Isoniazid urine spectrophotometry for prediction of serum pharmacokinetics in adults with TB

BACKGROUND

Isoniazid (INH) is an important drug in many TB regimens, and unfavorable treatment outcomes can be caused by suboptimal pharmacokinetics. Dose adjustment can be personalized by measuring peak serum concentrations; however, the process involves cold-chain preservation and laboratory techniques such as liquid chromatography (LC)/mass spectrometry (MS), which are unavailable in many high-burden settings. Urine spectrophotometry could provide a low-cost alternative with simple sampling and quantification methods.

METHODS

We enrolled 56 adult patients on treatment for active TB. Serum was collected at 0, 1, 2, 4, 6, and 8 h for measurement of INH concentrations using validated LC-MS/MS methods. Urine was collected at 0-4, 4-8, and 8-24 h intervals, with INH concentrations measured using colorimetric methods.

RESULTS

The median peak serum concentration and total serum exposure over 24 h were 4.8 mg/L and 16.4 mg*hour/L, respectively. Area under the receiver operator characteristic curves for urine values predicting a subtherapeutic serum concentration (peak <3.0 mg/L) were as follows: 0-4 h interval (AUC 0.85, 95% CI 0.7-0.96), 0-8 h interval (AUC 0.85, 95% CI 0.71-0.96), and 0-24 h urine collection interval (AUC 0.84, 95% CI 0.68-0.96).

CONCLUSION

Urine spectrophotometry may improve feasibility of personalized dosing in high TB burden regions but requires further study of target attainment following dose adjustment based on a urine threshold.

An expanded RT-PCR melting temperature coding assay to rapidly identify all known SARS-CoV-2 variants and sub-variants of concern

The continued emergence of vaccine-resistant SARS-CoV-2 variants of concern (VOC) requires specific identification of each VOC as it arises. Here, we report an expanded version of our previously described sloppy molecular beacon (SMB) melting temperature (Tm) signature-based assay for VOCs, now modified to include detection of Delta (B.1.617.2) and Omicron (B.1.1.529) sub-variants. The SMB-VOC assay targets the signature codons 501, 484 and 452 in the SARS-CoV-2 spike protein which we show can specifically detect and differentiate all known VOCs including the Omicron subvariants (BA.1, BA.2, BA.2.12.1, BA.4/BA.5). The limit of detection (LOD) of the assay was 20, 22 and 36 genomic equivalents (GE) per reaction with the Delta, Omicron BA.1 and BA.2 respectively. Clinical validation of the 3-codon assay in the LC480 instrument showed the assay detected 94% (81/86) of the specimens as WT or VOCs and 6% (5/86) of the tests producing indeterminate results compared to sequencing. Sanger sequencing also failed for four samples. None of the specimens were incorrectly identified as WT or as a different VOC by our assay. Thus, excluding specimens with indeterminant results, the assay was 100% sensitive and 100% specific compared to Sanger sequencing for variant identification. This new assay concept can be easily expanded to add newer variants and can serve as a robust diagnostic tool for selecting appropriate monoclonal antibody therapy and rapid VOC surveillance.

Simplified urine-based method to detect rifampin underexposure in adults with tuberculosis: a prospective diagnostic accuracy study

Variable pharmacokinetics of rifampin in tuberculosis (TB) treatment can lead to poor outcomes. Urine spectrophotometry is simpler and more accessible than recommended serum-based drug monitoring, but its optimal efficacy in predicting serum rifampin underexposure in adults with TB remains uncertain. Adult TB patients in New Jersey and Virginia receiving rifampin-containing regimens were enrolled. Serum and urine samples were collected over 24 h. Rifampin serum concentrations were measured using validated liquid chromatography-tandem mass spectrometry, and total exposure (area under the concentration-time curve) over 24 h (AUC0-24) was determined through noncompartmental analysis. The Sunahara method was used to extract total rifamycins, and rifampin urine excretion was measured by spectrophotometry. An analysis of 58 eligible participants, including 15 (26%) with type 2 diabetes mellitus, demonstrated that urine spectrophotometry accurately identified subtarget rifampin AUC0-24 at 0-4, 0-8, and 0-24 h. The area under the receiver operator characteristic curve (AUC ROC) values were 0.80 (95% CI 0.67-0.90), 0.84 (95% CI 0.72-0.94), and 0.83 (95% CI 0.72-0.93), respectively. These values were comparable to the AUC ROC of 2 h serum concentrations commonly used for therapeutic monitoring (0.82 [95% CI 0.71-0.92], P = 0.6). Diabetes status did not significantly affect the AUC ROCs for urine in predicting subtarget rifampin serum exposure (P = 0.67-0.92). Spectrophotometric measurement of urine rifampin excretion within the first 4 or 8 h after dosing is a simple and cost-effective test that accurately predicts rifampin underexposure. This test provides critical information for optimizing tuberculosis treatment outcomes by facilitating appropriate dose adjustments.

