Genetic Variants Associated with Biological Treatment Response in Inflammatory Bowel Disease: A Systematic Review

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the digestive tract usually characterized by diarrhea, rectal bleeding, and abdominal pain. IBD includes Crohn's disease and ulcerative colitis as the main entities. IBD is a debilitating condition that can lead to life-threatening complications, involving possible malignancy and surgery. The available therapies aim to achieve long-term remission and prevent disease progression. Biologics are bioengineered therapeutic drugs that mainly target proteins. Although they have revolutionized the treatment of IBD, their potential therapeutic benefits are limited due to large interindividual variability in clinical response in terms of efficacy and toxicity, resulting in high rates of long-term therapeutic failure. It is therefore important to find biomarkers that provide tailor-made treatment strategies that allow for patient stratification to maximize treatment benefits and minimize adverse events. Pharmacogenetics has the potential to optimize biologics selection in IBD by identifying genetic variants, specifically single nucleotide polymorphisms (SNPs), which are the underlying factors associated with an individual's drug response. This review analyzes the current knowledge of genetic variants associated with biological agent response (infliximab, adalimumab, ustekinumab, and vedolizumab) in IBD. An online literature search in various databases was conducted. After applying the inclusion and exclusion criteria, 28 reports from the 1685 results were employed for the review. The most significant SNPs potentially useful as predictive biomarkers of treatment response are linked to immunity, cytokine production, and immunorecognition.

Primary Sclerosing Cholangitis: Gender Effects in Valencia's Low-Prevalence Region

BACKGROUND AND AIMS

Recent studies point out to epidemiological changes in primary sclerosing cholangitis (PSC). Our aims were to determine in PSC patients followed in several centers in a Mediterranean geographic area: (i) changes in baseline features and (ii) effect of gender on clinical course.

METHODS

Retrospective multicenter study of PSC patients treated in 8 hospitals in a Mediterranean area between 2000 and 2021. Charts were reviewed compiling demographic, clinical, radiological, and histological variables.

RESULTS

Cohort of 112 PSC patients included, 42% women, 70% diagnosed after 2010. Women were increasingly diagnosed in recent cohorts. The median time from diagnosis to the combined endpoint liver transplantation (Lt) and/or death was 6.9 years. Asthenia at diagnosis (p = 0.009) was associated with lower transplant-free survival, while diagnosis before 2005 was associated with greater LT-free survival (p < 0.001). By Cox regression, LT-free survival was not influenced by age, sex, or cirrhosis at the time of diagnosis. Women were found to have less jaundice at diagnosis (2 vs 14%; p = 0.013), higher prevalence of ANA antibodies (43.9 vs 15.7%; p = 0.003), and lower GGT levels at diagnosis (GGT 123 vs 209U/L; p = 0.014) than men.

CONCLUSION

In an area traditionally considered to have low prevalence, the prevalence of affected women surpasses expectations based on existing literature. There appear to be gender-related variations in the presentation of the condition, highlighting the need for confirmation through larger-scale studies.

Effectiveness and safety of azathioprine for inflammatory pouch disorders: results from the RESERVO study of GETECCU

Background

The usefulness of thiopurines has been poorly explored in pouchitis and other pouch disorders.

Objective

To evaluate the effectiveness and safety of azathioprine as maintenance therapy in inflammatory pouch disorders.

Design

This was a retrospective and multicentre study.

Methods

We included patients diagnosed with inflammatory pouch disorders treated with azathioprine in monotherapy. Effectiveness was evaluated at 1 year and in the long term based on normalization of stool frequency, absence of pain, faecal urgency or fistula discharge (clinical remission), or any improvement in these symptoms (clinical response). Endoscopic response was evaluated using the Pouchitis Disease Activity Index (PDAI).

Results

In all, 63 patients were included [54% males; median age, 49 (28-77) years]. The therapy was used to treat pouchitis (n = 37) or Crohn's disease of the pouch (n = 26). The rate of clinical response, remission and non-response at 12 months were 52%, 30% and 18%, respectively. After a median follow-up of 23 months (interquartile range 11-55), 19 patients (30%) were in clinical remission, and 45 (66%) stopped therapy. Endoscopic changes were evaluated in 19 cases. PDAI score decreased from 3 (range 2-4) to 1 (range 0-3). In all, 21 patients (33%) presented adverse events and 16 (25%) needed to stop therapy.

Conclusion

Azathioprine may be effective in the long term for the treatment of inflammatory pouch disorders and could be included as a therapeutic option.

Real-world long-term effectiveness of ustekinumab in ulcerative colitis: results from a spanish open-label cohort

OBJECTIVE

Ustekinumab was recently approved for the treatment of moderate-to-severe ulcerative colitis (UC). Although data from the UNIFI clinical trial are encouraging, real-world data assessing effectiveness and safety are scarce. The aim of this study was to assess the effectiveness, safety and pharmacokinetics of ustekinumab in a large cohort of refractory UC patients.

METHODS

Multicenter observational study of UC patients who received ustekinumab for active disease. The Partial Mayo Score (PMS), endoscopic activity, C-reactive protein (CRP) and faecal calprotectin (FC) were recorded at baseline and at different time points. Demographic and clinical data, adverse events (AEs) and surgeries were documented.

