Clinical features and prognosis of malignant small bowel tumors: experience from a university hospital in Chile

BACKGROUND

Small bowel tumors (SBT) are infrequent and represent a small proportion of digestive neoplasms. There is scarce information about SBT in Latin America.

AIM

To describe the epidemiology, clinical characteristics, diagnostic methods, and survival of malignant SBTs.

METHODS

Retrospective observational study of adult patients with histopathological diagnosis of SBT between 2007-2021 in a university hospital in Chile.

RESULTS

A total of 104 patients [51.9% men; mean age 57 years] with SBT. Histological type: neuroendocrine tumor (NET) (43.7%, n=38), gastrointestinal stromal tumors (GIST) (21.8%, n=19), lymphoma (17.2%, n=15) and adenocarcinoma (AC) (11.5%, n=10). GIST was more frequent in duodenum (50%; n=12) and NET in the ileum (65.8%; n=25). Metastasis was observed in 17 cases, most commonly from colon and melanoma. Nausea and vomiting were significantly more often observed in AC (p=0.035), as well as gastrointestinal bleeding in GIST (p=0.007). The most common diagnostic tools were CT and CT enteroclysis with an elevated diagnostic yield (86% and 94% respectively). The 5-year survival of GIST, NET, lymphoma and AC were 94.7% (95%CI: 68.1-99.2), 82.2% (95%CI: 57.6-93.3), 40.0% (95%CI: 16.5-82.8) and 25.9% (95%CI: 4.5-55.7%), respectively. NET (HR 6.1; 95%CI:2.1-17.2) and GIST (HR 24.4; 95%CI:3.0-19.8) were independently associated with higher survival compared to AC, adjusted for age and sex.

CONCLUSIONS

Malignant SBT are rare conditions and NETs are the most common histological subtype. Clinical presentation at diagnosis, location or complications may suggest a more probable diagnosis. GIST and NET are associated with better survival compared to other malignant subtypes.

Amerindian ancestry proportion as a risk factor for inflammatory bowel diseases: results from a Latin American Andean cohort

Background and aims

Latin American populations remain underrepresented in genetic studies of inflammatory bowel diseases (IBDs). Most genetic association studies of IBD rely on Caucasian, African, and Asian individuals. These associations have yet to be evaluated in detail in the Andean region of South America. We explored the contribution of IBD-reported genetic risk variants to a Chilean cohort and the ancestry contribution to IBD in this cohort.

Methods

A total of 192 Chilean IBD patients were genotyped using Illumina's Global Screening Array. Genotype data were combined with similar information from 3,147 Chilean controls. The proportions of Aymara, African, European, and Mapuche ancestries were estimated using the software ADMIXTURE. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) for gender, age, and ancestry proportions. We also explored associations with previously reported IBD-risk variants independently and in conjunction with genetic ancestry.

Results

The first and third quartiles of the proportion of Mapuche ancestry in IBD patients were 24.7 and 34.2%, respectively, and the corresponding OR was 2.30 (95%CI 1.52-3.48) for the lowest vs. the highest group. Only one variant (rs7210086) of the 180 reported IBD-risk SNPs was associated with IBD risk in the Chilean cohort (adjusted P = 0.01). This variant is related to myeloid cells.

Conclusion

The type and proportion of Native American ancestry in Chileans seem to be associated with IBD risk. Variants associated with IBD risk in this Andean region were related to myeloid cells and the innate immune response.

Implementation of the updated Sydney system biopsy protocol improves the diagnostic yield of gastric preneoplastic conditions: Results from a real-world study

BACKGROUND

The updated Sydney system biopsy protocol (USSBP) standardizes the sampling of gastric biopsies for the detection of preneoplastic conditions (e.g., gastric intestinal metaplasia [GIM]), but the real-world diagnostic yield is not well-described.

AIM

To determine whether regular application of USSBP is associated with higher detection of chronic atrophic gastritis (CAG), GIM and autoimmune gastritis (AIG).

METHODS

We performed a real-world retrospective study at an academic urban tertiary hospital in Chile. We manually reviewed medical records from consecutive patients undergoing esophagogastroduodenoscopy (EGD) from January to December 2017. Seven endoscopists who performed EGDs were categorized into two groups (USSBP 'regular' and USSBP 'infrequent') based on USSBP adherence, using minimum 20% adherence as the prespecified threshold. Multivariable logistic regression models were used to estimate the odds ratios (aOR) and 95% confidence intervals (CI) for the association between endoscopist groups and the likelihood of diagnosing CAG, GIM or AIG.

RESULTS

1206 patients were included in the study (mean age: 58.5; 65.3% female). The USSBP regular group demonstrated a higher likelihood of detecting CAG (20% vs. 5.3%; aOR 4.03, 95%CI: 2.69-6.03), GIM (12.2% vs. 3.4%; aOR 3.91, 95%CI: 2.39-6.42) and AIG (2.9% vs. 0.8%; aOR 6.52, 95%CI: 1.87-22.74) compared to infrequent group. Detection of advanced-stage CAG (Operative Link for Gastritis Assessment stage III/IV) was significantly higher in the USSBP regular vs. infrequent group (aOR 5.84, 95%CI: 2.23-15.31).

CONCLUSIONS

Routine adherence to USSBP increases the detection rates of preneoplastic conditions, including CAG, GIM and AIG. Standardized implementation of USSBP should be considered in high gastric cancer risk populations.

High prevalence of SARS-CoV-2 detection and prolonged viral shedding in stools: A systematic review and cohort study

Objectives

Methods

Results

Conclusions

Quadruple therapies are superior to standard triple therapy for Helicobacter pylori first-line eradication in Chile

INTRODUCTION

Helicobacter pylori infection affects approximately 70% of the Chilean population. It is a public health problem whose eradication treatment is part of the explicit health guarantees in Chile.

OBJECTIVES

Characterize the most widely used H. pylori first-line eradication therapies in our environment and evaluate their efficacy.