Rifampin urinary excretion to predict serum targets in children with tuberculosis: a prospective diagnostic accuracy study

OBJECTIVE

Pharmacokinetic variability drives tuberculosis (TB) treatment outcomes but measurement of serum drug concentrations for personalised dosing is inaccessible for children in TB-endemic settings. We compared rifampin urine excretion for prediction of a serum target associated with treatment outcome.

DESIGN

Prospective diagnostic accuracy study.

SETTING

Inpatient wards and outpatient clinics, northern Tanzania.

PATIENTS

Children aged 4-17 years were consecutively recruited on initiation of WHO-approved treatment regimens.

INTERVENTIONS

Samples were collected after directly observed therapy at least 2 weeks after initiation in the intensive phase: serum at pre-dose and 1, 2 and 6 hours post-dose, later analysed by liquid chromatography-tandem mass spectrometry for calculation of rifampin total exposure or area under the concentration time curve (AUC0-24); urine at post-dose intervals of 0-4, 4-8 and 8-24 hours, with rifampin excretion amount measured onsite by spectrophotometry.

MAIN OUTCOME MEASURES

Receiver operating characteristic (ROC) curve for percentage of rifampin dose excreted in urine measured by spectrophotometry to predict serum rifampin AUC0-24 target of 31.7 mg*hour/L.

RESULTS

89 children, 52 (58%) female, with median age of 9.1 years, had both serum and urine collection. Only 59 (66%) reached the serum AUC0-24 target, reflected by a range of urine excretion patterns. Area under the ROC curve for percentage of rifampin dose excreted in urine over 24 hours predicting serum AUC0-24 target was 69.3% (95% CI 56.7% to 81.8%), p=0.007.

CONCLUSIONS

Urine spectrophotometry correlated with a clinically relevant serum target for rifampin, representing a step toward personalised dosing for children in TB-endemic settings.

Persistence of SARS-CoV-2 in saliva: Implications for late-stage diagnosis and infectious duration

Saliva has been a COVID-19 diagnostic specimen of interest due to its simple collection, scalability, and yield. Yet COVID-19 testing and estimates of the infectious period remain largely based on nasopharyngeal and nasal swabs. We sought to evaluate whether saliva testing captured prolonged presence of SARS-CoV-2 and potential infectiousness later in the disease course. We conducted an observational study of symptomatic COVID-19 patients at University Hospital in Newark, NJ. Paired saliva and nasal specimens from 96 patients were analyzed, including longitudinal analysis of paired observations from 28 of these patients who had multiple time-points. Saliva detected significantly more cases of COVID-19 beyond 5 days (86.1% [99/115] saliva vs 48.7% [56/115] nasal, p-value < 0.001), 9 days (79.4% [50/63] saliva vs 36.5% [23/63] nasal, p-value < 0.001) and 14 days (71.4% [20/28] saliva vs 32.1% [9/28] nasal, p-value = 0.010) of symptoms. Additionally, saliva yielded lower cycle thresholds across all time periods, indicative of higher viral loads in saliva. In the longitudinal analysis, a log-rank analysis indicated that the survival curve for saliva was significantly different from the curve for nasal swabs (p<0.001) with a median survival time for saliva of 18 days compared to 13 days for nasal swabs. We additionally performed saliva viral cultures among a similar COVID-19 patient cohort and noted patients with positive saliva viral cultures between 7 to 28 days of symptoms. Findings from this study suggest that SARS-CoV-2 RNA persists longer and in higher abundance in saliva compared to nasal swabs, with potential of prolonged propagating virus. Testing saliva may thus increase yield for detecting potentially infectious virus even beyond the first five days of symptomatic COVID-19.

How do nurses experience working with adolescents with a diagnosis of 'personality disorder' or 'emerging personality disorder'?

Nurses experience adults with a diagnosis of 'personality disorder' ('PD') as challenging, but nothing is known of their experiences working with young people with a diagnosis of 'PD' or 'emerging PD'. This study aimed to explore the experiences of nurses with this group. Six nurses were interviewed individually and the transcripts analysed employing interpretative phenomenological analysis. Two themes were identified: emotional impact, and conflict and need for support. Participants described powerful emotional responses and heavy time demands as particular challenges. They also reflected on tensions that arose in the wider team and service context. The importance of reflective space, training and the need for specialist approaches, such as therapeutic input, was emphasized by all participants. The study's findings suggest that while there are some similarities to adult services, there are also issues specific to nursing adolescents with 'PD', which merit further attention, including the implications of the lack of diagnostic clarity for treatment approaches and the difficult interpersonal dynamics of the condition. Recommendations for practice include additional training in relation to the theoretical understanding of diagnosis itself and in working therapeutically with young people with the diagnosis, employing approaches that have been found to be useful in adult services.