RESULTS

A total of 108 patients were analyzed from 4 referral Spanish hospitals. The clinical remission rates were 59%, 56.5%, 57% and 69% of patients at weeks 8, 16, 24 and 52, respectively. Normalization of FC was achieved in 39.6%, 41% and 51% at weeks 8, 24 and 52, respectively. CRP normalization was observed in 79%, 75% and 76.5% of patients at weeks 8, 24 and 52, respectively. Fewer previous anti-TNF agents and loss of response to anti-TNF were associated with clinical response and normalization of FC, respectively. AEs were observed in 5 patients, and 9 underwent colectomy. Ustekinumab persistence rates were 91%, 83% and 81% at 24, 48 and 96 weeks, respectively.

CONCLUSIONS

Ustekinumab demonstrated, in the real-world setting, long-term effectiveness and a favorable safety profile in a cohort of refractory UC patients.

Predictive model of persistent choledocholithiasis in patients with acute biliary pancreatitis

BACKGROUND

Choledocholithiasis causing acute biliary pancreatitis (ABP) may migrate to the duodenum or persist in the common bile duct (CBD). We developed a model for predicting persistent choledocholithiasis (PC) in patients with ABP.

METHODS

This retrospective cohort study included 204 patients, age ≥18 years (mean age: 73 years, 65.7% women), admitted for ABP in 2013-2018, with at least a magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP). Epidemiological, analytical, imaging, and endoscopic variables were compared between patients with and without PC. Multivariate logistic regression analyses were performed to develop a predictive model of PC.

RESULTS

Patients underwent MRCP (n=145, 71.1), MRCP and ERCP (n=44, 21.56%), EUS and ERCP (n=1, 0.49%), or ERCP (n=14, 6.86%). PC was detected in 49 patients (24%). PC was strongly associated with CBD dilation, detected in the emergency ultrasound (p<0.001; OR=27; 95% CI: 5.8-185.5), increased blood levels of gamma glutamyl transpeptidase, detected at 72h (p=0.008; OR=3.4; 95% CI: 1.5-8.9); and biliary sludge in the gallbladder (p=0.008; OR=0.03; 95% CI: 0.001-0.3).

CONCLUSIONS

The predictive model showed a validated area under the curve (AUC) of 0.858 for detecting PC in patients with ABP. A nomogram was developed based on model results.

CONCLUSIONS

The predictive model was highly effective in detecting PC in patients with ABP. Therefore, this model could be useful in clinical practice.

Fibrin glue treatment associated or not with diathermy for recurrent tracheoesophageal fistula: our results after more than 20 years' experience

INTRODUCTION

Recurrent tracheoesophageal fistula (RTEF) is a frequent complication (5-10%) in patients with esophageal atresia (EA). Open RTEF surgery has a high morbidity and mortality, so the endoscopic approach represents a promising alternative. We present the long-term results of fibrin glue (FG) bronchoscopic application in patients with RTEF secondary to EA, which was first used by our team in 1994.

MATERIAL AND METHODS

A retrospective review of all patients diagnosed with RTEF following EA repair and treated with FG bronchoscopic application from 1993 to 2019 was carried out. In most cases, diathermy was applied prior to FG sealing. The maximum number of endoscopic sessions was 5. In case of persistent RTEF following the fifth session, open surgery was performed.

RESULTS

14 RTEF patients were treated with FG. In all but the first 3 cases (11 patients, 78.6%), diathermy was applied concomitantly. Mean first treatment day was day 85 of life (range: 14-770). Patients received a mean of 2.1 (1-5) endoscopic sessions. Mean follow-up was 12.1 (10-20) years. Overall success rate was 71.4%, without significant differences according to whether diathermy was concomitantly applied or not (72.7% vs. 66.6%).

CONCLUSIONS

Fibrin glue bronchoscopic application associated or not associated with diathermy is an excellent option for RTEF treatment in EA patients. The endoscopic approach should be considered as the first-choice treatment for RTEF.

Effect of porcine circovirus type 2 (PCV2) load in serum on average daily weight gain during the postweaning period

Porcine circovirus type 2 (PCV2) is a ubiquitous virus that mainly affects nursery and fattening pigs causing systemic disease (PCV2-SD) or subclinical infection. A characteristic sign in both presentations is reduction of average daily weight gain (ADWG). The present study aimed to assess the relationship between PCV2 load in serum and ADWG from 3 (weaning) to 21 weeks of age (slaughter) (ADWG 3-21). Thus, three different boar lines were used to inseminate sows from two PCV2-SD affected farms. One or two pigs per sow were selected (60, 61 and 51 piglets from Pietrain, Pietrain×Large White and Duroc×Large White boar lines, respectively). Pigs were bled at 3, 9, 15 and 21 weeks of age and weighted at 3 and 21 weeks. Area under the curve of the viral load at all sampling times (AUCqPCR 3-21) was calculated for each animal according to standard and real time quantitative PCR results; this variable was categorized as "negative or low" (<10(4.3) PCV2 genome copies/ml of serum), "medium" (≥10(4.3) to ≤10(5.3)) and "high" (>10(5.3)). Data regarding sex, PCV2 antibody titre at weaning and sow parity was also collected. A generalized linear model was performed, obtaining that paternal genetic line and AUCqPCR 3-21 were related to ADWG 3-21. ADWG 3-21 (mean±typical error) for "negative or low", "medium" and "high" AUCqPCR 3-21 was 672±9, 650±12 and 603±16 g/day, respectively, showing significant differences among them. This study describes different ADWG performances in 3 pig populations that suffered from different degrees of PCV2 viraemia.

