sublay prosthetic repair for incisional hernia of the flank

PURPOSE

A large hernia after flank incision for nephrectomy is a challenging problem in hernia surgery. In recent decades preperitoneal prosthetic herniorrhaphy became a widely accepted procedure for hernias of the abdominal wall. To evaluate the outcome of mesh hernia repair of the flank we reviewed our data on all patients who underwent preperitoneal mesh repair.

MATERIALS AND METHODS

We identified 4 patients who underwent prosthesis repair after incisional hernia of the flank within the last 6 years. The primary reason for surgery was nephrectomy in 2 cases, pyeloplasty in 1 and complicated kidney cyst resection in 1. Mean followup time was 33 months.

RESULTS

In a mean operative time +/- SD of 208 +/- 55 minutes the patients underwent incisional hernia repair with prosthesis implantation in the sublay position. In 3 patients an expanded polytetrafluoroethylene patch was used and in 1 polypropylene mesh was implanted. Mean prosthesis size was 25 x 38 cm. (950 +/- 300 cm. ). There were no postoperative complications. Patients were discharged from the hospital after a mean of 15 +/- 2 days. Followup revealed that none of the 4 patients with flank incision had recurrent hernia. Pain persisted in 3 patients after flank incision. However, no regular analgesic drug prescription was necessary.

CONCLUSIONS

Mesh repair for incisional flank hernia provides reinforcement of the hernia. However, the flank remains paralyzed with a muscle bulge and some patients have persistent discomfort.

Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches

PURPOSE

Pilonidal sinus is a common disease and surgical removal and subsequent wound closure is crucial for lasting cure. To evaluate the outcome of different primary closure techniques we performed a pooled analysis of data published in the past 35 years.

METHODS

We identified reports on wound infection, early failure, and late recurrence status in relation to treatment modality. Surgical techniques were classified into five groups: simple closure technique in the midline, asymmetric or oblique closure techniques, and full-thickness flap techniques like rhomboid flaps, vy-plasty, and z-plasty. Estimations of the incidences resulted from the quotient of number of responses and the number of patients for each study, and these quotients were summarized over all studies.

RESULTS

The MEDLINE search identified 74 publications including 10,090 patients. Pooled data analysis revealed an inhomogeneous effect of the surgical techniques on the infection rate. In contrast, there was a significantly lower early failure rate and late recurrence rate of both the asymmetric-oblique closure techniques and the full-thickness flap techniques when compared with the midline repair technique. No difference was found between the asymmetric repairs and the full-thickness flap techniques.

CONCLUSION

Beside the various statistical considerations when using a pooled data analysis combining results from the literature, this overview suggests a significant benefit of asymmetric-oblique closure techniques or flap techniques in comparison with simple closure in the midline. Thus, we recommend an asymmetric closure technique for primary closure of a chronic pilonidal sinus. These asymmetric procedures provide better results than the simple closure in the natal midline. Furthermore, they are not as sophisticated as the full-thickness plasty techniques.

Extreme prematurity in the UK and Denmark: population differences in viability

BACKGROUND

Previous studies comparing different models of neonatal intensive care have generally not been population based. The objective of this study was to compare the perinatal services of two total populations.

METHODS

Observational study based on two geographically defined populations: the whole of Demark (some centralisation of neonatal intensive care but most delivered locally by small perinatal centres-48 in total) and the Trent Health Region of the UK (no formal centralisation however deliveries almost all focussed on 16 major hospitals with > 90% of the intensive care provided by 13 hospitals). Information was recorded about the course of every liveborn infant < 28 weeks gestation and or < 1000g birth weight and > or = 21 weeks gestation in 1994 and 1995.

RESULTS

Despite having a smaller population the number of liveborn children meeting the study criteria was significantly higher in Trent (Demark 461 (3.3 per 1000 births, 95% confidence interval (CI) 3.0 to 3.6); Trent 572 (4.9 per 1000 births, 95% CI 4.5 to 5.3)). In Denmark 91.1% of these infants were admitted for intensive care and 85.5% in Trent. Despite significantly more Trent infants being exposed to antenatal steroids their outcome was worse (median Clinical Risk Index for Babies (CRIB) score 7 v 4; proportion receiving ventilation 87.6% v 40.0%; survival to discharge (uncorrected for disease severity) 42.3% v 35.0%).

CONCLUSION

The population characteristics of Trent seemed to produce a higher prematurity rate compared to Denmark. These infants as a group appeared sicker and, despite more intensive care delivered by a more specialised service, outcomes were worse.

Bone mineralisation in premature infants cannot be predicted from serum alkaline phosphatase or serum phosphate

BACKGROUND

The bone mineral content of premature infants at term is lower than in mature infants at the same postconceptional age. Serum alkaline phosphatase and serum phosphate are often used as indicators of bone mineralisation.

OBJECTIVE

To analyse the association between bone mineral content and serum alkaline phosphatase and serum phosphate.

METHODS

Serum alkaline phosphatase and phosphate were measured at weekly intervals during admission in 108 premature infants of gestational age below 32 weeks (mean (SD) gestational age 29 (2) weeks; mean (SD) birth weight 1129 (279) g). Bone mineral content was measured at term (mean gestational age 41 weeks) by dual energy x ray absorptiometry and corrected for body size.

RESULTS

Serum alkaline phosphatase was significantly negatively associated with serum phosphate (p < 0.001). Bone mineral content was not associated with mean serum alkaline phosphatase (p = 0.8), peak serum alkaline phosphatase (p = 0.5), or mean serum phosphate (p = 0.2) at term.

