Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Spatial distribution and pollution evaluation in dry riverbeds affected by mine tailings

The objective of this study was to evaluate the level of pollution, sources and potential risk of heavy metals (Zn, Cu, Mn, Cd, Cr, Ni, Fe and Pb) and arsenic (As) in four dry riverbeds affected by mine tailing, which drain into one of the biggest coastal lagoon of Europe (Mar Menor). El Beal, La Carrasquilla, Las Matildes and Ponce dry riverbeds sediments were sampled along its course (20, 18, 13, 19 samples were collected, respectively), and total/soluble metal(loid)s, water soluble ions, nitrogen, and organic/inorganic carbon contents were analyzed. Spatial distribution, principal component analysis (PCA), hierarchical cluster analysis (HCA), contamination factor (Cf), pollution load index (PLI) and potential ecological risk index (RI) were used to identify the possible sources of metal(loid)s and to assess the sediment pollution status. The results showed that the mean total concentrations of As, Cu, Cd, Mn, Zn and Pb exceeded the natural background levels of the study area, with the highest values located close to the mining areas. Correlation and cluster analysis identified that Cd and Zn were associated mainly with anthropogenic activities for all riverbeds, while Cr and Ni come from parent. PLI graded the four riverbeds as contaminated by heavy metals, while RI manifested that 100% of samples located in El Beal, La Carrasquilla and Las Matildes had a significantly high ecological risk. Therefore, this study suggests that mine wastes are the main source of metal(loids) contamination in the dry riverbeds, which results can be used to design actions and measures to reduce the environmental impact of metal(loid)s in the Mar Menor coastal lagoon.

Are the soils and vegetation of a forest close to tailings ponds affected by metals and arsenic?

This study aimed to determine the transfer of metals (Cd, Pb and Zn) and As to a Mediterranean forest close to five tailings ponds in Cartagena-La Union mining district (SE Spain). In addition, the effect of the rhizosphere of two native plant species, Olea europaea (OE) and Pistacia lentiscus (PL), on soil properties and chemical speciation of metal(oid)s was evaluated. Results showed there was no influence of the rhizosphere in the total concentration of metal(loid)s in soil, decreasing as Pb > Zn > As > Cd. Chemical partitioning revealed that only Cd and As can be considered hazardous, with a high percentage of these elements in the soil-labile fractions (20-40%). The accumulation in vegetal tissues was only high for Pb in PL roots, which makes it a suitable species for phytostabilization. Additionally, translocation factors showed transfer of Pb and Zn in OE, and Zn in PL to aerial parts, although no toxicity evidences for plants or animals were found. Finally, soil properties affected metal(loid)s accumulation in plants. The OE species was related to soil-labile metal(loid) fractions and pH, total N, organic carbon and silt content. The PL species were associated with immobilized metal(loid) fractions, sand content, electrical conductivity and total concentrations of As, Cd and Pb. Hence, mining activity has affected native adjacent soils, with accumulation of metals in plant species, although translocation was low, likely due to physiological strategies of the studied species to protect themselves against hazardous elements, and to the high soil pH, which limits metals' mobility.

Assessing the behaviour of heavy metals in abandoned phosphogypsum deposits combining electrical resistivity tomography and multivariate analysis

This study presents the results of a physical-chemical characterisation of phosphogypsum deposits generated with hydrochloric and sulphuric acid during the wet acid process. The paper aims to establish an efficient methodology based on electrical resistivity tomography (ERT), chemical analysis and multivariate analysis identifying the areas most contaminated by heavy metals in an abandoned factory where fertiliser was derived from phosphoric rock. This fertiliser has provided many benefits to agriculture; however, it generates a vast amount of waste (5 tonnes phosphoric rock/1 tonne fertiliser). The chemical composition of this by-product varies according to the industrial process performed. Hydrochloric acid (HCl) recovers more than 90% of phosphorus, while sulphuric acid (H₂SO₄) recovers around 30%. Therefore, a chemical assessment of the remaining waste is a necessary step prior to initiating any remediation process. ERT provided the geometry of the deposits and the distribution of the phosphogypsum. The chemical analyses consistently validated the electrical contrast found within the deposits. We employed a correlation analysis combined with multivariate analysis to identify the relationships among the metal concentrations and resistivity. Principal component analysis (PCA) reduced the information contained in all the variables to a few principal components. The first three principal components accounted for 74% of the variability of all the studied variables. Partial least squares-discriminant analysis (PLS-DA) for classification allowed the discrimination of the two populations. Electrical resistivity was the most influential variable for separating HCl waste from that of H₂SO₄. The use of ERT saves time and reduces costs yielding a methodology which facilitates the environmental assessment of large areas.

Distribution of metal(loid)s in particle size fraction in urban soil and street dust: influence of population density

Assessment of street dust is an invaluable approach for monitoring atmospheric pollution. Little information is available on the size distribution of contaminants in street dusts and urban soils, and it is not known how the population density would influence them. This research was carried out to assess the size distribution of trace metal(loid)s in street dust and urban soil, and to understand how population density might influence the size-resolved concentration of metal(loid)s. Three urban areas with a high, medium and low population density and a natural area were selected and urban soil and street dust sampled. They were fractionated into 8 size fractions: 2000-850, 850-180, 180-106, 106-50, 50-20, 20-10, 10-2, and < 2 µm. The concentration of Pb, Zn, Cu, Cd, Cr, Ni, As, and Fe was determined, and enrichment factor and grain size fraction loadings were computed. The results indicated that the concentration of Pb, Zn, Cu, Cd, and Cr was highly size dependent, particularly for particles < 100 µm, especially for street dust. Low concentrations of Ni and As in street dust and urban soil were size and population density independent. Higher size dependency of the metals concentration and the higher degree of elemental enrichment in the street dust fractions than the urban soils indicate higher contribution of human-induced pollution to the dust. Findings also confirm the inevitability of size fractionation when soils or dusts are environmentally assessed, particularly in moderately to highly polluted areas. Otherwise, higher concentrations of certain pollutants in fine-sized particles might be overlooked leading to inappropriate decisions for environmental remediation.