Improvement of C peptide zero BMI 24-34 diabetic patients after tailored one anastomosis gastric bypass (BAGUA)

BACKGROUND

Although bariatric surgery proved to be a very effective method in the treatment of patients in whose pancreas still produce insulin (type 2 diabetes), the accompanied metabolic syndrome and their diabetes complications, there is no information on the effect of this type of surgery in BMI24-34 patients when pancreas do not produce insulin at all (type 1, LADA and long term evolution type 2 diabetes among others).

PATIENTS AND METHODS

We report preliminary data of a serie of 11 patients all with a C-peptide values below 0.0 ng/ml. They were followed for 6 to 60 months (mean 19 months) after surgery. We studied the changes in glycemic control, evolution of the metabolic syndrome and diabetes complications after one anastomosis gastric bypass (BAGUA).

RESULTS

All values relative to glycemic control were improved HbA1c (from 8.9 ± 0.6 to 6.7 ± 0.2%), FPG (Fasting Plasma Glucose) [from 222.36 ± 16.87 to 94 ± 5 (mg/dl)] as well as the daily insulin requirement of rapid (from 40.6 ± 12.8 to 0 (U/d) and long-lasting insulin (from 41.27 ± 7.3 U/day to 15.2 ± 3.3 U/day). It resolved 100% of the metabolic syndrome diseases as well as severe hypoglycaemia episodes present before surgery and improved some serious complications from diabetes like retinopathy, nephropathy, neuropathy, peripheral vasculopathy and cardiopathy.

CONCLUSIONS

Tailored one anastomosis gastric bypass in BMI 24-34 C peptide zero diabetic patients eliminated the use of rapid insulin, reduced to only one injection per day long-lasting insulin and improved the glycemic control. After surgery disappear metabolic syndrome and severe hypoglycaemia episodes and improves significantly retinopathy, neuropathy, nephropathy, peripheral vasculopathy and cardiopathy.

Resolution of diabetes mellitus and metabolic syndrome in normal weight 24-29 BMI patients with One Anastomosis Gastric Bypass

INTRODUCTION

Diabetes mellitus type 2 (DMT2) is a major cause of death in the world. The medical therapy for this disease has had enormous progress, but it still leaves many patients exposed to the complications developed from the disease. It is well known the beneficial effects of bariatric surgery in obese diabetic patients, however it is important to investigate if the same principles of bariatric surgery that improve diabetes in obese patients, could be applied to non obese normal weight diabetics.

MATERIAL AND METHODS

Thirteen diabetic patients operated by One Anastomosis Gastric Bypass (BAGUA), were evaluated in the preoperative period and 1,3 and 6 months after surgery. Body weight and composition, Fasting Plasma Glucose, HbA1c levels, blood pressure and serum lipids levels were analyzed, as well as the monitoring of the immediate postoperative treatment necessities for Diabetes and other metabolic syndrome comorbidities.

RESULTS

After the surgery the 77% of the patients resolves its T2DM, 46% from surgery, and rest noted an significant improvement of the disease in spite of having a C peptide level near to zero some of the patients. The comorbidities, mainly hypertension and lipid abnormalities experience improvement early. All patients reduce their weight and the amount of fat mass until values consistent with their age and height.

CONCLUSIONS

The One Anastomosis Gastric Bypass leads to resolution or improvement of T2DM in non obese normal weight patients. The best results are obtained in patients with few years of diabetes, without or short term use of insulin treatment and high C-peptide levels.

[Neuroprotection in Parkinson's disease: analysis though group of experts' methodology]

INTRODUCTION

Currently used antiparkinsonian drugs neither stop nor slow-down the progressive nature of the disease. The final phase of PD is characterized by the presence of symptoms and signs resistant to dopaminergic agents, such as depression, dementia, freezing and falls. Therefore, it is urgent to develop therapies able to positively modify this outcome. Despite neuroprotection is a research priority in PD, no effective strategies have been found so far.

METHOD

A key informants study was conducted. A group of experts in PD fulfilled a questionnaire of 10 questions to explore the most important topics related to neuroprotection. Afterwards a consensus about the current situation of neuroprotection in PD was established and future directions of development were suggested.

RESULTS

Most of the answers emphasized the need of new concepts, the limitations of animal models and the difficulties in the difficulties in demonstrating a neuroprotective effects in humans owing to a lack of biomarkers. Some of the experts believe that we are already exerting a disease modifying effect.

CONCLUSIONS

The concept of neuroprotection should be widened. Animal models should be improved. A reliable biomarker to start neuroprotective therapies long before the appearance of motor symptoms and to evaluate the neuroprotective effect of any therapy should be urgently developed.

[Neuropsychological impairment in patients with intracranial aneurysms: surgical versus endovascular treatment]

OBJECTIVES

To describe the neuropsychological status of patients with intracranial aneurysms and to compare the cognitive status of patients with intracranial aneurysm treated by surgical or endovascular methods.

MATERIAL AND METHODS

Ninety-three cases with intracranial aneurysms treated with surgery (n = 56) or embolization (n = 37) were included. A neuropsychological assessment was applied to both groups retrospectively, at least one year after treatment.