The Ukrainian-American study of leukemia and related disorders among Chornobyl cleanup workers from Ukraine: I. Study methods

There are relatively few data on the risk of leukemia among those exposed to external radiation during cleanup operations after the Chornobyl nuclear accident, and results have not been consistent. To investigate this further, we assembled a cohort of 110,645 male cleanup workers from Ukraine and identified cases of leukemia occurring during the period 1986 to 2000. Detailed interviews were conducted and individual bone marrow doses estimated using a new time-and-motion method known as RADRUE described in companion paper II. For the initial analyses we used a nested case-control approach with a minimum of five controls per case, matched for year of birth, oblast (region) of registration, and residence. All identified cases were reviewed by an international panel of experts; 87 of 111 were confirmed. The dose-response analysis and results are given in companion paper III. As background, we describe herein the design, procedures, outcome of case finding and confirmation, control selection, dose estimation and interviewing of subjects.

Model-based characterization of an amino acid racemase fromPseudomonas putida DSM 3263 for application in medium-constrained continuous processes

The amino acid racemase with broad substrate specificity from Pseudomonas putida DSM 3263 was overproduced and characterized with respect to application in an integrated multi-step process (e.g., dynamic kinetic resolution) that--theoretically--would allow for 100% chemical yield and 100% enantiomeric excess. Overexpression of the racemase gene in Escherichia coli delivered cell free extract with easily sufficient activity (20-50 U mg(-1) total protein) for application in an enzyme membrane reactor (EMR) setting. Model-based experimental analysis of a set of enzyme assays clearly indicated that racemization of the model substrates D- or L-methionine could be accurately described by reversible Michaelis-Menten kinetics. The corresponding kinetic parameters were determined from progress curves for the entire suitable set of aqueous-organic mixtures (up to 60% methanol and 40% acetonitrile) that are eligible for an integrated process scheme. The resulting kinetic expression could be successfully applied to describe enzyme membrane reactor performance under a large variety of settings. Model-based calculations suggested that a methanol content of 10% and an acetonitrile content of 20% provide maximum productivity in EMR operations. However product concentrations were decreased in comparison to purely aqueous operation due to decreasing solubility of methionine with increasing organic solvent content. Finally, biocatalyst stability was investigated in different solvent compositions following a model-based approach. Buffer without organic content provided excellent stability at moderate temperatures (20-35 degrees C) while addition of 20% acetonitrile or methanol drastically reduced the half-life of the racemase.

Malignant islet cell tumor with sarcomatous differentiation

Malignant mesenchymal neoplasms of the pancreas are rare and malignant islet cell tumors with sarcomatous dedifferentiation are rarer still. We present a case of malignant islet cell tumor with sarcomatous differentiation, which to our knowledge is only the second reported case showing such a combination of morphologic features. Clinically, the neoplasm was not hormonally active and immunohistochemical staining was negative for gastrin, glucagon, insulin and somatostatin. The sarcomatous component strongly reacted with an antibody directed against vimentin, and a minority of cells stained strongly with antisera directed against desmin and smooth muscle actin. The spindle cell component was nonreactive with antibodies directed against Factor VIII. The myogenous direction of differentiation in the present tumor is similar to that seen in the prior case report of malignant islet cell tumor with rhabdomyosarcomatous differentiation.

Assessing the risks of exposures to multiple chemicals with a common mechanism of toxicity: how to cumulate?

The Food Quality Protection Act (FQPA) of 1996 requires the U.S. EPA to consider the "cumulative effects" of pesticides and other substances that have a "common mechanism of toxicity." Several different methods for combining the exposures to estimate the risk of groups of common mechanism chemicals with different potencies and exposure characteristics are critically evaluated. These are the hazard index (HI), toxicity equivalence factor (TEF), and combined margin of exposure (MOE(T)) procedures as well as the point of departure index (PODI) and cumulative risk index (CRI) methods that are the reciprocals of the HI and MOE(T) approaches, respectively. Each of these methods ideally requires, at a minimum, the availability of in vivo toxicology data for the same toxicological endpoint in the same animal species. Furthermore, all assume that the effects of the individual components in the mixture are independent in nature (i.e., are additive rather than synergistic or antagonistic) and that the dose-response functions for all compounds have a similar slope. The point of departure (POD), preferably the dose corresponding to a given effect level (e.g., the ED(10)), can be used as a measure of the relative potency of the different chemicals in the group. If appropriate exposure and toxicology data are available, and the chemicals in the group have a common uncertainty factor (UF), all the procedures yield a numerically identical result. The fact that different chemicals in the group often have different UFs raises issues for all summation procedures and, in the case of the TEF approach, the UF of the index chemical selected dictates the final result of the assessment. A major distinction between the different methods for addition is the point in the process at which uncertainty is considered. The HI and CRI approaches are problematic because they require application of policy-driven UFs (in the form of RfDs) at that stage of the process where exposure should be expressed in terms of potency. In contrast, the PODI and MOE(T) approaches require application of a single group UF(G) at the end of the risk assessment process although they will also accommodate the application of data-based adjustments earlier in the analysis. Importantly, both the PODI and the MOE(T) approaches allow policy- and data-driven UFs to be separated and thus make the process more transparent; these should be considered the methods of choice for cumulative risk assessment. Assignment of a single group UF is somewhat different from developing an UF for a single chemical and the total weight of evidence available in the group database can be used to advantage to reduce the UFs that need to be applied to the group. This larger database can also be used to refine the PODs for individual members of the group. It is important to emphasize that there remains a great deal of scientific uncertainty about how to proceed with cumulative risk assessment as described in the FQPA. The serious difficulties associated with defining "common mechanism of toxicity" and "concurrent exposure" combined with the current paucity of data and methodology required to conduct cumulative risk assessment suggest that the procedure is not yet ready for use in pesticide regulation.