METHODS

A retrospective observational study was carried out where, in patients with certified H. pylori infection, the eradication therapy indicated by the treating physician, its efficacy, adherence and adverse effects, in addition to the eradication certification method used, were evaluated.

RESULTS

242 patients and 4 main therapies were analyzed: standard triple therapy, dual therapy, concomitant therapy, and bismuth quadruple therapy. Eradication rates of 81.9% (95% CI 74.44-87.63), 88.5% (95% CI 73.13-95.67), 93.7% (95% CI 78.07-98.44) and 97.6% (95% CI 84.81-99.67) were observed respectively, with concomitant therapy (RR: 1.14; 95% CI 1.01-1.29; p=.028) and quadruple therapy with bismuth (RR: 1.19; 95% CI 1.09-1.31; p<.001) being significantly more effective than standard triple therapy. Regarding the rate of reported adverse effects, it was 58.5% (95% CI 50.66-65.92), 35.4% (95% CI 24.6-48.11), 22.9% (95% CI 81-37.14) and 63.4% (95% CI 47.8-76.64), having the dual and concomitant therapy significantly fewer adverse effects compared with standard therapy.

CONCLUSIONS

Quadruple therapies are superior to standard triple therapy and should be considered as first-line treatment in Chile. Dual therapy is promising. More studies will be required to determine which therapies are most cost-effective.

[Chilean consensus on diagnosis and management of pancreatic cystic neoplasms]

Pancreatic cystic neoplasms (PCN) are frequently detected on abdominal images performed for non-pancreatic indications. Their prevalence in asymptomatic population ranges from 2.7 to 24.8%, and increases with age. There are several types of pancreatic cysts. Some may contain cancer or have malignant potential, such as mucinous cystic neoplasms, including mucinous cystadenoma (MCN) and intraductal papillary mucinous neoplasms (IPMN). In contrast, others are benign, such as serous cystadenoma (SCA). However, even those cysts with malignant potential rarely progress to cancer. Currently, the only treatment for pancreatic cysts is surgery, which is associated with high morbidity and occasional mortality. The Board of the Chilean Pancreas Club of the Chilean Gastroenterology Society developed the first Chilean multidisciplinary consensus for diagnosis, management, and surveillance of PCN. Thirty experts were invited and answered 21 statements with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree. A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. The consensus was approved by the Board of Directors of the Chilean Pancreas Club for publication.

[Diagnosis and management of eosinophilic esophagitis]

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease, induced by food allergens, clinically characterized by symptoms of esophageal dysfunction. Pathologically there is a predominant eosinophilic inflammation. This disease is relatively new, and its definitions have evolved over time. Its prevalence and incidence are increasing and causes clinical problems both in children and adults. Its symptoms include food impaction, dysphagia, symptoms that resemble gastroesophageal reflux, abdominal pain, and vomiting. It can also have extra-digestive symptoms such as rhinosinusitis, chronic cough, recurrent croup and hoarseness. EoE can be associated with other atopic conditions, such as asthma, eczema and food allergies. The diagnosis is made by the analysis of endoscopic biopsies (> 15 eosinophils per high power field). Proton pump inhibitors (PPIs) are currently accepted as a treatment for EoE. The clinical and pathological improvement with the use PPIs ceased to be a criterion to define Esophageal eosinophilia responsive to PPIs as a differential diagnosis, since this condition is currently considered within the EoE spectrum. There are three main treatment approaches for EoE: diet, drugs and dilation. Its diagnosis and early treatment are key to avoid or delay its complications, such as stenosis and severe esophageal dysfunction.

Adherence to a gluten-free diet and quality of life in Chilean celiac patients

INTRODUCTION

a gluten-free diet (GFD) is the treatment for celiac disease (CD), with adherence oscillating between 42 % and 91 %. The purpose of this study was to assess adherence to GFD and its relation to quality of life in Chilean celiac patients.

METHODS

three surveys were performed on-line: sociodemographic-health status, adherence to GFD and quality of life.

RESULTS

forty-eight per cent of respondents reported an excellent adherence to GFD and 49 % a good quality of life.

CONCLUSIONS

adherence to GFD is low among Chilean celiac patients.

High Helicobacter pylori Bacterial Load and Low Cytokine Expression Levels Are Associated with Nodular Gastropathy

BACKGROUND AND AIMS

Nodular gastropathy (NG) is an inflammatory condition of the gastric mucosa characterized by the endoscopic detection of multiple millimeter protrusions. A strong association between NG and Helicobacter pylori and a possible role of NG as a risk factor for undifferentiated gastric cancer have been described. The aim of this study was to characterize the pathogenic and inflammatory profile of patients with NG.

METHODS

Adult patients referred for upper gastrointestinal endoscopy were prospectively enrolled in this study. H. pylori infection status was determined by rapid urease test. Biopsies were stained with hematoxylin-eosin. Sydney and OLGA scores were used to assess gastritis characteristics and gastric cancer risk. PCR analysis was performed to determine bacterial load and virulence factors CagA (and its EPIYA motifs) and VacA alleles. Finally, gastric mucosa cytokine gene expression (IL-8, IL-1β, and TNF-α) was determined by real-time RT-PCR.

RESULTS

Forty-eight patients, mean age of 36 years, were recruited. All NG patients were infected by H. pylori. OLGA score was similar in both groups (NG patients and non-NG patients). NG patients had higher bacterial load in the gastric corpus (p = 0.01) and significantly less pro-inflammatory cytokine levels than non-NG infected patients (p = 0.01).

CONCLUSIONS

In our study, NG is not associated with preneoplastic lesions. An increase in bacterial load without a concomitant increase in mucosal inflammatory cytokine responses in H. pylori-infected subjects with NG may represent a general dampening of immune responses or an additional mechanism of H. pylori active immune evasion.

Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events

Background

The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy.

Methods

Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data.

Results

Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically.

Conclusion

Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.