RESULTS

Neuropsychological impairment was found in both groups. 35.7% of the patients treated with surgery and 43.2%, of those treated with embolization did not show any cognitive impairment. Visual Memory and Cued Recall of verbal information are better in patients treated by embolization.

CONCLUSIONS

Our results show that a large proportion of patients with intracranial aneurysms have cognitive impairment after treatment. Endovascular management may cause less impairment in visual and verbal memory. However, bleeding may be the most important factor to explain these cognitive impairments.

[The value of the internal capsule signs in the stimulation of the subthalamic nucleus in Parkinson's disease]

INTRODUCTION

The effectiveness of stimulating the subthalamic nucleus (DBS-STN) in advanced Parkinson's disease (PD) largely depends on the correct placement of the electrodes. Since the sensory-motor region of the STN lies beside the internal capsule (IC), we believe that the motor effectiveness of DBS-STN could be related to the stimulation threshold in which IC signs appear (IC threshold).

PATIENTS AND METHODS

An examination of 17 consecutive patients with advanced PD who had been submitted to bilateral DBS-STN (one case was unilateral) was carried out to determine the motor improvement on each side of the body (n = 33) and the energy consumption one year after surgery according to the IC threshold obtained during the programming.

RESULTS

A 45% improvement was observed in the UPDRS III in off and there was a 24% reduction in the equivalent dose of levodopa with bilateral DBS-STN. When the electrodes were considered, there was a statistically significant improvement that depended on the IC threshold. Energy consumption differed significantly between electrodes with an IC threshold of 3-7 V (1.5 +/- 1.2 microW) and those with an IC threshold > 7 V (8.3 +/- 9.4 microW).

CONCLUSIONS

During the stimulation phase and following the correct location of the STN, which was achieved by neurophysiological recording, the IC threshold has prognostic implications in medium-long term motor effectiveness and in the consumption of the battery in the generator.

[Thrombolysis in stroke: inappropriate consideration of the 'window period' as the time available]

AIMS

The earlier r-TPA is administered in ischaemic strokes, the more effective it is. The aim of this study is to analyse the delay times in health care afforded in a consecutive series of cases that had received treatment, with a view to shortening them.

PATIENTS AND METHODS

We analysed the medical records of the first patients to be treated in our centre. The paper describes several variables involving demographic and clinical factors, as well as the delay in entering the Emergency department, performing a CAT scan and especially the time elapsed between the CAT scan and starting treatment. We have examined the existence of an inappropriate correlation between delays that should be independent of one another.

RESULTS

The mean age of the 17 patients treated was 68 years and they had a stroke severity score of 17 points on the NIHSS. The mean time of delay until arrival, arrival-CAT, and CAT-treatment were slightly under 1 hour each, and onset-treatment delay was 165 minutes, which is very close to the limit of the therapeutic window period. We found a strong inverse linear association between the time elapsed between onset and the CAT scan, and from the latter to the beginning of treatment (Spearman's r: -0.664, p = 0.004).

CONCLUSIONS

Findings indicate that in our hospital, as in other centres in the initial phases of implementation, the therapeutic time window for intravenous thrombolysis in ischaemic stroke tends to run out. It must be highlighted that the resolve of the physician who indicates the treatment exerts a decisive effect on the delay.

Linear accelerator radiosurgery in treatment of central neurocytomas

OBJECTIVES

The purpose of this report was to review our experience with stereotactic radiosurgery in the management of patients with residual neurocytomas after initial surgery.

METHODS

Between October 1996 and December 2001, four patients with central neurocytoma were treated by surgery and subsequently underwent linear accelerator (LINAC) radiosurgery.

RESULTS

Two of the patients were cured, one exhibited a significant reduction in tumour size and the fourth remains stable. All four patients are alive and well.

CONCLUSIONS

In cases of small residual tumours or recurrences radiosurgery allows open surgery to be avoided and is a safe and potentially effective approach.

Molecular cloning of major allergen from Cupressus arizonica pollen: Cup a 1

The family Cupressaceae is a relevant source of allergens that causes winter respiratory allergies. Cloning and sequencing the major antigen of Cupressus arizonica is important for a better diagnosis and treatment of sensitized patients. To obtain a full-length complementary DNA for Cup a 1, the major allergen of Cupressus arizonica pollen. It was cloned and sequenced and the recombinant protein was expressed. Messenger RNA from Cupressus arizonica pollen was obtained and the Cup a 1 sequence was established using a 3'-RACE system and primers based on the N-terminal amino acid sequence. Recombinant Cup a 1 was cloned in pBluescript and expressed in a glycosylated form in rabbit reticulocytes. The cDNA was subcloned in pGEX-5X-1 and expressed in Escherichia coli as a fusion protein with GST. Recombinant Cup a 1 is highly homologous with the major allergens of mountain cedar (Jun a 1), Japanese cypress (Cha o 1) and Japanese cedar (Cry j 1). Cup a 1 contains three potential N-glycosylation sites that are different from those found in Jun a 1 and Cry j 1. The cloned protein contains a pectate lyase active site identical to those of Cry j 1 and Jun a 1. The IgE from patients' sera recognizes recombinant Cup a 1, and this reactivity is higher with the glycosylated protein. Cup a 1 has been cloned and sequenced. As expected, the high degree of homology with Cha o 1, Jun a 1 and Cry j 1 explains the cross-reactivity of conifer pollens. Different IgE reactivity with the glycosylated and non-glycosylated protein suggests the importance of carbohydrate moieties in the IgE binding site.