Trisomy 2p syndrome: a fetus with anencephaly and postaxial polydactyly

We report on a male fetus with partial trisomy 2p21-2pter and monosomy 15q26-15qter due to t(2,15)(p21;q26). This fetus had a typical trisomy 2p phenotype including minor facial anomalies, musculoskeletal defects and two unusual findings: polydactyly and anencephaly. The observation of anencephaly adds support to the theory that genetic material mapping to chromosome band 2p24 is involved in neural tube development. In addition, we propose that a gene on 2p23 may play a role in the morphogenetic patterning of hands and feet.

Phase I trial of retroviral-mediated transfer of the human MDR1 gene as marrow chemoprotection in patients undergoing high-dose chemotherapy and autologous stem-cell transplantation

PURPOSE

Normal bone marrow cells have little or no expression of the MDR p-glycoprotein product and, therefore, are particularly susceptible to killing by MDR-sensitive drugs, such as vinca alkaloids, anthracyclines, podophyllins, and paclitaxel and its congeners. Here we report the results of a phase I clinical trial that tested the safety and efficacy of transfer of the human multiple drug resistance (MDR1, MDR) gene into hematopoietic stem cells and progenitors in bone marrow as a means of providing resistance of these cells to the toxic effects of cancer chemotherapy.

PATIENTS AND METHODS

Up to one third of the harvested cells of patients who were undergoing autologous bone marrow transplantation as part of a high-dose chemotherapy treatment for advanced cancer were transduced with an MDR cDNA-containing retrovirus; these transduced cells were reinfused together with unmanipulated cells after chemotherapy.

RESULTS

High-level MDR transduction of erythroid burst-forming unit (BFU-E) and colony-forming unit-granulocyte macrophage (CFU-GM) derived from transduced CD34+ cells was shown posttransduction and prereinfusion. However, only two of the five patients showed evidence of MDR transduction of their marrow at a low level at 10 weeks and 3 weeks, respectively, posttransplantation. The cytokine-stimulated transduced cells may be out-competed in repopulation by unmanipulated normal cells that are reinfused concomitantly. The MDR retroviral supernatant that was used was shown to be free of replication-competent retrovirus (RCR) before use, and all tests of patients' samples posttransplantation were negative for RCR. In addition, no adverse events with respect to marrow engraftment or other problems related to marrow transplantation were encountered.

CONCLUSION

These results indicate the feasibility and safety of bone marrow gene therapy with a potentially therapeutic gene, the MDR gene.

Prenatal therapy for pericardial teratomas

Although the majority of reported pericardial teratomas have been excised successfully in the postnatal period, the outcome of prenatally diagnosed pericardial teratomas remains less favorable. Two recent cases of prenatally diagnosed pericardial teratomas and a review of previously reported cases suggest a new management algorithm for those pericardial teratomas discovered in utero. Fetuses in whom hydrops does not develop may be safely followed up and treated postnatally. However, if hydrops develops, the fetus requires treatment with either aspiration of the pericardial effusion, or fetal surgery and resection.

Evaluation of the TEOM method for measurement of ambient particulate mass in urban areas

Increased interest in the health effects of ambient particulate mass (PM) has focused attention on the evaluation of existing mass measurement methodologies and the definition of PM in ambient air. The Rupprecht and Patashnick Tapered Element Oscillating MicroBalance (TEOM) method for PM is compared with time-integrated gravimetric (manual) PM methods in large urban areas during different seasons. Comparisons are conducted for both PM10 and PM2.5 concentrations. In urban areas, a substantial fraction of ambient PM can be semi-volatile material. A larger fraction of this component of PM10 may be lost from the TEOM-heated filter than the Federal Reference Method (FRM). The observed relationship between TEOM and FRM methods varied widely among sites and seasons. In East Coast urban areas during the summer, the methods were highly correlated with good agreement. In the winter, correlation was somewhat lower, with TEOM PM concentrations generally lower than the FRM. Rubidoux, CA, and two Mexican sites (Tlalnepantla and Merced) had the highest levels of PM10 and the largest difference between TEOM and manual methods. PM2.5 data from collocation of 24-hour manual samples with the TEOM are also presented. As most of the semi-volatile PM is in the fine fraction, differences between these methods are larger for PM2.5 than for PM10.

Incidental cholecystectomy in the over-70 age group. A 19-year retrospective, comparative study

OBJECTIVES

To analyse the outcome of incidental cholecystectomy in the over 70 age-group during surgery for gastrointestinal malignancies.

DESIGN

Nineteen-year retrospective, comparative study.

SETTING

Department of Surgery B, Belinson Campus, Rabin Medical Center.