Use of N-acetylcysteine plus simethicone to improve mucosal visibility during upper GI endoscopy: a double-blind, randomized controlled trial

BACKGROUND AND AIM

Upper GI endoscopy (UGE) is essential for the diagnosis of gastrointestinal diseases. Mucus and bubbles may decrease mucosal visibility. The use of mucolytics could improve visualization. Our aim was to determine whether premedication with simethicone or simethicone plus N-acetylcysteine is effective in improving visibility during UGE.

METHODS

This was a randomized, double-blinded, placebo-controlled trial with 2 control groups: no intervention and water 100 mL (W); and 3 intervention groups: simethicone 200 mg (S); S + N-acetylcysteine (NAC) 500 mg (S+NAC500); and S + NAC 1000 mg (S+NAC1000). The solution was ingested 20 minutes before UGE. Gastric visibility was evaluated in 4 segments with a previously described scale. A score of less than 7 points was defined as adequate visibility (AV). Water volume was used to improve visibility, and adverse reactions were evaluated as a secondary outcome. Multiple group comparison was performed using non-parametric one-way analysis of variance (ANOVA).

RESULTS

Two hundred thirty patients were included in the study, 68% female, mean age 49 years. The most common indication for UGE was epigastric pain/dyspepsia (33%). AV was more frequent in the S+NAC500 and S+NAC1000 groups (65% and 67%) compared with no intervention (44%, P = .044) and water (41%, P = .022). The gastric total visibility scale (TVS) was significantly better in the S+NAC500 and S+NAC1000 groups compared with water (P = .03 and P = .008). Simethicone was not different from no intervention and water. S+NAC1000 required less water volume to improve visibility. No adverse reactions from the study drugs were observed.

CONCLUSIONS

Premedication with S+NAC500 and S+NAC1000 improves visibility during UGE. The use of simethicone did not show improvements in gastric visibility. TVS was worse in patients using water alone. (Clinical trial registration number: NCT 01653171.).

[Cilioretinal artery occlusion in hemochromatosis]

CLINICAL CASE

We report a case of a 31 year-old woman with a sudden visual loss due to a cilioretinal artery occlusion. The physical examinination showed hepatomegaly. Serum iron and ferritin and transferrin saturation were unusually high. The doppler scan of carotid arteries showed no relevant signs of atheromatous disease. Dilated cardiomiopaty was revealed in the B-scan with subendocardial calcium deposits. Genetic tests were positive for hemochromatosis.

DISCUSSION

Subendocardial calcification due to hemochromatosis could be the embolic source in our patient. This embolic ocular disease is the first presentation of hemochromatosis in this patient.

Management of Helicobacter pylori infection in Latin America: a Delphi technique-based consensus

AIM

To optimize diagnosis and treatment guidelines for this geographic region, a panel of gastroenterologists, epidemiologists, and basic scientists carried out a structured evaluation of available literature.

METHODS

Relevant questions were distributed among the experts, who generated draft statements for consideration by the entire panel. A modified three-round Delphi technique method was used to reach consensus. Critical input was also obtained from representatives of the concerned medical community. The quality of the evidence and level of recommendation supporting each statement was graded according to United States Preventive Services Task Force criteria.

RESULTS

A group of ten experts was established. The survey included 15 open-ended questions that were distributed among the experts, who assessed the articles associated with each question. The levels of agreement achieved by the panel were 50% in the first round, 73.3% in the second round and 100% in the third round. Main consensus recommendations included: (1) when available, urea breath and stool antigen test (HpSA) should be used for non-invasive diagnosis; (2) detect and eradicate Helicobacter pylori (H. pylori) in all gastroscopy patients to decrease risk of peptic ulcer disease, prevent o retard progression in patients with preneoplastic lesions, and to prevent recurrence in patients treated for gastric cancer; (3) further investigate implementation issues and health outcomes of H. pylori eradication for primary prevention of gastric cancer in high-risk populations; (4) prescribe standard 14-d triple therapy or sequential therapy for first-line treatment; (5) routinely assess eradication success post-treatment in clinical settings; and (6) select second- and third-line therapies according to antibiotic susceptibility testing.

CONCLUSION

These achievable steps toward better region-specific management can be expected to improve clinical health outcomes.

Advanced imaging technologies for the detection of dysplasia and early cancer in barrett esophagus

Advanced esophageal adenocarcinomas arising from Barrett esophagus (BE) are tumors with an increasing incidence and poor prognosis. The aim of endoscopic surveillance of BE is to detect dysplasia, particularly high-grade dysplasia and intramucosal cancers that can subsequently be treated endoscopically before progression to invasive cancer with lymph node metastases. Current surveillance practice standards require the collection of random 4-quadrant biopsy specimens over every 1 to 2 cm of BE (Seattle protocol) to detect dysplasia with the assistance of white light endoscopy, in addition to performing targeted biopsies of recognizable lesions. This approach is labor-intensive but should currently be considered state of the art. Chromoendoscopy, virtual chromoendoscopy (e.g., narrow band imaging), and confocal laser endomicroscopy, in addition to high-definition standard endoscopy, might increase the diagnostic yield for the detection of dysplastic lesions. Until these modalities have been demonstrated to enhance efficiency or cost effectiveness, the standard protocol will remain careful examination using conventional off the shelf high-resolution endoscopes, combined with as longer inspection time which is associated with increased detection of dysplasia.

Plasminogen activator inhibitor type 1 serum levels and 4G/5G gene polymorphism in morbidly obese Hispanic patients with non-alcoholic fatty liver disease

BACKGROUND

The plasminogen activator inhibitor type-1 (PAI-1) has been implicated in the regulation of fibrinolysis and extracellular matrix components. The single base pair guanine insertion/deletion polymorphism (4G/5G) within the promoter region of the PAI-1 gene influences PAI-1 synthesis and may modulate hepatic fibrogenesis.

AIM

To evaluate the influence of PAI-1 serum levels and 4G/5G polymorphism on the risk of liver fibrosis associated to non-alcoholic fatty liver disease (NAFLD) in morbidly obese patients.

