Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Improving influenza and Tdap vaccination during pregnancy: A cluster-randomized trial of a multi-component antenatal vaccine promotion package in late influenza season

BACKGROUND

Evidence-based interventions to improve influenza vaccine coverage among pregnant women are needed, particularly among those who remain unvaccinated late into the influenza season. Improving rates of antenatal tetanus, diphtheria and acellular pertussis (Tdap) vaccination is also needed.

PURPOSE

To test the effectiveness of a practice-, provider-, and patient-focused influenza and Tdap vaccine promotion package on improving antenatal influenza and Tdap vaccination in the obstetric setting.

METHODS

A cluster-randomized trial among 11 obstetric practices in Georgia was conducted in 2012-2013. Intervention practices adopted the intervention package that included identification of a vaccine champion, provider-to-patient talking points, educational brochures, posters, lapel buttons, and iPads loaded with a patient-centered tutorial. Participants were recruited from December 2012-April 2013 and included 325 unvaccinated pregnant women in Georgia. Random effects regression models were used to evaluate primary and secondary outcomes.

RESULTS

Data on antenatal influenza and Tdap vaccine receipt were obtained for 300 (92.3%) and 291 (89.5%) women, respectively. Although antenatal influenza and Tdap vaccination rates were higher in the intervention group than the control group, improvements were not significant (For influenza: risk difference (RD)=3.6%, 95% confidence interval (CI): -4.0%, 11.2%; for Tdap: RD=1.3%, 95% CI: -10.7%, 13.2%). While the majority of intervention package components were positively associated with antenatal vaccine receipt, a provider's recommendation was the factor most strongly associated with actual receipt, regardless of study group or vaccine.

CONCLUSIONS

The intervention package did not significantly improve antenatal influenza or Tdap vaccine coverage. More research is needed to determine what motivates women remaining unvaccinated against influenza late into the influenza season to get vaccinated. Future research should quantify the extent to which clinical interventions can bolster a provider's recommendation for vaccination. This study is registered with clinicaltrials.gov, study ID NCT01761799.

Epidemiology of canine distemper and canine parvovirus in domestic dogs in urban and rural areas of the Araucanía region in Chile

To assess whether the seroprevalence of canine distemper virus (CDV) and canine parvovirus (CPV) in domestic dogs is higher in urban versus rural areas of the Araucanía region in Chile and risk factors for exposure, a serosurvey and questionnaire survey at three, urban-rural paired sites was conducted from 2009 to 2012. Overall, 1161 households were interviewed of which 71% were located in urban areas. A total of 501 blood samples were analysed. The overall CDV and CPV seroprevalences were 61% (CI 90%: 58-70%) and 47% (CI 90%: 40-49%), and 89% (CI 90%: 85-92%) and 72% (CI 90%: 68-76%) in urban and rural areas, respectively. The higher seroprevalence in domestic dogs in urban areas suggests that urban domestic dogs might be a maintenance host for both CDV and CPV in this region. Due to the presence of endangered wild canids populations in areas close to these domestic populations, surveillance and control of these pathogens in urban dog populations is needed a priority.

[A screening program for colorectal cancer in Chilean subjects aged fifty years or more]

BACKGROUND

Mortality from colorectal cancer (CCR) in Chile has nearly doubled over the past 15 years. International studies have shown that CCR screening programs based on fecal occult blood test (FOBT) reduce CCR mortality.

AIM

To analyze the results from a CCR screening model in people over 50 years.

MATERIAL AND METHODS

Between 2007 and 2009, a prospective multicenter study was performed in seven major Chilean cities. FOBT using an immunological method, was measured in asymptomatic subjects aged 50 years or more, without risk factors. In patients with a positive FOBT, with symptoms or with family risk factors, a colonoscopy was indicated.

RESULTS

A total of 6348 subjects were assessed, FOBT was performed in 4938 of them, with a compliance of 77%. The result was positive in 9.6%. A total of 2359 colonoscopies were ordered, with an overall compliance of 50.1%. Of the 1184 colonoscopies performed, adenomas and high risk adenomas were found in 304 (26%) and 75 (6%) patients, respectively. Thirteen patients were diagnosed with stage I and IICCR. Three of these lesions were excised endoscopically and 10 surgically. The detection rate of polyps, high risk adenomas and cancer was 75, 12 and 2 per 1000 screened individuals, respectively.