Composition and risk assessment of roasted pyrite ash from fertiliser production

Pyrite ash is a residue from the roasting of pyrite ores to obtain sulphuric acid used in the fertiliser industry and its production is widely extended worldwide. The mismanagement of this waste may result in environmental and health damages due to its physico-chemical characteristics. The main objective of this study was to examine the physico-chemical and mineralogical composition of roasted pyrite ash from an abandoned fertiliser company, and to evaluate the environmental risk caused by the wind and water dispersion of metals posed by this waste. In order to achieve these objectives, a sequential extraction procedure and a physical fractionation into six size fractions: >100, 100-50, 50-20, 20-10, 10-2.5 and < 2.5 μm were applied. Results showed that pyrite ash is composed mainly of iron-oxides such as hematite (46%) and secondary minerals as anglesite and shows high concentrations of Pb (7464 mg kg^-1), Zn (2663 mg kg^-1) and Cu (585 mg kg^-1). The highest Risk Assessment Code (RAC) values were found for Cd, Pb and Zn, bound to the more labile fractions. Conversely, Pb showed the lowest water solubility due to the covering effect provided by a coating of anglesite in the pyrite ash surface. Most of the metals were associated to both the coarsest (>100 μm) and the finest (2.5-10 μm) fractions, although none represented an environmental risk according to the ecological risk index results. However, 30% of the metals were bound to the respirable fraction (≤100 μm) posing a potential risk for human health and a high potential dispersion by wind to the surrounding areas.

Phytoremediation of mine tailings with Atriplex halimus and organic/inorganic amendments: A five-year field case study

Mine tailings have adverse chemical and physical conditions, including high concentrations of metals and salts, low organic matter content, and unbalanced rates of nutrients which limit the development of vegetation. A large scale field experiment was conducted to reclaim a tailing pond by triggering the growth of native species by spontaneous colonization by tilling (TL) the tailing pond surface and using marble waste (CaCO₃; MW), pig slurry (PS) and their combination (MW + PS) as soil amendments. Soil physicochemical properties and water and DTPA extractable metal concentrations of bulk and rhizosphere soils were analyzed after five year from the application of the treatments. In addition, plants of Atriplex halimus from each treatment were collected and metals in roots, leaves and stems analyzed. Before amendments application, the studied pond showed a neutral pH, high salinity and a moderate organic carbon content. After five years, the pH value was significantly increased only in MW plot. The results showed significant increases of DTPA-extractable Zn in MW and MW + PS plots, Pb in all treatments except MW plot, Cd only in PS plot, and Cu only in MW + PS plot. A. halimus was the most dominant species, growing spontaneously in all plots, with lower vegetation cover in CT and MW plots, 6% and 2% respectively. Application of MW increased leaf Pb accumulation by 2.5-fold and Cd by 55%, when compared to the CT. The high initial salinity and probable substitution of metals by Ca²⁺ on exchangeable surfaces of soil particles may be the reasons for higher uptake of metals in MW plot when compared to the other plots. Although this plant is widely utilized in contaminated sites for phytostabilization purposes, it may absorb and translocate high concentrations of metals to the aboveground tissues in saline contaminated sites.

Change in metals and arsenic distribution in soil and their bioavailability beside old tailing ponds

The objectives of this study were to determine the metals and arsenic transfer from mining ponds to agricultural and forest soils, and identify the dynamic of metal(loid)s in the soil-plant system for a native plant species (Ballota hirsuta) in two old mining districts: La Unión and Mazarrón (Spain). Soils and plants from mining ponds and natural and agricultural areas were collected and analyzed for soil properties, and chemical partitioning of Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, Zn and As. Results showed that mine, forest and agricultural soils were contaminated by As, Cd, Cu, Pb, and Zn. Chemical partitioning revealed higher mobility of metals in mining ponds than natural and agricultural soils except for Fe and As which were mostly bound to soil matrix due to the mineralogical compositions of soils. The accumulation of metal(loid)s in B. hirsuta in La Unión decreased as Fe > As > Cr > Ni > Cu > Zn > Cd > Mn > Co > Pb while in Mazarrón was As > Fe > Cr > Pb > Cu > Ni > Co > Mn > Zn > Cd, showing that B. hirsuta has high ability to bio-accumulate Fe, As, Cr, Cu and Ni; and Pb (in Mazarrón), transferring a significant concentration of theses metal(loid)s, except Pb, to edible parts without exceeding the toxicity limits for animals. Therefore, B. hirsuta could be useful as phytoextractor species for Cr, Cu, As and Ni, while it can be used as phytostabilizer species for Zn, Co, Pb and Cd.

Use of multivariable and redundancy analysis to assess the behavior of metals and arsenic in urban soil and road dust affected by metallic mining as a base for risk assessment

The vicinity of abandoned mining ponds to populated areas may suppose a high environmental and health risk being necessary evaluate unreclaimed ponds as source of metal(loid)s. In order to evaluate the behaviour of metals and arsenic from tailing ponds and their effects in urban areas, 10 mine wastes samples, 10 urban soil and 10 urban road dust samples were collected from two mining districts (La Unión and Mazarrón, SE Spain). Physicochemical properties and total, available and water-soluble concentration of metals (Cd, Co, Cr, Cu, Fe, Ni, Mn, Pb, Zn) and As were analyzed. Results suggest enrichment in Fe, Mn, Pb and Zn of urban soil and road dust in both studied towns. Multivariable analysis indicated that Cd, Mn, Pb and Zn in La Unión urban soil, and As, Cd, Cu, Pb and Zn in soil and Fe in road dust of Mazarrón come from mining districts. In addition, redundancy analysis showed that mobility of metal(loid)s related to mining sources were more influenced by their total concentration, while metals with a lithogeny origin were more affected by physicochemical properties.