SUBJECTS

The hospitalization records of 4,072 patients who underwent cholecystectomy between 1975 and 1994 were reviewed. The incidental cholecystectomy cases for this period were identified and those performed during surgery for gastrointestinal malignancy were analysed separately. A sex- and age-matched control group was identified for comparison.

MAIN OUTCOME MEASURES

Postoperative complications, overall morbidity and mortality, postoperative hospitalization days. Statistical differences in gallbladder-related complications and mortality among groups.

RESULTS

Mortality and overall morbidity were significantly increased in the no-cholecystectomy group. Hospitalization days were increased significantly in the group not under-going cholecystectomy and although it didn't reach statistical significance, there was a clear trend for increased number of pulmonary complication in this same group. Sepsis and multiorgan failure, as an expression of acutely, postoperative symptomatic gallbladder were the major cause of death in the no-incidental-cholecystectomy group.

CONCLUSIONS

Incidental cholecystectomy is safe and should be considered in every case of abdominal surgery, regardless of the age of the patient. In the over 70 age group, complication and mortality rates increase significantly and dreadfully when the gallbladder is left in situ after surgery for gastrointestinal tumors. Incidental cholecystectomy is not warranted in patients undergoing palliative procedures or in whom life expectancy is less than 6 months.

Retroviral transfer and expression of the human multiple drug resistance (MDR) gene in peripheral blood progenitor cells

The multiple drug resistance (MDR) gene P-glycoprotein product is a transmembrane efflux pump that prevents toxicity of a variety of chemotherapeutic agents, including the anthracyclines, Vinca alkaloids, podophyllins, and taxol. The bone marrow toxicity of these drugs is due to the low or absent expression of MDR in marrow cells. Transfer and expression of the human MDR gene into bone marrow progenitors should prevent this toxicity. We report here the efficient transfer and expression of the MDR gene by retroviral-mediated gene transfer into CD34(+) cells isolated from peripheral blood progenitor cells (PBPCs), comparable to that obtained using bone marrow-derived progenitors. Optimal MDR transduction of these PBPC-derived cells requires exposure to growth factors and a period of preincubation. In addition, we demonstrate that we can transduce up to 100% of progenitor cells derived from PBPCs and can protect up to 25% of these progenitors from a dose of taxol toxic to untransduced controls.

Parturition and fetal adaptation

The fetus as "patient" during labor and birth has become an increasingly important concept during the past 20 years. However, what is understood about fetal status during labor and how the fetus prepares for its approaching separation from its mother? Current information indicates that not only is the term fetus well prepared for the adaptation to extrauterine life, but this transition is facilitated by normal labor.

Measurement of organic acids, aldehydes, and ketones in residential environments and their relation to ozone

Ozone and several polar volatile organic compounds (VOCs) including organic acids and carbonyls (aldehydes and ketones) were measured over an approximately 24 hour period in four residences during the winter of 1993 and in nine residences during the summer of 1993. All residences were in the greater Boston, Massachusetts area. The relation of the polar VOCs to the ozone concentration was examined. Indoor carbonyl concentrations were similar between the summer and winter, with the total mean winter concentration being 31.7 ppb and the total mean summer concentration being 36.6 ppb. However, the average air exchange rate was 0.9 hr-1 during the winter and 2.6 hr-1 during the summer. Therefore, the estimated carbonyl emission rates were significantly higher during the summer. Indoor organic acid concentrations were about twice as high during the summer as during the winter. For formic acid, the indoor winter mean was 9.8 ppb, and the summer indoor mean was 17.8 ppb. For acetic acid, the indoor winter mean was 15.5 ppb, and the summer indoor mean was 28.7 ppb. The concentrations of the polar VOCs were found to be significantly correlated with one another. Also, the emission rates of the polar VOCs were found to be correlated with both the environmental variables such as temperature and relative humidity and the ozone removal rate; however, it was difficult to apportion the relative effects of the environmental variables and the ozone removal.

Acute renal allograft dysfunction in the setting of deep venous thrombosis: a case of successful urokinase thrombolysis and a review of the literature

Acute renal allograft vein thrombosis is a rare but serious complication of renal transplantation. When occurring in the early posttransplant period it is usually associated with surgical complications and often results in the loss of the graft. At later stages, when graft function has stabilized, its development may then be associated with underlying disorders such as glomerulonephritis, immunosuppressive therapy, increased hematocrit, acute rejection, or extension of lower extremity venous thromboses. We report a case of acute allograft dysfunction occurring in the setting of extensive deep vein thrombosis. In our patient, thrombosis in the setting of acute graft tenderness and swelling, anuria, and an increasing creatinine strongly suggest a diagnosis of acute allograft renal vein thrombosis. We describe a successful reversal of acute renal failure through urokinase thrombolysis and review the current literature on the use of thrombolytic agents for the treatment of acute renal allograft vein thrombosis.