CONCLUSIONS

This program allowed the early detection of an important number of high risk colon lesions, and all patients with CCR were diagnosed at early stages.

New molecular breast cancer classification with adjuvant therapy in our population

e11624

Background: The molecular classification (Perou) helped to identify new groups of patients with different biological behaviors. A retrospective, descriptive, comparative trial with adjuvant chemotherapy treatment was conducted. Objectives: Analyze the natural history of the subgroups of patients, frequency, site of relapse and Disease-free survival (DFS). Materials and Methods: 200 Medical charts of patients with breast cancer were analyzed from 1997 to 2007, who had received adjuvant treatment without Trastuzumab. The 92, 5 % of Luminal A, 91 % of Luminal B y C, the 75.9 % of Her2 (+) and the 69.2 % of Triple Negative (TN) had received adjuvant therapy with FAC, while 30% of the last two groups were treated with taxanes and anthracyclines. We evaluated the site of the first relapse after adjuvant treatment in relation to the new molecular classification. Log-rank test was used to compare the rates of Disease-free survival (DFS). Results: Frequency: Luminal A (86, 42%) Luminal B y C (65, 33%) Her2 + (33, 17%) TN: (16, 8%) The locoregional relapse in the TN group was 36.4% (P = 0.003), the average of bone relapses were 64.5% on the four groups without statically significance compared to other groups. The CNS had a greater trend in TN groups (16.7%) and Her2+ (13.6%), compared to Luminal Type A-B (0 % y 8.3 %). Disease-free survival (DFS): Luminal A 65.0 ± 5.0 months Luminal B y C 50.3 ± 4.3 months HER2 42.9 ± 5.5 months TN 31.1 ± 7.3 months In the analysis of type A luminal subgroup, a prolonged disease free time was showed when compared with the others subgroups, of major statistical significance Log rank (p = 0.002). Conclusions: Her2 negative and TN tumors have less DFS and a higher locoregional and CNS relapse.

No significant financial relationships to disclose.

Localización simultánea de neoplasias de mama no palpables y estudio del ganglio centinela (GC) mediante técnicas radioisotópicas

OBJECTIVE

To obtain correct location of non-palpable breast lesions, with high suspicion of malignancy and detection of SN by radiosotopic techniques.

MATERIAL AND METHODS

Thirty-one patients whose ages ranged from 35 to 79 years, with non-palpable breast lesions detected by mammography and/or ultrasonography were studied. All the patients were diagnosed of breast cancer and treated with primary chemotherapy. All the patients underwent total axillary dissection. At 24 hours of the intervention, all patients received one dose of 37 MBq (1 mCi) of 99mTc labeled macroaggregated albumin (MAA) in the center of the lesion by ultrasonographic guide. Scintigraphic images were performed in anterior and lateral projections (in prone decubitus with hanging breast) to verify the correct location of the radiopharmaceutical. After, a study of the SN was performed by subdermal administration of an 18 MBq (0.5 mCi) dose of 99mTc labeled nanocolloid. The SN site was labeled on the skin with indelible ink. The intrasurgical site of the breast lesion and SN was performed using a gamma detector probe. Correct placement of the intralesional radiopharmaceutical, existence of disease free borders and histological study of SN were performed by the pathologist in the surgical act. The differed pathology study was performed with hematoxilin-eosin and immunohistochemistry.

RESULT

In 29 of the 31 lesion sites, there was good placement of the radiotracer (93.5 %). There was 1 case of contamination of the needle pathway and another that did not coincide with the lesion, due to poor placement. Location of the SN was 96 % in the axilla and 4 % in axilla and internal mammary chain. The SN was located in surgery in 28/31 patients (90 %).

CONCLUSION

Simultaneous radioguided location of the hidden breast lesions and sentinel node is a simple method, which is well tolerated by the patients and can be done in a single operation act.