Soil or Dust for Health Risk Assessment Studies in Urban Environment

To identify the best material (soil or dust) to be selected for health-risk assessment studies, road dust and urban soil from three cities with different population densities were collected, and size fractions were analysed for metal content (Pb, Zn, Cu, Cd, Cr, Co, and Ni). Results showed similar distribution of the size particles among cities, predominating fractions between 75 and 2000 μm in road dust and particles below 75 μm in soil. Metals were mainly bound to PM10 in both soil and road dust increasing the risk of adverse health effects, overall through inhalation exposure. The risk assessment showed that the most hazardous exposure pathway was the ingestion via, followed by dermal absorption and inhalation route. Values of hazard quotient showed that the risk for children due to the ingestion and dermal absorption was higher than adults, and slightly larger at PM10 comparing to <75-μm fraction for the inhalation route. Higher risk values were found for road dust, although any hazard index or cancer risk index value did not overreach the safe value of 10^-6.

Epitaxial thin films of pyrochlore iridate Bi2+xIr2-yO7-δ: structure, defects and transport properties

While pyrochlore iridate thin films are theoretically predicted to possess a variety of emergent topological properties, experimental verification of these predictions can be obstructed by the challenge in thin film growth. Here we report on the pulsed laser deposition and characterization of thin films of a representative pyrochlore compound Bi₂Ir₂O₇. The films were epitaxially grown on yttria-stabilized zirconia substrates and have lattice constants that are a few percent larger than that of the bulk single crystals. The film composition shows a strong dependence on the oxygen partial pressure. Density-functional-theory calculations indicate the existence of Bi_Ir antisite defects, qualitatively consistent with the high Bi: Ir ratio found in the films. Both Ir and Bi have oxidation states that are lower than their nominal values, suggesting the existence of oxygen deficiency. The iridate thin films show a variety of intriguing transport characteristics, including multiple charge carriers, logarithmic dependence of resistance on temperature, antilocalization corrections to conductance due to spin-orbit interactions, and linear positive magnetoresistance.

Digestion and nitrogen balance using swine diets containing increasing proportions of coproduct ingredients and formulated using the net energy system

Rising feed expenditures demand that our industry pursues strategies to lower the cost of production. One option is the adoption of the NE system, although many producers are hesitant to proceed without proof that NE estimates are reliable. The objective of this experiment was to compare the apparent total tract digestibility (ATTD) of energy and nutrients and the N retention (NR) of diets formulated using the NE system with increasing quantities of coproduct ingredients. The 5 dietary treatments included a control corn-soybean meal diet (CTL); the CTL plus 6% each of corn distiller's dried grains with solubles (DDGS), corn germ meal, and wheat middlings and NE equal to the CTL by adding soybean oil (CONS-18); the CONS-18 diet, without oil added, with NE content lower than the CTL (DECL-18); the CTL plus 12% each of corn DDGS, corn germ meal, and wheat middlings and NE equal to the CTL by adding soybean oil (CONS-36); and the CONS-36 diet, without oil added, with NE content lower than the CTL (DECL-36). Diets were formulated for both the growing period (GP; 40 to 70 kg) and the finishing period (FP; 70 to 110 kg). Forty gilts (PIC 337 × C22 or C29; 38.5 ± 0.4 kg initial BW) were randomly assigned to treatment and received feed and water ad libitum (8 pigs per treatment). For the last 13 d of the GP and FP, pigs were transferred to metabolism crates, where 2 total urine and fecal collections (d 4 to 6 and d 11 to 13) were performed. The GP fed diets with coproduct ingredients had lower ATTD of DM, N, and GE than those fed the CTL ( < 0.050). The ATTD of N and GE progressively decreased as coproduct inclusion increased from 0 to 18 to 36% in the FP ( < 0.010). In the GP and FP, there were no differences in ATTD of DM, N, or GE between CONS-18 and DECL-18 or between CONS-36 and DECL-36 ( > 0.050). The NR declined on all coproduct diets in the GP ( = 0.010) and tended to decline in the FP ( = 0.079). There were no differences in NR between CONS-18 and DECL-18 or between CONS-36 and DECL-36 ( > 0.050). In conclusion, digestion of diets containing up to 36% coproducts and formulated using NE resulted in expected DE and ME values; NR of diets with coproducts was lower than that of the simple CTL, which is not related to the accuracy of the energy estimations but rather to other factors such as imbalances in the AA concentrations or to postabsorptive energy metabolism, factors not accounted for by the current energy systems approach.

Stability, nutrient availability and hydrophobicity of biochars derived from manure, crop residues, and municipal solid waste for their use as soil amendments

We aimed to study the influence of feedstock properties, pyrolysis temperature and holding time on stability, nutrient contents and hydrophobicity of biochars derived from pig manure, crop residues and municipal solid waste. Biochars were prepared at 300 °C, 400 °C, 500 °C and 700 °C for 1 h, 2 h, 4 h and 5 h. All properties were influenced by feedstock except for pH and hydrophobicity. Temperature influenced all properties, whereas no effect of holding time was observed except for hydrophobicity and thermal stability. Increasing temperature increased aromatization and stability. Low temperatures provided higher cation exchange capacity and available nutrients, and lower salinity and alkalinity. Precipitation of phosphates and carbonates occurred with charring, explaining the decrease of available nutrients. Biochars produced at 300 °C showed high hydrophobity, which disappeared over 500 °C owing to the loss of labile aliphatic compounds. The high pH and carbonates contents at >500 °C resulted in suitable biochars for soil liming and decreasing soil metals availability.