Amino acid alcohols: growth inhibition and induction of differentiated features in melanoma cells

The effects of a series of D- and L-amino acid alcohols on the proliferation and phenotypic expression of B16 mouse melanoma cells were evaluated. B16 melanoma cells were incubated for different time intervals in the presence of D- or L-phenylalaninol (PHE), D- or L-alaninol (AL), D- or L-leucinol (LE), L-histidinol (HIS), L-tyrosinol (TYR) and L-methioninol (MET). All agents, including the D or L configuration, induced an anti-proliferative effect, although of considerably different magnitude. D-PHE was the most active growth inhibitor. The growth inhibitory effects were accompanied by phenotypic alterations, which included morphological changes and enhancement in the activities of NADPH cytochrome c reductase and tau-glutamyl transpeptidase. These phenotypic alterations correlated with the growth inhibitory effects of the different agents and seem to reflect a higher differentiated state.

State of the art in the diagnosis and management of acute cholecystitis

The analysis of 664 cases operated upon for acute cholecystitis as well as a review of the literature indicate the dramatic increase in the age of patients presenting with this complication. Other obvious changes: increasing rate of diabetes mellitus and acalculous cholecystitis. The development of preoperative and operative sonography has contributed greatly to the safety of surgery for acute cholecystitis. The majority of patients classified as having low risks should, at the present state of our knowledge, undergo early and definitive surgery. This approach has shown to be the most beneficial from both the medical and economic standpoint. High risk patients as well as patients refusing surgery are optimally treated by sonar-guided percutaneous transhepatic cholecystostomy. Among the recent changes observed over the last 5 years, a marked decrease in septic complications as well as in the length of hospital stay was noted. Both changes improve the cost-benefit ratio of early surgery in this condition.

The risk of cholecystectomy for acute cholecystitis in diabetic patients

In order to evaluate the risk of acute cholecystitis in diabetic patients, we analyzed 2,700 consecutive cholecystectomies, 566 of which were performed in the presence of acute cholecystitis. Of these patients 123 had diabetes mellitus (DM) and 433 had no diabetes (ND). The aim of this study was to establish the comparative risks in the two groups. We found that diabetics are more likely to be operated on in the acute stage of their disease (22% vs. 12%). The DM group had a higher rate of septic bile, gangrenous changes and perforations of the gallbladder wall. The morbidity rate was higher in the DM group (21% vs. 9%), and mortality was slightly higher in the DM group. The degree of additional operative risk does not in our view justify recommending cholecystectomy in diabetic patients with asymptomatic gallstones. Early surgery however, is highly recommended in diabetics with symptomatic gallstones and acute cholecystitis.

Multifactorial analysis of septic bile and septic complications in biliary surgery

A unifactorial analysis for possible risk factors was applied to 2,700 consecutive operations for benign disease of the biliary tract. A series of high risk factors in relation to positive bacteriology and septic complication could be identified. These risk factors were patients who were elderly (greater than 70 years; p less than 0.001), those who were diabetic, those who had a serum bilirubin greater than 1.1 mg% (p less than 0.001), those who had acute cholecystitis (p less than 0.001), and those in whom choledochal stones were found (p less than 0.001). Using a multivariate analysis, we concluded that in patients with no risk factors (56.9%) the incidence of a positive bacteriology was low (10.9%) and they should receive no antibiotic prophylaxis. Patients with one risk factor (24%), had a 36% incidence of positive bacteriology and minimal pre-operative prophylaxis is recommended. Patients with two or more risk factors (19.1%) had a 77.6% incidence of positive bacteriology and full peri-operative prophylaxis is recommended, starting pre-operatively and continuing for 3 to 5 days postoperatively. The aim of this study was to identify patients at risk for septic complication in biliary surgery and to create new guidelines for the antibiotic treatment of selected groups.

Surgical problems in octogenarians: epidemiological analysis of 1,083 consecutive admissions

Patients older than 80 years of age are the most rapidly increasing group among surgical admissions and patients visiting emergency rooms. Epidemiological data of this group are of enormous medical and economic relevance. The principle aim of this study was to determine factors predictive of operative mortality in octagenarians, their clinical profiles, and length of stay compared to younger patients in similar diagnostic categories. A computer-based registry of geriatric surgery was used to record and analyze all relevant clinical and epidemiological data. The rate of admissions in octogenarians increased during the 18-year period (1973-1989) from 0.7% to 7.5% of all admissions. The number of patients undergoing surgery was 700. Three hundred and seventy-one of the procedures were elective and 329 were emergencies. Operations in octagenarians as a percentage of all operative procedures increased during the period considered from 1.1% to 5.1%. The operative mortality in this series was 10.5% prior to 1984 and decreased to 6% during the last 5 years. The average hospital stay of octagenarians was 9.8 days as opposed to 4.9 days in patients less than 70 years of age. The prognostic classification described by the authors proved very helpful in predicting mortality.