The effects of superior ovarian nerve sectioning on ovulation in the guinea pig

The effects on spontaneous ovulation associated with the unilateral or bilateral sectioning of the superior ovarian nerves (SON) were analyzed in guinea pigs at different time intervals of the estrous cycle. Day 1 of the estrous cycle was defined as the day when the animal presents complete loss of the vaginal membrane (open vagina). Subsequent phases of the cycle were determined by counting the days after Day 1. All animals were autopsied on the fifth day of the estrous cycle after surgery. Sectioning the right, left, or both SONs on day 5 (early luteal phase) resulted in a significant increase in the number of fresh corpora lutea. Ovulation increased significantly when the left SON (L-SON) was sectioned during late follicular phase (day 1) and medium luteal phase (day 8). When surgery was performed on days 1 or 8, neither sectioning the right SON (R-SON) nor sectioning the SON bilaterally had an apparent effect on ovulation rates. Similarly, ovulation rates were not affected when unilateral (right or left) or bilateral sectioning of the SON was performed during late luteal phase two (day 12). Unilateral or bilateral sectioning of the SON performed during the early luteal phase (day 5) was associated with a significant decrease in uterine weight. A comparable effect was observed when the L-SON was sectioned during late follicular phase (day 1), or medium luteal phase (day 8). No effects on uterine weight were observed when unilateral or bilateral sectioning of the SON was performed during late luteal phase. Our results suggest that in the guinea pig the SON modulates ovulation, and that the degree of modulation varies along the estrous cycle. The strongest influence of the SONs on ovulation occurs during early luteal phase, and decrease thereafter, being absent by late luteal phase. In addition, sectioning the left or the right SON caused different responses by the ovaries of adult guinea pigs. This paper discusses the mechanisms by which ovulation increased when the SON was surgically cut.

Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy: applicability, immediate clinical outcome, inflammatory response, and cost

BACKGROUND

Hand-assisted laparoscopic surgery (HALS) represents a useful alternative to conventional laparoscopic surgery (LS). Its potential advantages--(a quicker, safer procedure and less need to convert to open surgery) are due to the recovery of tactile feedback. However, HALS requires the performance of a mini-laparotomy when surgery commences, and the wound is stretched and compressed throughout the procedure. In addition, it is associated with a more intense manipulation of the intraabdominal viscera. All of these factors increase the surgical trauma, it is not known whether HALS maintains the minimally invasive characteristics of conventional LS. Therefore, we set out to study the applicability, immediate clinical outcome, inflammatory response, and cost of HALS compared with conventional LS using colectomy as a model.

METHODS

We performed a prospective randomized trial comparing laparoscopic-assisted colectomy with HAL colectomy. The aims of the study were to assess (a) perioperative features, including time, advantages, and conversion; (b) the patient's immediate clinical response, including recovery of bowel sounds, refeeding time, postoperative pain, local and general morbidity, and hospital stay; (c) the effect on the inflammatory response, using interleukin-6 (ILG) and C-reactive protein (CRP) measurements; (d) oncological issues, including intraoperative cytology and features of the specimen; and (d) the relative costs of the two procedures.

RESULTS

A total of 54 patients were enrolled in the study, 27 laparoscopic and 27 HALS. The operative times were similar, but HALS was associated with a far lower conversion rate--7% vs 23%. Immediate clinical outcomes, oncological features, and costs were similar for the two procedures, but HALS was associated with a significantly greater increase in IL6 and CRP than the conventional laparoscopic procedure.

CONCLUSION

This comparative study shows that HALS simplifies difficult intraoperative situations, reducing the need for conversion. Although it is a more aggressive procedure, HALS preserves the features of a minimally invasive approach, maintains all of the oncological features of conventional laparoscopic surgery, and does not increase the cost. HALS should therefore be considered as a useful adjunct when difficult situations arise during conventional laparoscopic colectomy.

[Isotopic renal study in diabetic nephropathy]

This study aimed to evaluate the prognostic value of the kidney split function (KSF), the effective renal plasma flow (ERPF) and glomerular filtration rate (GF) in the evolution of diabetic nephropathy.

MATERIAL AND METHODS

125 patients (IDDM:10, NIDDM:115), including 62 men, ages 18-84 years, were studied. In all cases GF (Cr 51 EDTA), ERPF (131I-hippuran), kidney split function (obtained from the 99mTc-MAG3 renogram) and basal serum creatinine (SC) were evaluated at the beginning of the study and patients were clinically followed up for 5 years by SC. Ultrasound and/or intravenous digital angiography were performed in 120 patients.