[Functional surgery of the thalamus in movement disorders]

INTRODUCTION

Functional thalamic surgery as a treatment for movement disorders is half a century old. Although the accumulated experience is wide, their precise indications have varied depending on the available alternative therapies.

DEVELOPMENT

In this article the historical evolution, anatomofunctional basis and results of the functional surgery on the motor thalamus are reviewed. Considering new advances in this field, the current indications are proposed.

CONCLUSIONS

Nowadays, thalamic surgery is a valuable therapeutic option for patients with different tremor syndromes, when the upper limb tremor is disabling, and satisfactory relief with pharmacological treatment cannot be achieved. It can also be useful in selected patients with ballism and with secondary hemidystonia. When unilateral surgery is considered, both thalamotomy and thalamic stimulation can be acceptably safe and effective procedures in experienced surgical teams. The main advantage of stimulation is its irreversibility, making possible bilateral procedures with a lower morbidity. The objective of surgery should be to improve the patients' functional capacities and quality of life, therefore, the indication and selection of the procedure should be individualized.

[Lhermitte-Duclos disease associated with tuberous sclerosis. A case report and review of literature]

INTRODUCTION

Lhermitte-Duclos disease is a rare disorder of the cerebellum of unknown origin in which dysplasic thickening of the cerebellar convolutions is seen. It usually occurs in young adults. Currently it is included in the phacomatosis group of disorders.

CLINICAL CASE

A 19 year old woman attended the Emergency Department complaining of progressive orthostatic headache for the previous three months. On examination there were striking facial micronodular lesions suggestive of angiofibromas, a hypo-pigmented macula in the inframammary region and a hyperpigmented 'café-au-lait' macula in the right hypochondrium. On computerized tomography there was tetraventricular hydrocephalia. Cerebral magnetic resonance showed significant descent of the tonsils, hypertensive hydrocephalia and a lesion in the left cerebellum, apparently laminar hyperintensity in DP and T2, with thickening of some folia, not enhanced by intravenous contrast and suggestive of a dysplasic gangliocytoma. Laboratory investigations showed subclinical hypothyroidism. Other investigations were normal. The patient was treated by implanting a ventriculo-peritoneal shunt which has relieved the symptoms to date.

CONCLUSIONS

Lhermitte-Duclos disease is probably not a single anatomo-clinical condition, assuming that it may be a cerebellar hamartoma associated with a phacomatosis with few clinical signs, whether it be Cowden's disease, tuberous sclerosis as in this case or an 'overlapping' syndrome. The magnetic resonance findings are necessary and sufficient for the diagnosis of Lhermitte-Duclos disease.

Molecular cloning and characterization of an IgE-reactive protein from Anisakis simplex: Ani s 1

Ingestion of the parasitic nematode Anisakis simplex in undercooked fish can cause severe allergic reactions in some individuals. Using pooled human sera from sensitized patients we have probed an expression library for A. simplex antigens. One positive clone was found to encode a full length 21 kDa protein with strong homology to nematode troponins. The recombinant protein was expressed as a GST-fusion protein and found by immunoblot analysis to react with sera from 20% of allergic patients. The presence of functional EF-hand Ca(2+) binding motifs was demonstrated by gel-shift analysis.

[Prescription and costs of artificial nutrition before and after a new utilization protocol]

In order to improve the quality of prescription and reduce expenditure, the artificial nutrition department has designed a new usage protocol: justification sheet, table of indications for parenteral nutrition (PN), nutritional assessment, etc. The Pharmacy Department is in charge of the follow-up of this programme and maintaining the database derived from it. Comparing the data for the year before (1996) and after (1998) implementation of this programme, we can see that as a result 9 patients/day switched from total parenteral nutrition by central administration to hypocaloric peripheral nutrition, with the prevalence of the former dropping to 1.4% of admissions and 2% of stays. The share of enteral nutrition (30.6%) and hypocaloric peripheral nutrition (27.8%) increases in the overall expenditure on artificial nutrition, with a reduction in the total parenteral nutrition (41.6%). The costs of parenteral nutrition per admission and stay are reduced by 39.3% and 33.5%, respectively, to 1,625 and 183 pesetas. This represents a saving of 16.5 million pesetas. The expenditure on PN elements declines by two percentage points to 2.2% of pharmaceutical expenditure. As an additional benefit, it is possible to identify each of the clinical situations which give rise to this indication and to allocate costs by diagnosis and department. Together with the containment of expenditure, it has been possible to increase the participation of everyone in the rational use of clinical nutrition thus highlighting its interdisciplinary nature.

[Genotype-phenotype correlation in myotonic dystrophy and prediction of clinical seriousness]

INTRODUCTION

Since description of the expansion of the number of CTG trinucleotides on the long arm of chromosome 19 in the 19 q 13.2-13.3 interval as being responsible for myotonic dystrophy (DM), many studies have established a direct relationship between the size of the expansion and the severity of the manifestations.

OBJECTIVES

To evaluate the clinico-genetic correlation in a population with DM in Eastern Andalucia and to establish the predictive value of the increase in number of CTG repetitions with regard to clinical gravity.