Influence of population density on the concentration and speciation of metals in the soil and street dust from urban areas

Street dust and soil from high, medium and low populated cities and natural area were analysed for selected physical-chemical properties, total and chemical speciation of Zn, Pb, Cu, Cr, Cd, Co, Ni to understand the influence of human activities on metal accumulation and mobility in the environment. The pH, salinity, carbonates and organic carbon contents were similar between soil and dust from the same city. Population density increases dust/soil salinity but has no influence on metals concentrations in soils. Increases in metal concentrations with population density were observed in dusts. Cu, Zn, Pb, Cr can be mobilized more easily from dust compared to the soil. In addition, population density increase the percentage of Pb and Zn associated to reducible and carbonate phase in the dust. The behaviour of metals except Cd in soil is mainly affected by physico-chemical properties, while total metal influenced the speciation except Cr and Ni in dusts.

Marble wastes and pig slurry improve the environmental and plant-relevant properties of mine tailings

Poor soil fertility is often the biggest challenge to the establishment of vegetation in mine wastes deposits. We conducted field trials in the El Gorguel and El Lirio sites in SE Spain, two representative tailing ponds of similar properties except for pH, to understand the environmental and plant-relevant benefits of marble waste (MW) and pig slurry (PS) applications to mine tailings. Low pH (5.4) tailings (El Lirio) exhibit reduction of up to fourfold in bio-availability of metals as shown by the DTPA-Zn, Pb, water-soluble Zn, Pb and up to 3× for water-soluble Cd. Tailings in El Gorguel have high pH (7.4) and did not exhibit significant trends in the reductions of water-extractable Zn, Pb, Cd and Cu. Improvements to the edaphic (plant-relevant) properties of tailings after the amendments are not as sensitive to pH compared to the environmental characteristics. The two sites had increases in aggregate stability, organic matter (total N and organic C) although total N is higher in the El Gorguel (up to 212 μg N kg(-1)) than the El Lirio (up to 26 μg N kg(-1)). However, cation exchange capacities are similar in both sites at 15.2 cmol(+) kg(-1). We conclude that the characteristics, especially pH, of tailing materials significantly influence the fate of metals but not improvements to plant-relevant properties such as cation exchange capacity and aggregate stability 1 year after the application of MW and PS amendments.

Syrian bean-caper (Zygophyllum fabago L.) improves organic matter and other properties of mine wastes deposits

The omni-presence of Zygophyllum fabago L. (Syrian bean-caper) natural colonies in post mining areas prompted us to investigate its contributions to reclamation of mine wastes deposits in southeast Spain. Select plant-related (edaphic) characteristics and bio- and water soluble-Cd, Cu, Pb and Zn in rhizosphere of Z. fabago were compared to deposits one year since application of pig slurry and marble waste. Total N in rhizosphere increased up to a factor of 20X (339 vs 17 mg N kg(-1)) in El Gorguel and 27X (85 vs 3.1 mg N kg(-1)) in El Lirio sites. Organic matter accumulation in rhizosphere from litter and roots of Z. fabago increased organic C from 6.6 to 19.5 g kg(-1) in El Gorguel and from 2.1 to 5.7 g kg(-1) in El Lirio in one year. Dissolution of inorganic C takes place due to organic acids from root exudates of Z. fabago. Reduction in bio-available Cd, Cu, Pb, and Zn in rhizosphere of Z. fabago at El Lirio is attributed to increase in pH from 5.3 to 7.7 through marble waste addition, although increased cation exchange capacity may also have played a role. Addition of marble waste to encourage colonization by Z. fabago in acidic mine wastes deposits was recommended.

Salinity increases mobility of heavy metals in soils

The effect of salinity induced by CaCl(2), MgCl(2), NaCl and Na(2)SO(4) on the mobility of Cu, Cd, Pb and Zn was studied. An increase of ionic strength by any salts promoted a higher release of Cd than the others metals. When CaCl(2) and NaCl were applied, Cd and Pb showed the highest degree of mobilization. When MgCl(2) was applied, Cd and Cu were mobilized the most. Finally, an increase of Na(2)SO(4) also promoted the strongest mobilization of Cd and Cu. As the total heavy metal content was higher, the percentage of Pb and Cu released upon salinization decreased, indicating that these metals are strongly bound to soil constituents. An increase of carbonates in the soil promoted a higher release of Pb for all used salts and for Zn when MgCl(2) and NaCl were used. This indicates that Pb and Zn are adsorbed on the surface of carbonate crystals. An increase of fine particles promoted a decrease of percentage of released Cd for all salts, indicating that Cd is strongly retained in the fine fractions. The main mechanism regulating Pb and Cd mobility was competition with Ca(2+) for sorption sites followed for metal chloro-complexation, association between the Cd/Pb-sulfates and competition with Mg(2+). The main mechanism regulating Cu mobility was the formation of Cu-sulfate, followed by competition with cations (Mg > Ca) and chloride. For Zn, competition with Ca(2+) for sorption sites was the most important process for its mobility; followed by Zn-sulfate association and, finally, chloride and competition with Mg with the same effect.

Foot temperature in diabetic polyneuropathy: innocent bystander or unrecognized accomplice?

AIM

To explore mechanisms by which temperature could influence the pathogenesis and symptoms of diabetic polyneuropathy.

METHODS

We conducted a literature review attempting to identify mechanisms by which diabetic polyneuropathy could be affected by temperature.