RESULTS

In patients with decreased ERPF (76 patients) the SC increased progresively during the 5 years, in both those with elevated PC (N = 54) as well as in those with normal baseline SC (n = 22). In patients with normal ERPF the SC did not change significantly during the study. An asymethric split function (KSF < 40% in one kidney) was found in the renogram of 42 patients; in 32 of them the ERPF was decreased. Of these, ulttrasonography was normal in 9, and vascular and/or obstructive pathology was demonstrated by ultrasonography or digital angiography in only 6 patients.

CONCLUSION

The ERPF becomes altered earlier than serum creatinine in patients with diabetic nephropaty. ERPF and split function calculation, and FG seems to have higher prognostic value than ultrasounds in the management of diabetic nephropathy. Radionuclides seems to be an accurate test than the ultrasonography to detect renal function abnormalities in patients with diabetic and thus can be an examination of choice in these patients.

Gamma probe sentinel node localization and biopsy in breast cancer patients treated with a neoadjuvant chemotherapy scheme

The aim of this study was to analyse the accuracy of scintigraphic and gamma probe sentinel node (SN) localization in breast cancer patients who have been submitted to neoadjuvant chemotherapy (NC). Seventy-six patients with single breast cancer were included in the study, and were classified into two groups. Group 1 consisted of 40 women who had received NC, and Group 2 consisted of 36 women who did not receive NC. All patients received 111 MBq (3 mCi) of 99Tcm-nanocolloid in 3 ml, by peritumoural injection. Anterior and lateral thoracic scans were obtained 2 h post-injection. The following day (18-24 h post-injection) the patients underwent surgery and sentinel nodes were localized by using a gamma probe. Complete axillary lymph node dissection was performed in all patients. Histological analysis included haematoxylin-eosin in all cases and immunohistochemistry in 10 cases. In Group 1, SNs were localized in 36/40 patients, histological analysis was performed in 34 and there were four false negatives (22%). In Group 2, SNs were localized in 32/36 patients, histological analysis was performed in 29 and there were two false negatives (9%). Predictive negative values were 78% and 90% in Groups 1 and 2, respectively. In summary, sentinel node localization in breast cancer patients submitted to previous neoadjuvant chemotherapy is less accurate than in patients who do not receive this therapy. The procedure is not sufficiently accurate to localize the sentinel node, thus it cannot be recommended in these patients.

Synthesis of (+)-cyclozonarone and the absolute configuration of naturally occurring (-)-cyclozonarone

Synthesis of (+)-cyclozonarone (1) has been achieved using (-)-polygodial (3) as chiral starting material. The absolute configuration of naturally occurring (-)-cyclozonarone was established as 5R,10R by comparison of spectral data and optical rotation with those of (+)-cyclozonarone.

[Bone metastasis from gastrinoma without hepatic involvement. Utility of the scintigraphy with 111 In-pentetreotide]

The case of a 54 year old patient suffering from gastrinoma (within a type I multiple endocrine neoplasm) is presented. In 1990, she underwent a surgical resection. Eight years later, she suffered from a pain in the left thigh. The 99mTc-MDP bone scintigraphy showed bone metastasis. The CT scan did not show any hepatic involvement and the scintigraphy with 111In-Pentetreotide verified bone metastasis of a neuroendocrine tumor as a single expression of the recidive. In this case, the utility of the scintigraphy with octreotide to facilitate the localization and extent of the neuroendocrine tumors is demonstrated.