PATIENTS AND METHODS

A transverse study of persons from families known to have members with DM, classified with regard to the clinical gravity of their illness. Diagnosis was by means of clinical neurological, ophthalmological and neurophysiological examination and subsequently by genetico-molecular study, Southern blot, PCR, oligonucleotide CTC hybridization and Northern blot.

RESULTS

Genetic studies confirmed the previous clinical diagnosis of DM in 78 persons, of the 145 studied, who came from 32 families. The average size of the mutation was 1-5 kb. There was close correlation between the size of the expansion and the clinical condition. Logistic repression studies permitted adequate classification in function of the size of the expansion in 87.23% of the cases of clinically relevant illness and in 90% of the cases in which the condition was not clinically relevant.

CONCLUSIONS

There is a strong association between the clinical features of DM and the magnitude of the mutation. The size of the expansion has considerable predictive value in prognosis of the disorder. This may be useful when making decisions during prenatal diagnosis.

Subarachnoid ketamine in swine--pathological findings after repeated doses: acute toxicity study

BACKGROUND AND OBJECTIVES

The purpose of this study was to investigate whether 5% ketamine with and without preservative, administered intrathecally to swine, produced a clinical anesthetic effect and caused direct subacute neurotoxicity.

METHODS

Twenty pigs were used. Under general anesthesia, a subarachnoid catheter was placed at L5-L6 or L6-S1 spinal interspace. Five animals were used for initial clinical evaluation of the anesthetic effects of subarachnoid ketamine (12.5 and 25.0, and 500 mg). Two animals were excluded because of bloody taps, two served as controls (catheterization without drug administration), four received ketamine racemate (25.0 mg/d), four received ketamine racemate preservative free (25.0 mg/d), and three received benzethonium chloride, the ketamine excipient (0.05 mg/d). All drugs were administered for 7 days. The catheters were withdrawn at the end of the treatment period. After 35 days, the pigs were euthanized and the spinal cord removed and preserved for histopathologic study with hematoxilyn-eosin and luxol-fast blue myelin staining. Histopathologic effects were defined as absent/minimal, mild, or severe by a pathologist, unaware of group allocation, by evaluating the presence and intensity of peripheral and/or central chromatolysis, spongiosis, neuronal loss, perivascular neuroglia, neuronolysis, and myelin degeneration.

RESULTS

All doses of ketamine produced immediate cutaneous anesthesia and motor block; benzethonium chloride did not. Histopathologic examination showed no neurotoxic effect of ketamine without preservative; ketamine with preservative showed a discrete neurotoxic effect, and the preservative alone produced a moderate neurotoxic effect.

CONCLUSIONS

Clinically, in swine, subarachnoid ketamine without preservative is a safe and effective anesthetic and did not show significant neurotoxic effects. However, ketamine with preservative produces minimal changes, and benzethonium chloride alone produces moderate neurotoxic effects.

[Diagnostic usefulness of glutamic acid decarboxylase antibodies in stiff-man syndrome]

Stiff-man syndrome (SMS) is a rare neurological disorder characterized by progressive rigidity of the axial musculature with superimposed spasms. Frequently, SMS remains undiagnosed for prolonged periods or the patients are diagnosed of a primary psychiatric disorder. 60% of the SMS patients harbor GAD-autoantibodies (GAD-Ab). We have analyzed the diagnostic value of GAD-Ab in a syndrome whose clinical expression is not well known, but its diagnosis is performed by clinical criteria. Five patients were studied following the established clinical criteria for diagnosis of SMS. GAD-Ab were analyzed by radioimmunoassay (RIA) and immunohistochemistry, and confirmed by immunoblot. The GAD-Ab titers were compared with those of 49 patients with insulin-dependent diabetes mellitus (IDDM), 322 with other neurological disorders, 14 non-IDDM first-degree relatives of IDDM patients with antibodies anti-islet cells and 91 normal subjects. Three patients fulfilled all clinical criteria (typical SMS). Unilateral limb symptoms alone, and acute onset with rapid progression involving the distal limb muscles constituted the atypical features of SMS in the remaining 2 patients. The 5 patients presented several serum organ-specific autoantibodies. All but one also presented autoimmune diseases. By RIA, GAD-Ab titers from all patients were elevated (mean: 24,532 +/- 26,892 U/ml) and significantly higher than the titers of IDDM patients without neurological disorders (mean: 48 +/- 112 U/ml) (p < 0.0001). GAD-Ab were absent in the non-SMS patients and in normal subjects. These findings suggest that clinical expression of SMS is more extensive than that recognized by the established criteria. GAD-Ab are helpful to define the clinical spectrum of SMS.