RESULTS

Cooling can theoretically hasten the progression of diabetic polyneuropathy through several different mechanisms. Specifically, cooling can enhance neuronal ischaemia, increase formation of reactive oxygen species, slow axonal transport, increase protein kinase C activity, and interfere with immune function. Short-term temperature fluctuations (both warming and cooling) can initiate and exacerbate neuropathic pain by causing neuronal hyperexcitability and functional deafferentation. Although normal fluctuations of distal extremity temperature may be sufficient for these effects, impaired thermoregulation may make the distal extremities more susceptible to temperature extremes. Eventually, a 'vicious cycle' may ensue, resulting in neuronal deterioration with further disruption of temperature regulation. Limited epidemiological data suggest a higher prevalence of diabetic polyneuropathy in populations living in colder locations, supporting our hypothesis.

CONCLUSIONS

Variations in foot temperature may play an important but as yet unrecognized role in the development and symptoms of diabetic polyneuropathy. Further basic and clinical research exploring this concept could help elucidate the natural history of diabetic polyneuropathy and lead to novel therapeutic strategies.

Neurotoxic, hemorrhagic and proteolytic activities of Duvernoy's gland secretion from Venezuelan opisthoglyphous colubrid snakes in mice

Many colubrid snakes produce toxic oral secretions. We studied venom (Duvernoy's gland secretion) collected from Venezuelan opisthoglyphous (rear-fanged) colubrid snakes. Different proteins were present in Thamnodynastes stigilis Duvernoy's gland secretion and were characterized by 20% SDS-PAGE protein electrophoresis. The venom displayed proteolytic (gelatinase) activity that was partially purified on a chromatography ionic exchange mono Q2 column. We demonstrated hemorrhagic activity of Thamnodynastes stigilis Duvernoy's gland secretion on chicken embryos and mouse skin and peritoneum. Mice inoculated with Thamnodynastes stigilis Duvernoy's gland secretion presented signs of neurotoxicity. Thamnodynastes stigilis Duvernoy's gland secretion had proteolytic, hemorrhagic, and neurotoxic activities, not previously described in this species and identifies the presence of a new venomous colubrid in Venezuela.

Production and biochemical characterization of the recombinant Boophilus microplus Bm95 antigen from Pichia pastoris

The new antigen Bm95 from the cattle tick Boophilus microplus was recently isolated, cloned and expressed in the methylotrophic yeast Pichia pastoris. The recombinant protein has shown to induce protection in cattle against infestations of B. microplus under controlled and production conditions. In this paper we report the production and large-scale purification of the Bm95 protein, following a simple and cost-effective process. The antigen was obtained highly aggregated, forming particles ranging from 26 to 30 nm and with purity higher than 80%. The process yield was 0.55 g of pure Bm95 protein per liter of culture. The 98% of the primary structure of the recombinant protein was verified by mass spectrometry. Three amino acid changes in comparison with the sequence deduced from cDNA were detected by LC-MS/MS. The antigen was also obtained N-glycosylated, as previously reported for heterologous protein expression in P. pastoris.

Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients

AIMS

To determine whether a specific high-protein enteral formula with a similar caloric percentage of fat and carbohydrates achieves greater control over glycemic levels and reduces insulin requirements in hyperglycemic critically ill patients when compared to a control high-protein enteral formula.

DESIGN

A prospective, randomized, controlled, single-blind trial in two University Hospital Intensive Care Units in Spain.

METHODS

We enrolled 50 patients with diabetes mellitus or stress hyperglycemia with basal glycemia > or =160 mg/dl and indication for enteral nutrition > or =5 days. Patients with severe kidney failure, liver failure or obesity were excluded from the study. In the first 48 h of admission, after randomization, 26 patients received the study diet and 24 patients received the control diet. The variables were monitored for 14 days. The Harris-Benedict formula with a fixed stress factor of 1.2 was used to calculate caloric needs. Insulin was administered by continuous infusion. An intention-to-treat analysis was performed.

RESULTS

On admission, there were no differences between the study and control group in plasma glucose levels (mg/dl) (190.9+/-45 vs 210.3+/-63) and capillary glucose levels (mg/dl) (226.1+/-73 vs 213.8+/-67). After the feeding trial, there were differences between the study and control group in plasma glucose levels (mg/dl) (176.8+/-44 vs 222.8+/-47, P=0.001), capillary glucose levels (mg/dl) (163.1+/-45 vs 216.4+/-56, P=0.001), insulin requirements/day (IU) 8.73 (2.3-27.5) vs 30.2 (21.5-57.1) (P=0.001), insulin/received carbohydrates (UI/g) 0.07 (0.02-0.22) vs 0.18 (0.11-0.35) (P=0.02) and insulin/received carbohydrates/kg 0.98 (0.26-3.59) vs 2.13 (1.44-4.58) (P=0.04). These differences remain in a day-to-day comparison. There were no differences in the analytical tests, or in digestive or infectious complications. Intensive Care Unit length of stay, mechanical ventilation and mortality were similar in both groups.

CONCLUSIONS

Hyperglycemic critically ill patients fed with a high-protein diet with a similar caloric percentage of fat and carbohydrates show a significant reduction in plasma glucose levels, capillary glucose levels and insulin requirements in comparison to patients on a conventional high-protein diet. This better glycemic control do not modify Intensive Care Unit length of stay, infectious complications, mechanical ventilation and mortality.

Analysis of motor vehicle ejection victims admitted to a level I trauma center

OBJECTIVES

The objective of this study was to compare the injuries and outcomes of ejected victims who reached a Level I trauma center with nonejected MVC occupants.

METHODS

Data from 6,909 MVC victims admitted to a Level I trauma center, over a 91/2-year period, were retrospectively reviewed. Three mutually exclusive groups were studied: ejected, nonejected nonrestrained, and nonejected restrained.