Sensitivity to new generation of antibiotics in biliary surgery

The treatment of septic complications of cholecystectomy patients requires special attention. In a prospective study of 1009 consecutive cholecystectomy patients (including all acute and elective patients, excluding cases of malignancy), we routinely took cultures from the cystic duct and the gallbladder, and checked the strain for sensitivity. Positive cultures were found in 31.4% of the series, the most frequent bacteria being E. coli (50.3%). The aminoglycosides and the second and third generations of cephaloridins were found more specific for the strains that were cultured. While the new cephaloridins are the first choice for prophylaxis, the combination of aminoglycosides with ampicillin is to be preferred from the medical and cost effective standpoint while the aim is therapeutic.

Choledochoduodenostomy an important surgical tool in the management of common bile duct stones. A review of 126 cases

Of 2,000 patients who underwent cholecystectomy between 1965-1984, 457 had their common bile ducts explored and of these 126 had choledochoduodenostomies. There were 70 women and 56 men and a third were over 70 years old. Forty-three also had acute cholecystitis or pancreatitis, and 73 had an increased serum concentration of bilirubin. Of the 126, 103 had stones in the common duct, and 16 had benign strictures of the sphincter of Oddi. Morbidity included wound infections in 18 (14%) and bile discharge from the drain for over 14 days in four (3%). Five patients died (4%), and they were all over 70 years old. Ninety-seven of 103 patients followed-up over 1-19 years were symptom free (94%). Two patients required re-operation for a narrow anastomosis. Three patients developed a "sump" syndrome; two were treated with antibiotics, and the third responded to endoscopic sphincterotomy. Choledochoduodenostomies should be considered during operation for benign biliary disease, when stones or a stricture in the common bile duct are anticipated.

Hemosuccus pancreaticus and intraperitoneal bleeding secondary to spontaneous rupture of the splenic artery

Hemosuccus pancreaticus is a rare condition where bleeding occurs through the pancreatic duct, usually due to a pseudoaneurysm of the splenic artery. We describe a patient with spontaneous rupture of the splenic artery that caused hemosuccus pancreaticus and later massive hemoperitoneum. The pathological process had lasted at least 10 days before the diagnosis was established. The patient underwent an emergency operation during which splenectomy and distal pancreatectomy were successfully performed.

Changing trends in surgery for acute cholecystitis

Surgery for acute cholecystitis has become the most frequent abdominal surgery in most hospitals, yet aspects of its management remain controversial. The aim of this study was to focus on the recent trends by demonstrating the principal differences between 2 series of patients operated on during 10-year intervals. Two hundred fifty-six consecutive operations for acute cholecystitis were performed from 1970 to 1977 (group O) and were compared to 260 cases operated from 1980 to 1987 (group N). Thirty-six variables were recorded in each case. All data obtained were computer recorded and analyzed. Several trends were observed in group N: 1. The population was significantly older with a higher proportion of males and diabetics. 2. There was a marked increase in common bile duct stones, acalculous cholecystitis, and gangrenous changes in the gallbladder. 3. There was a significant increase in patients operated on within 48 hours of admission. 4. There was a significant increase in the number of patients without previous history of biliary symptoms. 5. There was a significant decrease in the rate of wound infections and no statistically significant differences in mortality (N: 3.0%, O: 2.7%). 6. A decrease of the average postoperative hospital stay of 3.2 days was observed. In spite of the older and sicker population in group N, no significant increase in mortality occurred and the postoperative hospital stay was reduced.

Transient induction of vinculin gene expression in 3T3 fibroblasts stimulated by serum-growth factors

When stimulated with serum, quiescent Balb/C-3T3 fibroblasts were found to induce vinculin transcription transiently within 30 min, followed by accumulation of vinculin mRNA and protein synthesis between 2 and 4 h after stimulation and a decrease to the basal level by 6-8 h. Platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), and 12-O-tetradecanoylphorbol-13-acetate (TPA) each could elicit a similar response, albeit to a lesser extent, whereas epidermal growth factor (EGF) was inefficient in inducing vinculin expression. In cells stimulated with serum and cycloheximide, vinculin expression was superinduced and vinculin mRNA levels persisted longer than in cells stimulated with serum alone. Cells arrested in the presence of serum by anchorage denial in methyl cellulose suspension culture also induced vinculin expression and formed large vinculin positive plaques when reattaching and spreading on the substrate in the presence of serum. Cells replated from suspension culture in the absence of serum on either plastic or extracellular matrix (ECM) components were capable of extensive spreading, but failed to elevate vinculin expression and displayed diffuse vinculin staining. The results indicate that the changes in vinculin organization and expression in response to growth factor stimulation may reflect either a necessary step in the progression through the cell cycle or a response related to complex cellular processes such as wound repair and embryogenesis.

Achievements of physical therapy in patients after modified radical mastectomy compared with quadrantectomy, axillary dissection, and radiation for carcinoma of the breast

Flexion of the shoulder, abduction, and external rotation in 90 degrees abduction are impaired after operations for breast cancer. We compared postoperative range of motion in 27 patients who underwent modified radical mastectomy and 21 patients who underwent quadrantectomy with axillary dissection and radiation therapy. The patients in the quadrantectomy group demonstrated a significantly higher range of flexion on postoperative day 1 and the day of suture removal. After 3 months, all patients had regained their preoperative range of flexion, with no difference between the groups. The better compliance of the quadrantectomy group to physical therapy may indicate that they suffer less pain and require a briefer or less intensive course of physical therapy.