Sensitivity of trypanosomatid protozoa to DFMO and metabolic turnover of ornithine decarboxylase

alpha-Difluoromethylornithine (DFMO), the specific and irreversible inhibitor of ornithine decarboxylase (ODC), was able to induce the arrest of proliferation in Leishmania mexicana and ODC-transformed Trypanosoma cruzi cultures grown in a semi-defined medium essentially free of polyamines. Conversely, Crithidia fasciculata and Phytomonas 274 were not affected by the inhibitor. The drug-resistance of Crithidia and Phytomonas was neither caused by an impairment of DFMO uptake nor by a decrease of the enzyme affinity for the inhibitor. We were also able to rule out the possibility of ODC overexpression in the drug-tolerant parasites. The measurements of ODC metabolic turnover indicated that the enzymes from Crithidia and Phytomonas have a short half-life of 20-40 min, while ODC from Leishmania and transgenic Trypanosoma cruzi are rather stable with a half-life longer than 6 hours. Analyses of polyamine internal pools under different growth conditions have shown that DFMO was able to markedly decrease the levels of putrescine and spermidine in all parasites, but the depletion of spermidine was higher in trypanosomatids containing an ODC with slow turnover. Our results suggest that in these parasites cultivated in the presence of the drug, spermidine might decrease below critical levels needed to maintain trypanothione concentrations or other conditions essential for normal proliferation.

Catecholamines-evoked cytosolic Ca2+ rise in endothelial cells from bovine adrenal medulla

The effects of catecholamines on intracellular Ca2+ concentrations ([Ca2+]i) in single acutely dissociated bovine adrenal medulla endothelial cells (BAMECs) were measured using the intracellular fluorescent probe Fluo-3 AM. 100 microm epinephrine or norepinephrine induced a biphasic [Ca2+]i rise with an initial peak followed by a delayed phase. 10 microm phenylephrine (alpha1-adrenergic agonist) caused a [Ca2+]i rise similar to that evoked by catecholamines. The increase in [Ca2+]i induced by 10 microm phenylephrine was reverted by 10 microm phenoxybenzamine (alpha-adrenergic antagonist). Neither isoproterenol (beta-adrenergic agonist) nor clonidine (alpha2-adrenergic agonist) induced [Ca2+]i rise. The initial peak was insensitive to zero external Ca2+ and it was abolished after Ca2+ internal storages were emptied by 10 mM caffeine. The delayed phase was reduced to near zero by external Ca2+ removal. These results indicate that BAMECs possess alpha1-adrenergic receptors associated to both the release of caffeine-sensitive intracellular Ca2+ stores and the entry of extracellular Ca2+. We suggest that chromaffin cell secretion may activate BAMECs in vivo through an increase in [Ca2+]i which could induce the secretion of vasoactive factors allowing a rapid entry of hormones into the circulation.

Synthesis of 11,12-epoxydrim-8,12-en-11-ol, 11,12-diacetoxydrimane, and warburganal from (-)-sclareol

The first syntheses are reported for recently isolated drimanes 11, 12-epoxydrim-8,12-en-11-ol (2) and 11,12-diacetoxydrimane (3), from (-)-sclareol (1). Furthermore, two efficient new routes to the potent bioactive warburganal (4) starting also from 1 are described.

Beta 2-microglobulin and immunoglobulins are more useful markers of disease progression in HIV than neopterin and adenosine deaminase

Reference change values of six biochemical quantities (beta 2-microglobulin, neopterin, adenosine deaminase and immunoglobulins IgA, IgG and IgM) have been established in asymptomatic human immunodeficiency virus (HIV)-infected patients following the method described by Harris and Yasaka in 1983. Patients included in the evaluation were classified as A1, A2 or A3 according to the classification of the Centers for Disease Control (CDC) (January 1993). All patients were followed-up quarterly, with a minimum of four samples each available for statistical analysis. The main objective of this paper was to study whether differences found to be greater than calculated reference change values could predict clinical or immunological worsening in patients' status. Retrospective analysis was made in asymptomatic patients (n = 256) included in an HIV infection protocol carried out in our hospital. Of these patients, 179 showed clinical or immunological worsening during the study period and 77 maintained their clinical and immunological status. Changes in beta 2-microglobulin showed the greatest sensitivity to detect clinical or immunological worsening (43.0%), whereas changes in adenosine deaminase showed the lowest (21.8%). Clinical or immunological worsening in 169 of the 179 patients was detected by one of the six biochemical quantities evaluated. Ten patients showed clinical or immunological worsening, although differences between measurements were lower than the reference change values calculated. Of 77 patients whose clinical state did not deteriorate, there was a change in biochemical analytes greater than the reference value calculated in 29 patients (a period of 12 months had elapsed since detection). In 48 patients, no increases greater than calculated reference change values were detected. The sensitivity obtained using the six analytes was 94.4% and the specificity was 62.3%.