MATERIAL AND METHODS

Case-control study of 50 obese patients undergoing bariatric surgery and 71 non-obese subjects matched by age and sex. Anthropometric and biochemical measurements were performed, including PAI-1 serum levels. Genomic DNA was obtained to assess the presence of 4G/5G polymorphism.

RESULTS

BMI, insulinemia, triglycerides, HOMA-IR, hypertension and diabetes were significantly higher in obese patients compared to control subjects. PAI-1 serum levels observed in obese patients were significantly lower (10.63 ± 4.82) compared to controls (14.26 ± 11.4; p < 0.05). No differences were observed in the PAI-1 4G/5G promoter genotypes frequencies (p = 0.12). No differences were observed in PAI-1 plasma levels among obese patients with liver fibrosis (10.64 ± 4.35) compared to patients without liver fibrosis (10.61 ± 5.2; p = 0.985). PAI-1 4G/5G promoter genotypes frequencies were similar in patients with or without liver fibrosis associated to NASH (p = 0.6).

CONCLUSIONS

Morbidly obese patients had significantly lower PAI-1 serum levels with similar PAI-1 4G/5G genotypes frequencies compared to non-obese subjects. The frequency of 4G/5G genotypes in Chilean Hispanic healthy subjects was similar to that described in other populations. No association was found between PAI-1 serum levels or 4G/5G genotype with liver fibrosis in obese patients.

[A national online survey applied to patients with celiac disease in Chile]

BACKGROUND

Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Its prevalence in Europe and the USA is 0.5 to 1%.

AIM

To analyze epidemiological aspects and degree of compliance with gluten-free diet (GFD) among Chilean individuals with CD.

MATERIAL AND METHODS

Subjects with confirmed or suspected CD were invited to answer an online survey published on the web at www.fundacionconvivir.cl. The answers were reinforced with a telephone interview.

RESULTS

The survey was answered by 1212 subjects (79% females). Median age at diagnosis was 25.8 years (range 1 to 84 years), with a bimodal curve with two peaks at less than 3 years and at 20 to 40 years of age. The diagnosis was made only by serologic markers in 9%, only by intestinal biopsy in 17.5%, and by a combination of both methods in 70%o. Conditions associated with CD were reported by 30% > of subjects and 20% > had relatives with CD. The GFD was strictly adhered to by 70% >, occasionally by 27% > and never by 3% >. Seventy five percent of subjects with a strict adherence to GFD had a favorable clinical response compared with 42% > of those with incomplete or lack of adherence (odds ratio 4.0, 95% > confidence intervals 2.8-5.7p < 0.01).

CONCLUSIONS

In 30% of respondents, the diagnosis of CD was not confirmed according to international guidelines that require serology and duodenal biopsy. One third of subjects recognized a poor compliance with GFD. Those with a strict adherence to it had a more favorable clinical course. However, 25% > did not experience a clinical improvement despite a strict GFD, a finding which requires further study.

[Helicobacter pylori infection in symptomatic patients with benign gastroduodenal diseases: analysis of 5.664 cases]

Infection with Helicobacter pylori (H. pylori) is highly prevalent in Chile, but there are no systematic studies in patients with upper gastrointestinal symptoms.

AIM

To determine the prevalence of H. pylori infection, according to age, gender and endoscopic pathology in a large sample of patients.

METHODS

We studied 7,893 symptomatic patients submitted to upper gastrointestinal endoscopy between July 1996 and December 2003 in the context of a screening program of gastric cancer in a high risk population. H. pylori infection was determined by rapid urease test (RUT) in antral mucosa. We excluded 158 patients with gastric cancer (2%) and 2,071 patients without RUT.

RESULTS

We included 5,664 patients, mean age 50.7 +/- 13.9 years, women 72.1%. Endoscopic diagnoses were normal in 59.3%, erosive esophagitis in 20%, gastric ulcer (GU) in 8.1%, duodenal ulcer (DU) in 6.4%, and erosive gastropathy in 6.2%. RUT was positive in 78% of patients. After adjusting for age and sex and with respect to patients with normal endoscopy, frequency of H. pylori infection was 86.6% in DU (OR 2.1, 95% CI 1.5-2.8, p < 0.001); 81.4% in GU (OR 1.8, 95% CI 1.4-2.4; p < 0.001 ); 79.9% in erosive gastropathy (OR 1.4, 95% CI 1.03-1.8; p = 0.03) and 77.4% in erosive esophagitis (OR 1.1, 95% CI: 0.9-1.3; p = NS). The probability of H. pylori infection decreased significantly with age, more markedly in men with normal endoscopy.

CONCLUSIONS

Prevalence of H. pylori infection is very high in symptomatic Chilean patients and even higher in those with gastroduodenal ulcer or erosions, while in patients with erosive esophagitis is similar to those with normal endoscopy. The frequency of infection decreases with age, probably as a consequence of rising frequency of gastric mucosal atrophy.

[Cost effectiveness analysis of the diagnosis of carpal tunnel syndrome using electrophysiological studies]

INTRODUCTION

The high demand for electrophysiological studies (EP studies) in paucisymptomatic patients with suspected carpal tunnel syndrome (CTS) creates overloads in neurological examination departments. Most of these requests in the referenced section of our hospital come from primary health care, however it also comes from other specialists. Many EP Studies for CTS are normal or have minimal alterations so that no change in the therapeutic attitude is required. Thus, it is not clear whether EP studies are cost-effective for suspected CTS without clinical evidence of axonal degeneration.

METHODS

A decision-making and economic evaluation model was made to compare three strategies: option A (EP Studies for all patients with suspected CTS), option B (prior selection by neurologist and EP studies only if axonal CTS was suspected) and option C (prior selection by neurologist and EP studies only if CTS, axonal or otherwise was suspected). The study was conducted over a two month period on patients referred to the neurology department with suspected CTS. EP studies were considered to be the proof that established the final diagnosis. The consequences were determined in terms of correct diagnoses, cost and cost/effectiveness ratio for each strategy. A total number of 188 studies were performed, option C being the most cost-effective, but also the most expensive.