RESULTS

The patient distribution was as follows: ejected 6.4% (n = 443), nonrestrained 50.1% (n = 3,461), and restrained 43.5% (n = 3,005). Ejected patients were younger, required ICU care more frequently, and a higher percentage were males compared with nonrestrained or restrained patients. Injury Severity Score (ISS) and length of stay (LOS) were significantly higher in ejected patients. Ejected patients suffered more injuries per anatomic region, and had a higher number of severe injuries in the head and neck region. The overall in-hospital mortality was 3.9% (272/6,909), and 10.8% (48/443) for the ejected group. The incidence of restrained patients increased during the study period but was not associated with a change in the incidence of ejected patients.

CONCLUSION

Patients who were ejected after motor vehicle collisions were more severely injured and had a worse outcome than those not ejected. Efforts should be concentrated on enforcement and enactment of better seat belt laws, as well as the development of new strategies that will prevent ejection regardless of occupant behavior.

Nose muscular dynamics: the tip trigonum

In 1995, the senior author (E.E.F.) published an article in which he described the musculus digastricus septi nasi labialis. In the article presented here, work carried out by anatomists and other researchers who, over the last two centuries, studied nose muscular dynamics is described. The present study is based on Gray's Anatomy, which, in 1858, first described the nasal tip muscles, along with the other nasal muscles. Later works not only used different terminology for these muscles but also ignored some, creating tremendous confusion. The study presented here provides an update of the exact terms, location, insertions, and muscle functions of the muscles of the nose. Each nose muscle is described with regard to the two portions able to produce separate contractions. In this study, the term "dual function" is used and characterizes the nasal mimetic muscles that do not have well-defined fascia. Therefore, there is doubt about the existence of a real nasal superficial muscle aponeurotic system. The musculus myrtiformis seems to have a dual function, inserting in the canine fosse and in the periosteum of the central incisors, forming two portions-one to the septum and the other to the nostril-each of which has specific functions. This study has been based on research in physiognomy, the science of expression. With regard to the basis for nose expressions, common anatomical research is excluded because it provides a different view of the dynamics studied to date. The term trigonum musculare apicis nasi defines the interaction of the musculi compressor narium minor and dilator naris anterior, connecting with the columellar bundle of the musculus digastricus and levering the nasal spine. This muscular trigone creates circular concentric and eccentric movements of the nasal tip.

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study

BACKGROUND

The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications.

METHODS

This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications.

RESULTS

Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome.

CONCLUSION

The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Validation of selective cardiac evaluation prior to aortic aneurysm repair

OBJECTIVE

To evaluate perioperative and long-term morbidity in patients undergoing selective evaluation of coronary artery disease prior to abdominal aortic aneurysm (AAA) repair.

DESIGN

Case series.

SETTING

University and Veterans' Administration medical centers.

PATIENTS

One hundred eighty-nine consecutive patients undergoing AAA repair between January 1989 and September 1996 were selectively evaluated for coronary artery disease and assigned to 1 of 3 groups: group 1, no abnormal cardiac history, normal electrocardiogram; group 2, minimal symptoms, history of myocardial infarction (MI), older than 70 years, diabetes mellitus, or congestive heart failure; or group 3, severe or unstable angina, ventricular dysfunction.

INTERVENTIONS

Group 1 patients proceeded to AAA repair without further workup. Group 2 patients underwent pharmacologic or exercise stress testing followed by coronary angiography and intervention as required. Group 3 patients went directly to coronary angiography and intervention as needed.

MAIN OUTCOME MEASURES

Perioperative MI, arrhythmias, or death. Long-term follow-up measures included MI and death.

RESULTS

Adequate documentation was available on 171 patients. Twenty-four patients (14%) were in group 1. Of 136 patients (79.5%) in group 2, coronary angiography was performed in 36 (26%), followed by percutaneous transluminal coronary angioplasty (PTCA) in 9 (7%) and coronary artery bypass (CAB) in 5 (4%). Of 11 patients in group 3, 3 (27%) each received PTCA and CAB. Remote CAB or PTCA had been performed in 32 (19%) and 12 (7%) patients, respectively. Two perioperative deaths (1.1%) occurred in the 189 patients, one due to MI in a group 2 patient. There were 2 (1%) nonfatal MIs, both in group 2 patients who had no preoperative intervention. Arrhythmias and/or congestive heart failure occurred in 17 (9%) cases, 7 (39%) having had recent coronary revascularization (P = .001). By univariate analysis, only preoperative renal dysfunction predicted perioperative complications (P = .03) Overall survival by lifetable analysis was 87.9% and 69.7% at 3 and 5 years, respectively.

CONCLUSION

Coronary artery disease is common in patients undergoing AAA repair, with 35.7% having preoperative coronary revascularization at some point. Selective preoperative coronary artery disease screening achieves excellent perioperative and late results in this population.

Depletion of intracellular Ca2+ stores, phosphorylation of eIF2alpha, and sustained inhibition of translation initiation mediate the anticancer effects of clotrimazole

Regulation of translation initiation plays a critical role in the control of cell growth and division in eukaryotic cells. Translation of many growth regulatory proteins including cyclins depends critically on translation initiation factors because their mRNAs are translated inefficiently. We report that clotrimazole, a potent antiproliferative agent both in vitro and in vivo, inhibits cell growth by interfering with translation initiation. In particular, clotrimazole causes a sustained depletion of intracellular Ca2+ stores, which results in activation of PKR, phosphorylation of eIF2alpha, and thereby in inhibition of protein synthesis at the level of translation initiation. Consequently, clotrimazole preferentially decreases the expression of the growth promoting proteins cyclin A, E and D1, resulting in inhibition of cyclin-dependent kinase activity and blockage of cell cycle in G1.

Lethal injuries and time to death in a level I trauma center

BACKGROUND

The purpose of this study was to identify the causes and time to death of all trauma victims who died at a level I trauma center during an 11-year period.