Microbial hydroxylation of natural drimenic lactones

Incubation of confertifolin and isodrimenin with Mucor plumbeus, Aspergillus niger or Rhizopus arrhizus gave in good yields the corresponding 3 beta-hydroxy derivatives. From isodrimenin, the known natural 7 alpha-hydroxy derivative (futronolide) was also obtained and its structure was definitely established by X-ray crystallographic study of its acetate derivative.

Patients with thrombocytosis have normal or slightly elevated thrombopoietin levels

BACKGROUND AND OBJECTIVE

The distinction between clonal and reactive thrombocytoses is a frequent problem and implies different therapeutic options. As thrombopoietin (TPO) is the main regulator of megakaryocytopoiesis and thrombopoiesis, we measured TPO levels in patients with thrombocytosis in an attempt to understand the regulation and potential utility of distinguishing thrombocytoses.

DESIGN AND METHODS

Serum TPO levels, platelet counts, mean platelet volume, hemoglobin, erythrocyte sedimentation rate and age were evaluated in 25 patients with clonal thrombocytosis (15 with essential thrombocythemia, 6 with polycythemia vera and 4 with chronic myeloid leukemia) and in 50 patients with reactive thrombocytosis distributed in three groups: 1) patients in post-surgical states; 2) patients with solid tumors; and 3) patients with inflammatory diseases.

RESULTS

TPO levels were slightly increased in patients with clonal (135+/-50 pg/mL) and reactive (147+/-58 pg/mL) thrombocytosis compared with controls (121+/-58 pg/mL). Analyzing the different groups, patients with essential thrombocythemia had the lowest TPO levels (120+/-28 pg/mL) and patients with solid tumors the highest levels (162+/-59 pg/mL). Patients with clonal thrombocytosis were older, had higher platelet counts, mean platelet volume and hemoglobin, and lower erythrocyte sedimentation rate than patients with reactive thrombocytosis.

INTERPRETATION AND CONCLUSIONS

Minor differences were observed in TPO levels between patients with primary and secondary thrombocytoses. Erythrocyte sedimentation rate, but not TPO levels, may be a useful tool for discriminating both types of thrombocytoses.

The predictive value of several markers in the progression to acquired immunodeficiency syndrome

Serum beta 2-microglobulin, neopterin, immunoglobulins A, G and M, adenosine deaminase and CD4+ lymphocyte count were evaluated as predictors of progression of HIV-1 infection to AIDS. A population of HIV-1 seropositive, initially asymptomatic men (n = 213) and women (n = 101) was followed up quarterly. We estimated the AIDS-free time using the actuarial method (median survival time 47.2 months). Cox proportional hazard analysis revealed that all markers studied were significant (p < 0.05) in relation to progression to AIDS. The best markers for predicting progression to AIDS were, in descending order, CD4+ lymphocyte count, beta 2-microglobulin, IgA, neopterin, IgG, IgM and adenosine deaminase. On stratifying population into four groups (divided at percentiles 25, 50 and 75--from group 1, with values nearest to reference ranges, to group 4, with most abnormal values) we observed statistically significant differences (p < 0.05) for all markers except for adenosine deaminase. The relative risk from the Cox proportional hazards model were used to quantify the effects of the best markers and compared to the risk obtained in group 1. CD4+ lymphocyte count was the best predictor of progression to AIDS. When considering beta 2-microglobulin and CD4+ together, the relative risk in the group with lowest CD4+ cell count (group 4) ranged from 25.6% (with lower beta 2-microglobulin values) to 41.1% (with higher beta 2-microglobulin values). Similar results were obtained when considering neopterin and CD4+ together. The addition of beta 2-microglobulin or neopterin values to CD4+ lymphocyte count improved the predictive value of CD4+ lymphocyte count.