CONCLUSIONS

When there is neurological screening, the cost-effectiveness ratio is better but it is also more expensive. It is recommended to favor option A with intermediate cost and an acceptable cost-effectiveness ratio. However, this also generates great pressure on bud- 45 gets and care facilities which means that CTS diagnosis and criteria for referring patients to the neurological examination departments must be improved.

First Report of Tomato torrado virus on Weed Hosts in Spain

Tomato torrado virus (ToTV) is a recently identified Picorna-like virus that causes "torrado disease" in tomatoes (4). Typical symptoms of "torrado disease" seen in tomato crops (Solanum lycopersicum L. formerly Lycopersicon esculentum L.) were initially defined as yellow areas at the base of the leaflet that later developed into necrotic spots that sometimes abscised, leaving holes in the leaflet. Other plants showed extensive necrosis progressing from the base to the tip of the leaflet. Fruits were distorted with necrotic lines on the surface that often cracked. Affected plants had a burnt-like appearance and the production was seriously reduced. These symptoms have been observed in tomato crops in Murcia (Spain) and the Canary Islands (Spain) (1). To identify possible alternative hosts that may serve as virus reservoirs, samples of 72 different common weed species were collected in greenhouses in Murcia and the Canary Islands where "torrado disease" symptoms were observed in tomatoes. Forty-seven showed virus-like symptoms and 25 were asymptomatic. Symptoms included mild mosaic, blistering, vein clearing, interveinal yellowing, yellow spots, necrosis, leaf distortion, and curling. Samples were analyzed by one-step reverse transcription (RT)-PCR using primers specific for ToTV to amplify 580 bp of the polyprotein region of RNA2 (3) and dot-blot hybridization with a digoxygenin-labeled RNA probe complementary to the same portion of the ToTV genome. Twenty-two of the 72 weed samples belonging to Amaranthus sp. (Amaranthaceae); Spergularia sp. (Caryophyllaceae); Atriplex sp., Chenopodium ambrosioides L., Chenopodium sp., and Halogetum sativus (Loef. ex L.) Moq. (Chenopodiaceae); Senebiera didyma Pers. (Cruciferae); Malva sp. (Malvacae); Polygonum sp. (Polygonaceae); and Nicotiana glauca Graham and Solanum nigrum L. (Solanaceae) were positive for ToTV by molecular hybridization (10 samples) and RT-PCR (22 samples, including the samples positive by molecular hybridization). PCR products obtained from Atriplex sp. (Canary Islands) and S. didyma (Murcia) were sequenced (GenBank Accessions EU090252 and EU090253). BLAST analysis showed 99% identity to ToTV RNA2 sequence (GenBank Accession DQ388880). Two tomato plants were positive for ToTV by RT-PCR after mechanical back-inoculation, although no symptoms were observed. This study showed ToTV infects common weeds present in Spanish tomato crops. Recently, Trialeurodes vaporariorum has been reported to transmit ToTV (2), although the efficiency of transmission is unknown. The vector-assisted transmission of ToTV could explain the infection of weeds in affected greenhouses. To our knowledge, this is the first report of natural infection of weeds by ToTV. References: (1) A. Alfaro-Fernández et al. Plant Dis. 91:1060, 2007. (2) H. Pospieszny et al. Plant Dis. 91:1364, 2007. (3) J. Van der Heuvel et al. Plant Virus Designated Tomato Torrado Virus. Online publication. World Intellectual Property Organization WO/2006/085749, 2006. (4) M. Verbeek et al. Arch. Virol. 152:881, 2007.

First Report of Tomato torrado virus in Tomato in the Canary Islands, Spain

In 2003, greenhouse-grown tomato crops (Lycopersicon esculentum Mill.) in the Canary Islands (Spain) were observed showing an initial yellowing in defined areas at the base of the leaflet that later developed into necrotic spots or an extensive necrotic area progressing from the base to tip. Fruits were also affected, showing necrotic areas and often developing cracking. Generally, the plants that were affected seemed to be burnt, their growth was reduced, and the production level was seriously damaged. Similar symptoms have been observed in Murcia (Spain) since 2001, which have been recently associated with Tomato torrado virus (ToTV) infection (2). Twenty-two tomato samples showing "torrado disease" symptoms were collected from different greenhouses between 2003 and 2006 in Las Palmas (Canary Islands, Spain). To verify the identity of the disease, double-antibody sandwich (DAS)-ELISA was performed on leaf and fruit extracts of symptomatic plants using polyclonal antibodies specific to Potato virus Y (PVY), Tomato mosaic virus (ToMV), Tomato spotted wilt virus (TSWV) (Loewe Biochemica, Sauerlach, Germany), and Pepino mosaic virus (PepMV) (DSMZ, Braunschweig, Germany). Total RNA was extracted from the 22 tomato samples with the RNAwiz Extraction kit (Ambion, Huntingdon, United Kingdom) and tested using one-step reverse-transcription (RT)-PCR with the SuperScript Platinum Taq kit (Invitrogen Life Technologies, Barcelona, Spain) with primers specific to PepMV (1) and ToTV (2). All analyses included healthy tomato plants as negative controls. Five of the twenty-two tomato samples were positive for PepMV and negative for the other viruses tested by serological analysis. However, all 22 samples were positive in RT-PCR performed with the primers specific to ToTV segment RNA2. The RT-PCR assay to detect ToTV produced an amplicon of the expected size (580 bp). No amplification product was observed when healthy plants or a water control were used as a template in the RT-PCR reaction. The ToTV RT-PCR product was purified (High Pure PCR Product Purification kit, Roche Diagnostics, Mannheim, Germany) and sequenced. BLAST analysis of one sequence (GenBank Accession No. EF436286) showed 99% identity to ToTV RNA2 sequence (GenBank Accession No. DQ388880). To our knowledge, this is the first report of ToTV in the Canary Islands. References: (1) I. Pagán et al. Phytopathology 96:274, 2006. (2) M. Verbeek et al. Online Publication. doi:10.1007/s00705-006-0917-6. Arch. Virol., 2007.