CONCLUSION

Routine measurements of serum alkaline phosphatase and serum phosphate are of no use in predicting bone mineralisation outcome in premature infants.

Assessment of infant physiology and neuronal development using magnetic resonance imaging

Previous work has demonstrated both that there are substantial individual differences in the rate of physiological development,and that infants with risk factors for Sudden Infant Death Syndrome (SIDS) develop more slowly, suggesting that their increased vulnerability may be due to delayed neuronal development associated with compromised development in fetal or early neonatal life. This project aims to test the hypothesis that individual differences in the rate of physiological development of infants correlate with measurable differences in the rate of brain development as assessed by magnetic resonance imaging (MRI). Sixty infants were recruited to this study in three different groups that are known to have differing rates of physiological development. MRI was performed successfully in 49 cases at 6 weeks of age without sedation. Forty-one of these cases had full follow-up (15 normal; 19 IUGR; 11 'high risk'). Postnatal physiological development was assessed by measuring age-related deep body temperature patterns during sleep. Neuronal development was assessed by subjective analysis of MRI images and objective measurements relating to myelination using T1 and diffusion weighted (23 cases) MRI images. As expected the normal group acquired the adult temperature pattern earlier, but this was not statistically significant. All MRI scan appearances were within normal limits. Ranking cases subjectively in order of maturity revealed no significant pattern. The normal group had a significantly higher myelination score than the IUGR and 'high risk' groups (P = 0.001). This trend was also shown by the diffusion weighted myelination score but did not reach statistical significance. No significant differences were seen in both the subjective and objective MRI measurements and development of nocturnal temperature patterns. The results suggest there may be differences in neurodevelopment between the different groups at 6 weeks of age but these are not linked to late development of temperature patterns. It is therefore unlikely that this related to a global delay in maturation.

Immunohistochemically detected p53 mutations in epithelial tumors and results of treatment with chemotherapy and radiotherapy. A treatment-specific overview of the clinical data

BACKGROUND

The aim was to ascertain whether many hundreds of clinical reports over the last decade are consistent with the prediction of a poorer outcome in cancer patients with p53 abnormalities treated with cytotoxic drugs and radiation.

MATERIAL AND METHOD

There are 301 studies on the influence of p53 overexpression published through summer 2000, in which chemotherapy or radiotherapy was used alone or in combination with surgery. From 45 reports meeting stringent selection rules, comparison groups are identified in whom the same measure of outcome was reported for the same treatment applied to the same tumor, with results corrected for important prognostic factors. Metaanalysis techniques are then applied to the comparison groups. Attention was limited to reports using immunohistochemical techniques, to form comparison groups of sufficient size.

RESULTS

Four comparison groups were identified by treatment and endpoint: 1) Stage I-III breast cancer (surgery and chemotherapy, disease-free survival, seven studies); 2) stage I-III breast cancer (surgery and chemotherapy, overall survival, six studies); 3) stage II-IV head and neck cancer (radiotherapy and chemotherapy, overall survival, five studies); 4) FIGO I-IV ovarian cancer (surgery and chemotherapy, overall survival, six studies). In the breast (disease-free survival) and ovarian (overall survival) comparison groups, the hazard ratio for a deleterious effect of p53 overexpression was significant or marginally significant, depending on assumed ranges for unreported hazard ratios in non-significant studies.

CONCLUSIONS

Despite the many caveats related to metaanalysis applied to retrospective data, high variability of immunohistochemical technique, etc., a nearly significant negative effect of p53 overexpression on outcome of treatment with cytotoxic drugs and radiation emerges in the few studies where heterogeneity can be sufficiently reduced or accounted for.

[Surgical management of severe peritonitis]

Despite all the efforts made in the areas of intensive care and surgery, severe peritonitis remains a feared condition that is associated with a high mortality rate. Severe abdominal infections are accompanied with a high level of endotoxin production, resulting in the so called systemic inflammatory response syndrome (SIRS), which is often complicated by multiple organ failure. The surgical eradication of the infectious focus is the most important prerequisite for a successful treatment. According to the severity of the local inflammation, different forms of abdominal lavage can be applied. We analysed patient characteristics and the clinical outcome of 180 patients with diffuse peritonitis, including 36 patients with more than 29 MPI-Points. The mean severity of peritonitis (n = 36) was 33 using the Mannheim Peritonitis Index (MPI). The hospital mortality rate was 58 % in this group.

Macronutrients in milk from mothers delivering preterm

Premature infants require large amounts of protein and energy to achieve normal growth. Feeding with human milk alone is therefore only regarded acceptable if the protein and energy content is adequate.

METHODS

476 milk samples from 101 mothers delivering before the 32nd gestational week (mean gestational age, 28 weeks) were obtained on a weekly basis until 36 weeks of gestational age and analyzed for true protein, total carbohydrate, and fat content by infrared analysis. Fat measurements were validated with the Folch method. Milk was collected by complete expression with an electric pump into 24-hour pools.

RESULTS

The protein concentration decreased significantly with time (P = 0.00001). The carbohydrate, fat, and energy concentration was significantly lower in the first 2 weeks after delivery, after which they increased to a constant level. The macronutrient level in milk was not associated with gestational age (P = 0.3). The energy content of these milk samples was high, and feeding 200 mL/kg would provide sufficient energy until 36 weeks of gestational age for all infants, and 65% of the infants would receive > or =3g total protein/kg/day.