Protein degradation in red cells exposed to 2,2'-azo-bis(2-amidinopropane) derived radicals

Extensive proteolysis is observed when red blood cells are exposed to free radicals produced in the thermolysis of 2,2'-azo-bis(2-amidinopropane). It is evaluated that nearly one amino terminal group is produced by each free radical introduced into the system. These groups are considered to arise mainly from band 3 fragmentation due to the action of red cell proteinases. Protein fragmentation takes place prior to significant hemolysis or lipid peroxidation, as evaluated by thiobarbituric acid-reactive substances measurements.

Calculation of LDL-cholesterol by using apolipoprotein B for classification of nonchylomicronemic dyslipemia

In this paper we propose a calculation of LDL-cholesterol (LDL-C) not affected by hypertriglyceridemia by using lipid quantities directly measured in total serum. We also propose an algorithm for the classification of nonchylomicronemic dyslipemias. Plasma apolipoproteins (apo) A-I, B, total cholesterol (TC), triglycerides (TG), and cholesterol of lipoproteins were measured in a group of 38 normolipemic and 120 dyslipemic patients (42 phenotype IIa, 38 IIb, and 40 IV) classified according to TG and LDL-C values. Discriminant analysis was applied to obtain the best classification with the lowest number of quantities directly measured from total serum (TC, TG, and apo B), and multiple regression analysis was performed to find an equation to calculate LDL-C from these quantities. Apo B seems to be a useful discriminator between normolipemic and phenotype IIa patients, by using a cutoff value of 1.35 g/L obtained by ROC curve analysis. The proposed algorithm, based on lipid quantities measured by easily automated methods, is shown to be a good alternative for the classification of nonhyperchylomicronemic dyslipemia. LDL-C calculated from TC, TG, and apo B proved a better estimate of true LDL-C than the estimate obtained with Friedewald's formula.

[Intraoperative anesthetic management of kidney failure in adult liver transplantation. Conventional hemodialysis]

OBJECTIVE

To evaluate our application of indications, use and benefits of conventional hemodialysis during surgery in patients with advanced liver disease and acute or chronic renal failure undergoing liver transplantation (LP), liver retransplantation (LRT) or combined hepatorenal transplantation (CHRT).

PATIENTS AND METHODS

We retrospectively reviewed the cases of 22 patients with advanced liver disease, 11 with acute renal failure and 11 with chronic renal failure. We performed 6 LT, 5 LRT and 11 CHRT. The following data were recorded in the periods before, during and immediately after surgery: metabolic, hemodynamic and coagulation parameters; bicarbonate, calcium and inotropic drug requirements; incidences during reperfusion of the graft; surgical technique used; and survival.

RESULTS

Seven patients (32%) needed hemodialysis, 4 (18%) needed ultrafiltration, 7 (32%) needed both and 4 (18%) required neither. For 6 patients total clamping of the inferior vena cava (ICV) was required with external venovenous bypass. For 8 patients total clamping of the IVC was performed without venovenous bypass. For 8 others IVC clamping was partial with retrohepatic preservation (piggy-back). There were 2 deaths during surgery, 4 more within the first month after surgery and 4 more in the second month. Overall survival was 36.4% among acute patients and 72.7% among CHRT patients.

CONCLUSIONS

1) Conventional hemodialysis during surgery is feasible and gives good results; 2) conventional "high efficiency" hemodialysis is more effective and useful in these patients than is either slow, continuous hemodialysis or filtration; 3) the survival rate of CHRT patients is similar to that of patients undergoing LT with normal kidney function, and 4) partial IVC clamping in the anhepatic phase may decrease the need for ultrafiltration.

Long-term rat survival after malignant brain tumor regression by retroviral gene therapy

Total regression of malignant brain tumors was observed in Wistar rats after retrovirus-mediated gene therapy. Tumors were induced by inoculation of C6 rat glioblastoma cells to a specific location in the rat brain and the tumors that developed were visualized by magnetic resonance imaging (MR). Retroviral vectors were constructed from a defective murine retrovirus to which the thymidine kinase (tk 1) gene from herpes simplex was added (HSV1tk). The vectors produced therapeutic viruses upon their introduction into retrovirus packaging cells. Delivery of the producer cells to the tumor mass and subsequent antiherpetic treatment eradicated the tumors completely, as observed using MRI. Some of the treated animals have been followed for over 8 months and show no signs of recurrence.