[Thiazide induced acute pulmonary edema: report of one case]

Acute pulmonary edema caused by thiazides is uncommon and of difficult diagnosis. It is considered an idiosyncratic reaction and the physiopathology or cardiac function changes are not well known. We report a 60 year-old female with a thiazide induced acute pulmonary edema who was followed with serial measurements of type B n-terminal natriuretic peptide fraction as marker for cardiac dysfunction. There was a significant elevation of the peptide, not associated to evidences of ventricular dysfunction. Its normalization paralleled the resolution of the clinical picture.

Quantification of the drawing of an Archimedes spiral through the analysis of its digitized picture

We have developed a new quantitative analysis of spiral drawing that is able to evaluate any spiral execution and it has not temporal or spatial limitations in the obtaining of specimens. Thirty-one patients with action tremor and 24 control subjects were asked to draw an Archimedes spiral over a print template. Specimens were scanned and then treated through a semiautomatic computer program that reconstructs the temporal sequence of the spiral drawing by the subject. The spirals were first analysed by means of the cross-correlation coefficient with the spiral template. Secondly, the mean and the standard deviation of the distance between each point of the spiral drawing and the corresponding point of the spiral model were determined. Finally, the reconstructed spiral was analysed using the Fourier Transform. Its results were interpreted with the aid of a computer model of a tremulous spiral. The experimental variables were greater in the patients group respect to age-matched controls. There was also a high linear correlation between them and the clinical score given by three neurologists. Finally, Receiver Operating Characteristic (ROC) curves analysis shown that the method classified the spirals better than human ratters.

Apolipoprotein E epsilon4 association with dementia in a population-based study: The Framingham study

Apolipoprotein E type 4 allele (apoE epsilon4) is associated with Alzheimer's disease (AD) in the late-onset familial form and in sporadic cases, but the age-associated risk in a randomly sampled elderly population is not established. We examined the association of apoE epsilon4 with AD and other dementias (mainly multi-infarct or dementia following stroke) in 1,030 persons aged 71 to 100 years in the population-based Framingham Study cohort. Kaplan-Meier survival analysis revealed that 55% of the apoE epsilon4/epsilon4 homozygotes developed AD by age 80, whereas 27% of apoE epsilon3/epsilon4 heterozygotes developed AD by age 85, and 9% of those without a 4 allele developed AD by age 85 years. In comparison with persons without a 4 allele, the risk ration for AD was 3.7 (95% CI = 1.9 to 7.5) for apoE epsilon3/epsilon4 heterozygotes and 30.1 (95% CI = 10.7 to 84.4) for apoE epsilon4 homozygotes. ApoE epsilon2 (2/2, 2/3, or 2/4 genotypes) was associated with an absence of AD. One-half (n=21) of the 43 AD patients were either homozygous or heterozygous for apoE epsilon4. We found evidence for an association of apoE epsilon4 with other dementia, primarily multi-infarct dementia and stroke. The risk ratio was 2.3 (95% CI = 0.9 to 6.1) for non-AD dementias among persons with apoE epsilon3/epsilon4. Although the apoE epsilon4 allele is a potent risk factor for AD and may be associated with other forms of dementia, most apoE epsilon4 carriers do not develop dementia, and about one-half of AD is not apoE epsilon4 associated. The low positive predictive value of this marker (0.10) suggest that use of apoE genotyping as a screening test for AD is not supported.

MPP+ toxicity in rat striatal slices: relationship between non-selective effects and free radical production

Incubations of rat striatal slices have been used to assay MPP+ neurotoxicity. MPP+, at concentrations of 1 mM or higher, caused a marked increase in hydroxyl radicals, measured as malondialdehyde (MDA) accumulation, but not in nitric oxide production. At these doses, MPP+ showed an effect on dopamine terminals, causing a massive dopamine decrease, and on non-neuronal glial cells, where a marked reduction in glutamine synthetase activity was detected. At lower concentrations (25 mu M), the toxic effect on dopaminergic endings was maintained without increasing malondialdehyde concentrations or inhibiting glutamine synthetase activity. The effect on glutamine synthetase was prevented by the addition to the medium of 0.5% dimethyl sulfoxide, a hydroxyl-radical scavenger, but this did not protect the effect of dopamine depletion. We propose that non-selective effects of MPP+, at doses of 1 mM or higher, are mediated by extracellular overproduction of hydroxyl radicals. The main factor responsible for this overproduction would not be the released dopamine but rather the MPP+ itself through non selective inhibition of the mitochondrial respiratory chain or through a redox cycling that can trigger oxygen radical production.

Chronic effects of single intrastriatal injections of 6-hydroxydopamine or 1-methyl-4-phenylpyridinium studied by microdialysis in freely moving rats

Extracellular dopamine (DA) and its main cerebral metabolites, dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA), were measured by bilateral striatal microdialysis in rats at different times (2, 7, 15 and 60 days) after unilateral administration into the right striatum of 1-methyl-4-phenylpyridinium ion (MPP+) or 6-hydroxydopamine (6-OHDA). In both cases the decrease in extracellular dopamine did not exceed 40% of control values. The response of DOPAC and HVA depended on the treatment: MPP+ caused a marked acute decrease in the dopamine metabolites but allowed a progressive recovery that was very evident after 60 days; 6-OHDA caused a progressive decrease in the dopamine metabolites throughout the two months of the study. Tyrosine hydroxylase immunostaining revealed severe neuronal loss in substantia nigra two months after striatal administration of 6-OHDA, whereas no significant neuronal loss was found at the same time after MPP+ administration. A bilateral challenge infusion of MPP+ through the microdialysis probe was used to assess the dopaminergic capacity of both striata: at all the times studied there was a sharp depletion of DA on the non-lesioned side; both MPP(+)- and 6-OHDA-treated striata were unresponsive after a short time (2 days); after 2 months the response in MPP(+)-lesioned rats was similar on both sides, whereas 6-OHDA-lesioned striata were still unresponsive to MPP+. In rats, then, the effects of MPP+ could be partly reversed whereas the effects of 6-OHDA were not. These results suggest that neurotoxins causing striatal dopamine loss may act through different mechanisms, which could be significant for the etiopathogenic development of Parkinson's disease.