STUDY DESIGN

Autopsies were performed on all patients who died secondary to trauma. Retrospective review of these autopsies was carried out and appended to existing trauma registry data. Standard definitions were used to attribute the cause of death in each case. Preventable deaths were determined by a standardized peer review process.

RESULTS

Between January 1985 and December 1995, a total of 900 trauma patients died. This represented 7.3% of all major trauma admissions (12,320). Seventy percent of these patients died within the first 24 hours of admission. Thoracic vascular and central nervous system (CNS) injuries were the most common causes of death in the first hour after admission to the hospital. CNS injuries were the most common causes of death within the 72 deaths after admission. Acute inflammatory processes (multiple organ failure, acute respiratory distress syndrome, and pneumonia) and pulmonary emboli were the leading causes of death after the first 72 hours. Overall, 43.6% (393 of 900) of all trauma deaths were caused by CNS injuries, making this the most common cause of death in our study. The preventable death rate was 1%.

CONCLUSIONS

The first 24 hours after trauma are the deadliest for these patients. Primary and secondary CNS injuries are the leading causes of death. Prevention, early identification, and treatment of potentially lethal injuries should remain the focus of those who treat trauma patients.

The transient pore formed by homologous terminal complement complexes functions as a bidirectional route for the transport of autocrine and paracrine signals across human cell membranes

BACKGROUND

We have previously shown that the membrane attack complex (MAC) of complement stimulates cell proliferation and that insertion of homologous MAC into the membranes of endothelial cells results in the release of potent mitogens, including basic fibroblast growth factor (bFGF). The mechanism of secretion of bFGF and other polypeptides devoid of signal peptides, such as interleukin 1 (IL-1) is still an open problem in cell biology. We have hypothesized that the homologous MAC pore itself could constitute a transient route for the diffusion of biologically active macromolecules in and out of the target cells.

MATERIALS AND METHODS

Human red blood cell ghosts and artificial lipid vesicles were loaded with labeled growth factors, cytokines and IgG, and exposed to homologous MAC. The release of the 125I-macromolecules was followed as a function of time. The incorporation of labeled polypeptides and fluorescent dextran (MW: 10,000) was measured in MAC-impacted human red blood cells and human umbilical endothelial cells (HUVEC), respectively.

RESULTS

Homologous MAC insertion into HUVEC resulted in the massive uptake of 10-kD dextran and induced the release of bFGF, in the absence of any measurable lysis. Red blood cell ghosts preloaded with bFGF, IL-1 beta, and the alpha-chain of interferon-gamma (IFN-gamma) released the polypeptides upon MAC insertion, but they did not release preloaded IgG. MAC-impacted ghosts took up radioactive IFN-gamma from the extracellular medium. Vesicles loaded with IL-I released the polypeptide when exposed to MAC.

CONCLUSIONS

The homologous MAC pore in its nonlytic form allows for the export of cytosolic proteins devoid of signal peptides that are not secreted through the classical endoplasmic reticulum/Golgi exocytotic pathways. Our results suggest that the release, and perhaps the uptake, of biologically active macromolecules through the homologous MAC pore is a novel biological function of the complement system in mammals.

T1 breast carcinoma in women 70 years of age and older may not require axillary lymph node dissection

BACKGROUND

The current trend in breast cancer treatment is toward breast conservation and selective use of axillary lymph node dissection. Patient eligibility criteria for treatment without axillary dissection are evolving.

METHODS

We retrospectively reviewed the tumor registry over a 10-year period at Naval Medical Center San Diego and included all women aged 70 and older with T1 breast carcinoma (n = 78). Data included tumor size, surgical therapy, post-operative therapy, recurrence, and survival. The women were divided into groups by the approach taken toward the axilla.

RESULTS

No patient was given adjuvant chemotherapy. There were no axillary cancer recurrences in our patients. No statistically significant difference existed, regardless of the approach to the axilla, in recurrence or survival between groups.

CONCLUSION

Axillary dissection in this population did not influence postoperative treatment, decrease recurrence, or improve survival. Our study suggests breast cancer treatment in this population should not include axillary dissection.

Angiodysplasia as the cause of massive lower gastrointestinal hemorrhage in a young adult. Report of a case

PURPOSE

This study was undertaken to clarify the importance of bleeding vascular ectasia of the colon as the etiology of massive lower gastrointestinal hemorrhage in patients 40 years of age or younger.

METHODS

An otherwise healthy 21-year-old male was admitted to a tertiary medical center with massive lower gastrointestinal hemorrhage. Technetium-labeled red blood cell scan, selective visceral angiography, and colonoscopy identified the source of bleeding as vascular abnormality of the descending colon. Segmental colonic resection was performed.

RESULTS

Histologic review of the specimen demonstrated a vascular ectasia. The patient recovered uneventfully and has had no further stigmata of hemorrhage. A review of the literature was undertaken to make clear the significance of vascular ectasia as the source for massive colonic hemorrhage in the young adult.

CONCLUSION

This is the first report that documents histologically a vascular ectasia as the source of massive lower gastrointestinal hemorrhage in an otherwise healthy patient less than 40 years of age. Vascular ectasia is an uncommon cause of lower gastrointestinal hemorrhage in the young adult.

Surgical margins after needle-localization breast biopsy

BACKGROUND

The use of needle-localization breast biopsy (NLBB) for the early diagnosis of breast cancer is common. The therapeutic adequacy of tumor-free margins following NLBB is unknown. We hypothesized that the presence of residual tumor after reexcision (mastectomy, tylectomy, or quadrantectomy) does not depend on the margin status following NLBB.

PATIENTS AND METHODS

Retrospective cohort analysis was performed on 890 consecutive NLBBs executed between January 1990 and June 1994. Patients with invasive breast neoplasia were divided into two groups based on the tumor margins after NLBB. Group 1 were the women with positive margins, and group 2 had negative margins. Breast specimens after reexcision were reviewed for evidence of residual invasive carcinoma.