Trough-to-peak ratio and circadian blood pressure profile after treatment with once-daily extended-release diltiazem, 240 mg, in patients with mild-to-moderate essential hypertension

Once-daily diltiazem extended-release 240 mg (Lacerol-HTA Retard) was evaluated for safety, efficacy, and trough-to-peak ratio in a multicenter open study by using 24-h blood pressure (BP) monitoring in mild-to-moderate essential hypertension. After a 4-week washout period, 30 patients (17 men, 13 women) aged 25-76 years, showing a mean daytime diastolic BP (DBP) >90 mm Hg, were treated with diltiazem-ER, 240 mg, given once daily for 8 weeks. Ambulatory BP monitoring was obtained at the end of a 4-week placebo run-in period and during the last week of treatment. A significant reduction of the mean values of clinical BP [161.6 +/- 16.2 to 151.2 +/- 15.6 mm Hg; p < 0.01 for systolic BP (SBP); and 101.1 +/- 4.8 to 93.3 +/- 9.2 mm Hg; p < 0.001 for DBP] was observed at the end of treatment in the group of 30 patients, with no significant changes in heart rate (77.1 +/- 9.9 to 73.1 +/- 11.1 beats/min; p = NS). Likewise, mean values of 24-h SBP, DBP, SBP-load, and DBP-load were significantly reduced. In the group of 21 responders, the average reduction at peak was -18.6 +/- 12.9 mm Hg for SBP and -14.7 +/- 9.5 mm Hg for DBP. The residual effect at trough was -12.2 +/- 14.7 and -8.1 +/- 10 mm Hg, respectively. The trough-to-peak ratio was estimated as 0.66 for SBP and 0.55 for DBP. Long-term variability expressed as the mean standard deviation of BP for the 24-h period was reduced in responders (16.2 +/- 4.3 to 14.6 +/- 2.7 mm Hg for SBP; p = 0.0395; and 12.1 +/- 2.7 to 10.7 +/- 2.5 mm Hg for DBP; p = 0.0019), although no changes were observed in the variation coefficient (10.58-10.57% for SBP and 12.88-12.87% for DBP). We conclude that once-daily diltiazem-ER, 240 mg, was effective and well tolerated. Blood pressure was controlled over the entire period of 24 h, preserving the circadian profile and reducing long-term variability in responders. The significant reduction of both BP values and long-term variability may have implications involving protection from end-organ damage in essential hypertension.

A multicenter, parallel comparative study of the antihypertensive efficacy of once-daily lisinopril vs enalapril with 24-h ambulatory blood pressure monitoring in essential hypertension

The aim of the study was to compare the antihypertensive efficacy of once-daily lisinopril vs enalapril both during normal daily activity and sleep, in mild-to-moderate essential hypertension. After a 4-week wash-out period, 34 patients (17 M, 17 F) aged 22 to 67 years were randomized in a multicenter, open, parallel fashion: 17 received lisinopril (10-20 mg) and 17 enalapril (10-20 mg) for a 12-week period. Twenty-four hour ambulatory blood pressure monitoring (ABPM) was performed using an oscillometric non-invasive automated device at both the end of the 4-week drug-free baseline period and during the last week of treatment. With no differences in initial blood pressure (BP) between groups, both drugs significantly reduced office and ABPM values. Lisinopril tended to reduce BP in a greater extension than enalapril, but only the reduction of office systolic BP (SBP) (p = 0.0062), 24-h SBP load (P = 0.0182) and night time SBP load (P = 0.0316) reached statistical significance. We conclude that, in spite of a more prominent reduction of SBP by lisinopril, both drugs have a similar efficacy in reducing BP, assessed by both office and ABPM measurements.

[Intralobar pulmonary sequestration as the cause of neonatal respiratory distress]

A male infant 15 hours old with congenital intralobar pulmonary sequestration is described. The boy was born with tachypnea and cyanosis. A chest film revealed mediastinal displacement secondary to a cystic lesions in the lower left lobe. During surgery the lesion was found to be irrigated by an artery coming from the thoracic aorta and venous drainage was into the inferior vena cava. The lesion was spongiform and microscopic examination revealed alveolar parenchyma with irregular, dilated bronchiolar structures. Intralobar sequestrations have seldom been described in infants. Our case suggests that this malformation is congenital. We discuss the diagnostic possibilities of pulmonary cystic lesions that cause respiratory distress in neonates.

[Four new cases and a review of the literature concerning the migraine with csf pleocytosis syndrome]

The syndrome known as migraine with cerebrospinal fluid (CSF) pleocytosis is a clinical syndrome of controversial pathogenesis characterized by typical migraine headaches occurring in a fixed period of time along with lymphocyte pleocytosis in CSF which persists during intercritical periods. We present four new cases of this syndrome diagnosed in our service and we review those cases published in the literature in which there were no personal headache antecedents, attempting in this way to separate this syndrome from other types of migraine as included in the present classification. There also exists the possibility that it might be a question of a secondary process, the pathogenesis of which may play a part in the activation of the humoral immune system, given the frequent existence of immunogenic antecedents the previous days as well as that of a humoral reaction expressed as an increase in IgG levels in CSF with normal blood electrophoresis.

[Association of dystrophinopathy with facial-scapular-humeral dystrophy in the same family]

We present the association of a distrophinopathy with a case of facioscupulohumeral dystrophy in two individuals belonging to the same family. The discrepancy in the seric creatinphosphokinase (CPK) of the two patients together with certain clinical data suggests the possibility that it is a question of two different processes. This impression was confirmed later through dystrophine analysis and genetic examination techniques. This case drew attention to the vital need today to insist on a combination of genetic examinations and dystrophine analysis when diagnosing muscular dystrophies, thus avoiding mistakes derived from diagnostic assumptions made on the basis of antecedents in the family involving neuromuscular disorders and the consequences that this might have regarding vital prognosis and advice to the family. This is the first case of coincidental association of these two processes within one family that has so far come to our knowledge.