Lipoprotein concentrations in normolipidemic males consuming oleic acid-rich diets from two different sources: olive oil and oleic acid-rich sunflower oil

The effects on plasma lipid concentrations of two oleic acid-rich diets, prepared with two different plant oils--olive oil and sunflower oil high in monounsaturated fatty acids (MUFAs)-- were compared with a National Cholesterol Education Program (NCEP) I diet. Twenty-one healthy, normolipidemic, young males consumed an NCEP-I diet (30% of energy as fat) during a 25-d period. Subjects were then assigned to two 4-wk study periods, according to a randomized, crossover design. Group one was placed on an olive oil-enriched diet (40% fat, 22% MUFAs), followed by a 4-wk period of a sunflower oil-enriched diet (40% fat, 22% MUFAs). In group two, the order of the diets was reversed. Both MUFA dietary periods resulted in an increase in high-density-lipoprotein (HDL) cholesterol (7% for the olive oil diet and 4% for the sunflower oil diet) and in apolipoprotein (apo) A-I (9% for both) compared with the NCEP-I diet. Low-density-lipoprotein (LDL) cholesterol and apo B concentrations (x +/- SEM) were lower (P < 0.05) during the sunflower oil diet (2.40 +/- 0.11 mmol/L, 0.85 +/- 0.04 mg/L) than during the olive oil diet (2.64 +/- 0.15 mmol/L, 0.93 +/- 0.05 mg/L). No significant differences were observed in these variables between the sunflower oil and NCEP-I (2.48 +/- 0.13 mmol/L, 0.89 +/- 0.04 mg/L) diets.(ABSTRACT TRUNCATED AT 250 WORDS)

[Possible relationship between overweightness and prevalence of hyperlipemia in the children of patients with heterozygote familial hypercholesterolemia and combined familial hyperlipemia]

BACKGROUND

Heterozygote familial hypercholesterolemia and combined familial hyperlipemia are associated to a greater risk of coronary disease. Combined familial hyperlipemia has classically been indicated to manifest after the second decade in life. The aim of this study was to establish whether a systematic search would demonstrate the existence of combined familial hyperlipemia earlier and analyze whether the antropometric parameters related with the overweightedness accompany the appearance of the lipid disorders of this disease found at an early age.

PATIENTS AND METHODS

Different lipid parameters were studied in 89 subjects under the age of 18 who were children of patients with heterozygote familial hypercholesterolemia and combined familial hyperlipemia. Likewise the weight, height and waist/hip quotient were evaluated. Hyperlipemia was considered as the presence of cholesterol/LDL and/or triglicerides greater than the 95 percentile for age and sex.

RESULTS

Hyperlipemia was observed in 51% and 40% of the children of patients with heterozygote familial hypercholesterolemia and combined familial hyperlipemia, respectively. The body mass index and the waist/hip quotient of the latter children significantly correlated with the cholesterol-HDL values and the LDL/HDL quotient.

CONCLUSIONS

The patients with known combined familial hyperlipemia have a high percentage of children with hyperlipemia during infancy. These data suggest a possible association between obesity in the appearance of hyperlipemia in the children of patients with combined familial hyperlipemia at this age.

CSF somatostatin increase in patients with early parkinsonian syndrome

Somatostatin-like immunoreactivity levels (SLI) in cerebrospinal fluid (CSF) were determined in twenty-three patients with untreated parkinsonian syndrome (15 with Idiopathic Parkinson's disease (IPD) and 8 with other forms of parkinsonism) at the moment of clinical diagnosis (mean duration of disease 1.1 +/- 0.2 years), and in 26 subjects without neurological symptoms. None of the IPD patients had a diagnosis of dementia at the moment of inclusion in the study. CSF-SLI content was found to be significantly higher in patients with parkinsonian syndrome (107.9 +/- 9.8 pg/ml) than in control subjects (73.5 +/- 8.4 pg/ml). The increase was also significant when controls were compared with IPD patients. In addition, a positive correlation between SLI and homovanillic acid was found in CSF of all patients. A test of learning memory was used to evaluate the mental state of patients and a significant increase in CSF-somatostatin levels was observed in patients with Idiopathic Parkinson's disease and severe affectation of memory. These results indicate that in the early steps of untreated parkinsonian syndrome, somatostatin concentration in cerebrospinal fluid may increase, probably due to the neurodegenerative depletion of somatostatin from striatal or cortical neurons.

Comparison of lovastatin and bezafibrate on lipoprotein(a) plasma levels in cardiac transplant recipients

Our results suggest that bezafibrate may be useful in the treatment of high Lp(a) levels in heart transplant patients.