Clinical experience with fetal echocardiography

Current ultrasound technology allows for accurate evaluation of the fetal heart. To evaluate the importance and accuracy of the routine clinical use of fetal echocardiography at our center, a consecutive series of 338 fetal cardiac studies of 323 patients was reviewed. Average gestational age was 24 weeks (range, 17 to 39 weeks). Forty-seven (15%) patients with abnormal conditions were detected. The most common indication for fetal cardiac scan was a family history of congenital heart disease (28%). Other indications were maternal diabetes mellitus (25%), fetal dysrhythmia (14%), other major defect (10%), drug exposure (10%), and obstetrician suspicion of fetal congenital heart disease on routine scan (10%). The highest yield of significant abnormal findings was among those referred for dysrhythmia (31%) and obstetrician suspicion of congenital heart disease (29%). Five fetuses with sustained supraventricular tachycardia and hydrops were successfully treated. The combination of fetal bradycardia and structural heart disease was the most ominous finding. Fifteen (4.6%) patients had clear changes in management based on the fetal echocardiogram. Our experience suggests that the routine use of fetal echocardiography is accurate and an important part of the overall management of the pregnancy considered at risk for producing an infant with congenital heart disease.

Clinical experience treating varicose veins in the aged

Patients over 70 years of age suffering from varicose veins or complications of venous insufficiency formed 6.7 per cent of the population treated in our phlebologic clinic in 10 years. This group of patients is unable to perform intensive walking exercises and fails to use high-pressure elastic stockings; thus, most of the so-called "conservative armamentarium" is nonapplicable. This challenged us to find alternative or modified ways of treatment for this high-risk-for-surgery group. An isolated Trendelenburg procedure under local anesthesia, with sclerotherapy and/or transfixion sutures as an outpatient procedure, was used. In the case of stasis ulceration, patients were treated with sequential intermittent pneumatic compression including local hyperbaric oxygen and teaching the use of elastic support as an inhospital procedure. Both methods proved successful, thereby offering a more acceptable solution to one of the chronic problems of the older age group.

Small bowel obstruction: a review of 264 cases and suggestions for management

Two hundred and sixty-four cases of acute small bowel obstruction were retrospectively reviewed for the purpose of defining factors which could point to the presence of strangulated bowel. History, physical signs and investigations, including body temperature, X-rays, white blood count, and serum amylase, were not significantly different in the simple and strangulated groups. Although an elevated urinary white blood count and a palpable mass were more common in the strangulated group, they were not sufficiently reliable for early diagnosis of strangulation. In reviewing the literature, it is clear that all hernias with obstruction must undergo emergency surgery. Cases with intra-abdominal complete intestinal obstruction should also undergo emergency surgery. A more conservative attitude can only be taken when there is incomplete obstruction.

Multifactorial analysis of prognostic factors in emergency abdominal surgery in patients above 80 years. Analysis of 154 consecutive cases

Patients above 80 have been the most rapidly growing group in the surgical department. The number of major laparotomies in this segment of the population has grown by 15% in the last two decades and is expected to grow by another 100% by the end of the century. The principal aim of the study was to identify by multifactorial analysis the combination of factors predictive of mortality in abdominal emergencies in this age group. A computer-held data base established by the Authors in 1978 was used to register all relevant information in 1327 major laparotomies performed in patients above 70. Of the base of 1327 patients, 219 (16.5%) were above 80. Of this group, 154 cases (70.3%) underwent emergency procedures and are the focus of this study. The principal conclusions of the Authors are as follows: A. The main differences between the two age groups 70-79 (Group A) and above 80 (Group B) are as follows: 1. Emergency laparotomies are much more frequent in Group B (70% versus 33%). 2. The overall mortality is over two and a half times as high (21.4% versus 8%). 3. The diagnostic profile and the mix of cases is different with an increased number of intestinal obstructions and malignancies in Group B. B. Unifactorial analysis of postoperative mortality disclosed the following factors associated with increased mortality: 1. Vital System Category III (Table 6-A). 2. Presence of generalized peritonitis or gangrenous bowel. 3. Presence of widespread malignant disease. 4. Belonging to the following diagnostic groups: carcinoma of pancreas, mesenteric thrombosis. 5. Age 85 or above.(ABSTRACT TRUNCATED AT 250 WORDS)

Involvement of chromosome 22 in a Merkel cell carcinoma in a patient with a previous meningioma

The relatively simple cytogenetic findings in an aggressive metastatic Merkel cell carcinoma are reported. Deletion 2p was found in 100% of the cells. Nevertheless, this was considered a secondary (metastatic?) change because the same aberration has been found in several other kinds of malignancy. The involvement of chromosome 22 [del(22q) and -22] in 85% of the cells seemed more intriguing, considering the fact that the Merkel cell carcinoma followed a previous meningioma.