Dinoflagellates have a eukaryotic nuclear matrix with lamin-like proteins and topoisomerase II

Unicellular Dinoflagellates represent the only eukaryotic Phylum lacking histones and nucleosomes. To investigate whether Dinoflagellates do have a nuclear matrix that would modulate the supramolecular organization of their non-nucleosomal DNA and chromosomes, cells of the free-living unarmored Dinoflagellate Amphidinium carterae were encapsulated in agarose microbeads and submitted to sequential extraction with non-ionic detergents, nucleases and 2 M NaCl. Our results demonstrate that this species has a residual nuclear matrix similar to that of vertebrates and higher plants. The cytoskeleton-nuclear matrix complex of A. carterae shows a relatively intricate polypeptide pattern. Immunoblots with different antibodies reveal several intermediate filament types of proteins, one of which is immunologically related to vertebrate lamins, confirming that these proteins are ancestral members of the IF family, which is highly conserved in eukaryotes. A topoisomerase II homologue has also been identified in the nuclear matrix, suggesting that these structures could play a role in organizing the Dinoflagellate DNA in loop domains. Taken together our results demonstrate that the nuclear matrix is an early acquisition of the eukaryotic nucleus, independent of histones and nucleosomes in such a way that the mechanisms controlling the two levels of organization in eukaryotic chromatin would be molecularly and evolutionarily independent.

[Post-traumatic cholelithiasis]

A 5 year old patient, without any lithogenic antecedent, suffered a trauma, resulting in a shrunken fracture of the left parietal bone, and a splenic parenchymal hematoma. A hemoperitoneum developed at the 3rd postoperation day, with an overall blood loss of 15% of the total blood volume. At the 6th day a well formed biliary calculi was detected in the gallbladder. As the patient remain asymptomatic related to his cholelithiasis, an ultrasound follow-up was instituted. At 3 month postinjury all biliary stones dissolved completely. In this report, the etiopathogenic factors responsible of stone formation in the biliary tree, and current therapeutic recommendations are reviewed.

Immunological characterization of lamins in the nuclear matrix of onion cells

We have used polyclonal and monoclonal antibodies against different lamins from vertebrates, and the IFA antibody recognizing all kinds of intermediate filament proteins, to investigate the lamins of the nuclear matrix of Allium cepa meristematic root cells. All the antibodies react in the onion nuclear matrix with bands in the range of 60–65 kDa, which are enriched in the nuclear matrix after urea extraction, and do not crossreact with other antibodies recognizing intermediate filaments in plants (AFB, anti-vimentin and MAC 322), ruling out crossreaction with contaminating intermediate filaments of cytoplasmic bundles. In 2-D blots the chicken anti-lamin serum reacts with one spot at 65 kDa and pI 6.8 and the anti B-type lamin antibodies with another one at 64 kDa and pI 5.75. Both crossreact with IFA. The lamin is localized at the nuclear periphery and the lamina by indirect immunofluorescence. Immunogold labelling of nuclear matrix sections reveals that the protein is not only associated with the lamina, but also with the internal matrix. Taken together these results reveal that higher plants, which do not possess an organized network of cytoplasmic intermediate filaments, nevertheless present a well-organized lamina containing lamins in which at least one of them is immunologically related to vertebrate lamin B. Our data confirm that lamins are very old members of the intermediate filament proteins that have been better conserved in plants during evolution than their cytoplasmic counterparts.

Ribonucleoprotein components of root meristematic cell nuclei of the tomato characterized by application of mild loosening and immunocytochemistry

Immunocytochemistry and hypotonic-formaldehyde fixation have been used to study the extranucleolar ribonucleoprotein (RNP) constituents of the nucleus of tomato root meristematic cells. The study of the distribution of small nuclear uridine-rich RNPs (snRNP) by means of a monoclonal anti-Sm antibody recognizing a 29-kDa protein in plants, after standard fixation, shows a preferential labeling of the perichromatin region and a lower labeling of the interchromatin space. These results suggest that in the tomato there is a perichromatin region similar to that of animal cells, in which much of the nonnucleolar transcription and splicing takes place. In hypotonic-formaldehyde-detergent-fixed nuclei, fibrogranular polyparticles have been visualized reacting with anti-snRNP antibody. These structures are frequently associated with filaments of extended chromatin characterized by their reaction with an anti-DNA monoclonal antibody.

[A parametric description of the parenteral nutrition protocols of 19 American hospitals]

In the preparation of a centralized parenteral nutrition unit project in our hospital, following the creation of a multi-disciplinary commission entrusted with the study of this project, we proceeded to evaluate parenteral nutrition protocols of national and foreign hospitals, as a first approach to the subject. This study evaluates and extracts the data we consider most relevant in a sample of 19 American hospitals. With regard to the types of parenteral diet, we observed that most of them (63%) had "standard diets", mainly formulated with 25% glucose and 4.25% crystalline amino acids. None of the protocols studied contained alternatives to glucose as a calorie-contributor, nor were there special formulae for amino acids, although many of them included it in their therapies for use if considered necessary. In all protocols, the contribution of fats was reduced to concrete situations and administered in a different way to the rest of the food in 73% of cases. With regard to additives, despite the existence of standard formulations of electrolytes and vitamins and oligoelements, in 100% of the hospitals studied, there was the possibility of formulating each element separately. Administration was done in several doses per day in 42% of cases and in 100%, using perfusion pumps. The data obtained from this review was of great value in preparing our own parenteral nutrition protocols.