RESULTS

Invasive neoplasia was present in 107 patients (12%). Surgical margins and definitive records of care were available for 96 of them (90%). All 45 patients in group 1 and 38 (75%) of 51 patients in group 2 underwent reexcision of the initial biopsy site (P = 0.36). Residual invasive carcinoma was present in 10 patients (22%) in group 1 and 3 (8%) in group 2 (P = 0.13).

CONCLUSION

Invasive breast neoplasia diagnosed by NLBB requires reexcision regardless of tumor margins to achieve complete local surgical eradication of tumor.

Precholecystectomy esophagogastroduodenoscopy: is it of value?

Patients with cholelithiasis and history of atypical abdominal pain present the surgeon with a challenging clinical problem. We hypothesized that preoperative esophagogastroduodenoscopy before cholecystectomy would identify patients with concomitant upper gastrointestinal pathology. Retrospective review of 143 patients who presented with atypical abdominal pain, gallstones, and underwent EGD before their cholecystectomy between July 1989 and March 1994. A total of 1162 cholecystectomies were performed during the study period; 143 patients (12 per cent) underwent a preoperative EGD because of atypical abdominal pain. One hundred ten patients (77 per cent) had normal endoscopies. Thirty-three patients (23 per cent) had abnormal findings. Gastric polyps were found in three patients and esophageal varices in one patient. There were 36 findings in 29 patients, which included peptic ulcer disease, esophagitis, gastritis, and duodenitis. Seven patients had two abnormal findings. Moderate to severe disease was found in a total of 13 (9 per cent) patients. We recommend that patients who present with cholelithiasis and atypical abdominal pain undergo preoperative esophagogastroduodenoscopy, as we have found that at least 9 per cent of the patient population will have significant findings that may alter their management.

Colonoscopic evaluation of rectal bleeding in young adults

The role of colonoscopy in the evaluation of blood loss per rectum has been studied extensively in older patients but not in the younger adult population. The objective of this study was to review the diagnostic yield of colonoscopy in patients 40 years of age or younger with passage of minimal amounts of bright red blood per rectum or occult blood positive stools. Retrospectively, 5924 colonoscopic examinations were reviewed. All patients, 40 years of age or younger, with rectal bleeding as the only indication for colonoscopy were selected. A total of 280 patients met these criteria and 59 (21%) had significant findings. Polyps were present in 25 (8.9%) of patients. Other findings included colitis, diverticular disease, and angiodysplastic lesions present in 8.6 per cent, 2.1 per cent, and 1.1 per cent, respectively. Adenocarcinoma was present in one patient (0.03%). These results suggest that colonoscopy in patients 40 years of age or younger with rectal bleeding may be justified because significant findings may be present in up to 21 per cent of patients.

Colonic diverticular disease in patients 40 years old or younger

Diverticular disease in patients 40 years of age or younger has been described as rare but virulent. Previous studies, based on age, on diverticular disease are often confusing because of inexact definitions of the disease status. With these criticisms in mind, the authors studied 322 clinical records on patients admitted with a diagnosis of colonic diverticulosis or diverticulitis to the University of New Mexico Hospital and the Lovelace Medical Center. Of these patients, 285 had documented evidence of colonic diverticula with only 6 per cent of these being 40 years of age or younger. The criteria for acute diverticulitis were met by 86 patients, 17 of whom were 40 years of age or younger. The younger group had disproportionately more men, particularly Hispanics. The authors conclude that acute diverticulitis is more common in the young than suggested by previous reports, but the behavior of the disease is not distinctive.

Barotrauma associated with high-frequency jet ventilation for hypoxic salvage

Most reports describe reduction in proximal airway pressures with high-frequency jet ventilation. This led us to speculate that high-frequency jet ventilation might reduce barotrauma by providing alveolar ventilation at lower airway pressures. We describe a group of patients in whom a high incidence of barotrauma was observed after institution of high-frequency jet ventilation despite reduction in measured airway pressures. Fifteen hypoxic patients who could not be treated with conventional ventilation and who had no roentgenographic evidence of barotrauma were entered into the study. Airway pressures were measured during conventional ventilation and at 2 and 24 hours after high-frequency jet ventilation. Despite significant reduction in peak inspiratory and mean airway pressures, pneumothorax developed in seven of the 15 patients, an average of 21 hours after initiation of high-frequency jet ventilation. Five patients had bilateral pneumothorax and three developed tension pneumothorax. Despite reductions in proximal airway pressures, barotrauma is a significant potential complication of high-frequency jet ventilation in patients with noncompliant lungs. We currently place bilateral prophylactic thoracostomy tubes in patients with adult respiratory distress syndrome prior to initiation of high-frequency jet ventilation.

Efecto del Mo aplicado por sumersión a semillas de algodonero sobre la respiración de plantillas y su germinación

<div>Se trataron semillas de algodonero manteniéndolas sumergidas en: a) agua destilada; b) sol. de molibdato de sodio 0,05 O/C, y e) sol. de molibdato de amonio 0,05 % durante 24 hs. a una temperatura de 30°C, con el objeto de determinar el efecto del elemento Mo sobre la germinación y respiración.</div><div>Para el ensayo de germinación se realizaron 36 repeticiones de cada variante.</div><div>Cada repetición consistió en 25 semillas dispuestas en una caja de Petri entre papel de filtro humedecido. Los resultados indican que el Mo tiene un efecto deprimente sobre la germinación, significativo al 1 %. La respiración se midió 24. hs. después de terminado el tratamiento sobre radículas y cotiledones separadamente. El Mo aumenta la respiración de las radículas en forma altamente significativa. Sobre los cotiledones el Mo, acompañado por el catión sodio, deprime la respiración, y acompañado por el catión amonio la aumenta.</div>