The effect of cyclosporine and methylprednisolone on plasma lipoprotein levels in rats

The aim of this study was to evaluate in rats the effects of cyclosporine, methylprednisolone, and the combination of both (CyP) on plasma lipids and lipoproteins levels. Three groups received a low doses of cyclosporine, methylprednisolone, and CyP (cyclosporine, 15 mg/kg/day; methylprednisolone, 1 mg/kg/day; and CyP, 15 plus 1 mg/kg/day of cyclosporine and methylprednisolone, respectively). Three additional groups received high doses (cyclosporine, 30 mg/kg/day; methylprednisolone, 2 mg/kg/day; and CyP, 30 plus 2 mg/kg/day of cyclosporine and methyprednisolone, respectively). The administration of cyclosporine produced an increase in plasma levels of triglycerides, very low density lipoprotein (VLDL) triglycerides, low-density lipoprotein (LDL) cholesterol and in total cholesterol/HDL cholesterol and LDL cholesterol/high-density lipoprotein (HDL) cholesterol ratios. In addition, cyclosporine decreased plasma HDL cholesterol and HDL2 cholesterol levels. The administration of methylprednisolone produced an increase in triglycerides and VLDL triglycerides and a decrease in HDL cholesterol and HDL2 cholesterol levels. Total cholesterol/HDL cholesterol and LDL cholesterol/HDL cholesterol ratios did not change after administration of methylprednisolone. The association of both drugs resulted in a greater increase in triglycerides and VLDL triglycerides than the separated administration of either cyclosporine or methylprednisolone alone. In rats receiving cyclosporine the increase in triglycerides and VLDL triglycerides may be due to a significant decrease in plasma lipoprotein lipase activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrospinal dopamine metabolites in rats after intrastriatal administration of 6-hydroxydopamine or 1-methyl-4-phenylpyridinium ion

Dopamine (DA) and its main cerebral metabolites, dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) were measured in striatum and cerebrospinal fluid (CSF) from cisterna magna in rats bilaterally lesioned by intrastriatal administration of 6-hydroxydopamine (6-OHDA) or 1-methyl-4-phenylpyridinium ion (MPP+). 6-OHDA caused a progressive lesion in striatum that is only moderately reflected in the decrease in dopamine metabolite concentration in CSF. MPP+ caused an acute but less selective lesion in the dopamine striatal system, as indicated by a significant reduction in striatal GABA content, followed by a slow recovery in dopamine striatal metabolism and content. The locomotor activity was dramatically reduced in both groups 48 hours after the treatment but remained significantly decreased after two months only in 6-OHDA lesioned animals. A positive correlation was found between HVA CSF concentration and striatal DA content in MPP+ lesioned rats, but not in 6-OHDA lesioned rats. It is concluded that the concentration of dopamine metabolites in CSF can be altered only after a severe striatal lesion: reduction of striatal dopamine content below 50% of normal values and involvement of neuronal or non-neuronal elements other than the dopaminergic system, similarly to the lesions caused by MPP+. These results may partly explain why CSF dopamine metabolites concentrations were significantly decreased both in advanced stages of parkinsonism and in other neurodegenerative disorders.

Cerebrospinal monoamine metabolites and amino acid content in patients with parkinsonian syndrome and rats lesioned with MPP+

Monoamine metabolites and amino acid concentration in cerebrospinal fluid (CSF) of 33 untreated patients with parkinsonian syndrome, and 20 control patients without specific neurological symptoms have been compared with those obtained in cerebrospinal fluid of rats intrastriatally lesioned with 1-methyl-4-phenylpyridinium ion (MPP+) and sham operated animals. Homovanillic acid content was found to be significantly lower in patients with severe parkinsonism (motor score of UPDRS > 24), but not in patients with mild symptoms (motor score < or = 24). A correlation between the loss of striatal dopamine and the decrease in cerebrospinal homovanillic acid has been established in rats treated with MPP+. The extrapolation of these results to those obtained from human patients could be important in assessing the degree of striatal dopamine loss shown by humans with parkinsonian syndrome at the moment of clinical diagnosis. No significant differences were found between the other monoamine metabolites analyzed and free amino acid content in human and rat CSF.

Influence of mutation in human apolipoprotein A-1 gene promoter on plasma LDL cholesterol response to dietary fat

The plasma lipid response to changes in dietary fat and cholesterol can vary between individuals. At present, responders cannot be identified in advance. An adenine to guanine (A-->G) mutation in the promoter of the apolipoprotein A1 gene (apoA-1) has been suggested as affecting plasma high-density lipoprotein cholesterol. In 50 young men we examined the effect of the same mutation on the responses of both high and low density lipoprotein cholesterol to low-fat diet. The frequency for the A allele was 0.14. Subjects were fed a low-fat diet for 25 days, followed by a diet rich in monounsaturated fatty acid (MUFA, 22% out of 40% fat) for 28 days and lipoproteins were measured at the end of each diet. There were no differences in initial total cholesterol between subjects with the G/G mutation (170 mg/dL: 100 mg/dL = 2.59 mmol/L) and the G/A mutation (169 mg/dL) genotypes. After consumption of the high monounsaturated fat diet, significant increases were noted in plasma LDL cholesterol (10 mg/dL, p = 0.035) in the G/A subjects but not in the G/G subjects (1 mg/dL, p = 0.996). These differences showed that a significant diet-gene interaction (p = 0.015) existed. No differences were observed on HDL cholesterol between groups. Plasma low-density lipoprotein cholesterol responsiveness to diet may be explained by variation at the apoA-I gene locus.

Stereotaxic administration of 1-methyl-4-phenylpyridinium ion (MPP+) decreases striatal fructose 2,6-bisphosphate in rats

The stereotaxic administration of 1-methyl-4-phenylpyridinium ion (MPP+) into the neostriatum of male rats caused a lesion that resulted in a large dose-dependent loss of striatal fructose 2,6-bisphosphate; initial values were restored 5 days after the treatment. This effect was not protected by systemic administration of MK-801 or by nitroarginine. The content of hexose 6-phosphates and ATP was also reduced by MPP+ treatment, whereas lactate was increased. Biochemical and histological results suggested that MPP+ caused a nonselective cell death, followed by a pronounced astroglial response, parallel to fructose 2,6-bisphosphate recovery. The stereotaxic administration of rotenone showed a different time effect on fructose 2,6-bisphosphate cerebral content, with a significantly faster recovery. These results indicate that cerebral fructose 2,6-bisphosphate may be a sensitive metabolite related to brain damage caused by potent neurotoxins such as MPP+. On the other hand, they show that MPP+ acts in the brain through a quick, strong cytotoxic mechanism, which probably involves mechanisms other than mitochondrial chain blockage.