The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

How are we measuring health-related quality of life in patients with a Barrett Esophagus? A systematic review on patient-reported outcome measurements

Purpose

Barrett esophagus (BE) is associated with a significant decrease of health-related quality of life (HRQoL). Too often, patient-reported outcome measures (PROMs) are applied without considering what they measure and for which purposes they are suitable. With this systematic review, we provide researchers and physicians with an overview of all the instruments previously used for measuring HRQoL in BE patients and which PROMs are most appropriate from the patient’s perspective.

Methods

A comprehensive search was performed to identify all PROMs used for measuring HRQoL in BE patients, to identify factors influencing HRQoL according to BE patients, and to evaluate each PROM from a patients’ perspective.

Results

Among the 27 studies, a total of 32 different HRQoL instruments were identified. None of these instruments were designed or validated for use in BE patients. Four qualitative studies were identified exploring factors influencing HRQoL in the perceptions of BE patients. These factors included fear of cancer, anxiety, trust in physician, sense of control, uncertainty, worry, burden of endoscopy, knowledge and understanding, gastrointestinal symptoms, sleeping difficulties, diet and lifestyle, use of medication, and support of family and friends.

Conclusion

None of the quantitative studies measuring HRQoL in BE patients sufficiently reflected the perceptions of HRQoL in BE patients. Only gastrointestinal symptoms and anxiety were addressed in the majority of the studies. For the selection of PROMs, we encourage physicians and researchers measuring HRQoL to choose their PROMs from a patient perspective and not strictly based on health professionals’ definitions of what is relevant.

Biochemical effects of two different hyaluronic acid products in a co-culture model of osteoarthritis

OBJECTIVES

To compare the effects of two hyaluronic acid (HA) formulations on mediators of matrix turnover and inflammation in an IL-1-treated cartilage-synovium co-culture model with the aim of elucidating mechanisms by which viscosupplementation exerts beneficial effects in osteoarthritic joints.

DESIGN

A co-culture model (100 ng/ml interleukin-1beta (IL-1beta) added to canine synovial and cartilage explants) was used to investigate the effects of HA on cartilage-synovium interactions. Three concentrations (1x, 0.5x, and 0.1x) of two commercial sources of HA (A: Synvisc [hylan G-F 20]; B: Hyalgan [sodium hyaluronate]) were used. Co-cultures without IL-1beta (negative) or with IL-1beta (positive) but neither HA product served as controls. The liquid media were collected every 3 days and explants of cartilage and synovium were collected on days 3, 6, and 20. Media and explants were analyzed histologically, biochemically, and immunohistochemically.

RESULTS

Glycosaminoglycan (GAG) content was measured in cartilage explants. GAG content in explants was higher in both HA groups at the beginning and the conclusion of the study compared to the IL-1beta-treated group. GAG content of the media was significantly (P<0.05) lower in the Synvisc group than all other groups early. The Hyalgan group demonstrated progressively less GAG release later in the study. The addition of Synvisc did not decrease the matrix metalloproteinase (MMP)-3 concentrations at any point. MMP-3 concentrations were significantly (P<0.05) lower among the 1x and 0.5x Hyalgan groups on day 20 compared to the IL-1beta-treated group. On day 3, prostaglandin E(2) concentrations were significantly (P<0.05) higher in the IL-1beta-treated group compared to other groups. Both HA groups had less nitric oxide production than the control groups throughout the study.

CONCLUSIONS

This study supports two potential mechanisms for viscosupplementation: a biosynthetic-chondroprotective mechanism, with a possible delay in onset depending on the form of HA; and an anti-inflammatory mechanism.

Méthode de prise en charge globale non médicamenteuse des patients déments institutionnalisés

INTRODUCTION

Over the last decades many approaches have been developed to manage cognitive and behavioral disturbances in dementia. The present work describes a global intervention program carried out with moderately to severely demented institutionalized patients. The aims of the intervention program are to stimulate and maintain the preserved abilities of demented patients in a supportive context, to decrease the behavioral disturbance and to avoid burnout of care-unit staff.

METHODS

This intervention combines different means: psychosocial care (validation therapy, social interaction), cognitive stimulation (memory and verbal training), and motor and sensitive stimulation. The global intervention program requires a special trained team composed of a supervisor, six aid-nurses, an occupational therapist, a speech therapist, a psychomotor therapist and a psychologist. The team cared for the patients five days per week over a three-month period. Assessments were conducted before and after the intervention program to measure the benefit.

RESULTS

Positive effects were shown for cognitive abilities, nutritional problems and staff burnout. However, due to the small sample size for this study, more research is needed to verify the effectiveness of this global intervention program, particularly the implications for nutrition.

CONCLUSION

This global intervention combined with pharmacological treatment seems to be useful for managing psychological and behavioral disorders of institutionalized demented patients.

Phosphotyrosine signalling as a regulator of neural crest cell adhesion and motility

We demonstrate that neural crest cell-cell adhesion, cell-substrate adhesion, and ultimately cell motility, are highly dependent on the balanced action of tyrosine kinases and tyrosine phosphatases. Neural crest cell migration on fibronectin is diminished in the presence of the tyrosine phosphatase inhibitor vanadate or tyrosine kinase inhibitor herbimycin A, while cadherin-rich cell-cell adhesions are significantly increased. In contrast, cells treated with the kinase inhibitor genistein have decreased motility, rearrange rapidly and reversibly into a pavement-like monolayer, but have no increase in cadherin interactions. Genistein-sensitive tyrosine kinases may therefore abrogate a latent sensitivity of neural crest cells to contact-mediated inhibition of movement. Furthermore, we show that the activity of herbimycin A-sensitive kinases is necessary for focal adhesion formation in these cells. Moreover, the size and distribution of these adhesions are acutely sensitive to the actions of tyrosine phosphatases and genistein-sensitive kinases. We propose that in migrating neural crest cells there is a balance in phosphotyrosine signalling which minimises both cell-cell adhesion and contact inhibition of movement, while enhancing dynamic cell-substrate interactions and thus the conditions for motility.

Retinotectal ligands for the receptor tyrosine phosphatase CRYPalpha

The cell adhesion molecule-like tyrosine phosphatase CRYPalpha is localized on retinal axons and their growth cones. We present evidence that two isoforms of this type IIa phosphatase, CRYPalpha1 and CRYPalpha2, have extracellular ligands along the developing retinotectal pathway. Using alkaline phosphatase fusion proteins containing the CRYPalpha1 ectodomain, we detect a prominent ligand on basement membranes of the early retina, optic stalk, and chiasm. A second ligand is observed in the endfeet region of radial processes in the developing stratum opticum, the site of initial retinal axon invasion. This latter ligand binds CRYPalpha2 preferentially. Further ligand interactions are detected for both CRYPalpha protein isoforms in retinorecipient tectal laminae and on retinal fibers themselves. CRYPalpha thus has cell- and matrix-associated ligands along the entire retinotectal projection. Moreover, these ligands appear to be heterotypic and interact with CRYPalpha through both its immunoglobulin and fibronectin type III regions. The anteroposterior levels of the ligands are relatively uniform within the retina and tectum, suggesting that the CRYPalpha protein within retinal axons does not directly recognise topographically graded guidance cues. We propose that CRYPalpha may have a permissive role in promoting retinal axon growth across the eye and tectum and that its functions are modulated temporally and spatially by isoform-specific interactions with cell- and matrix-associated ligands.

The expression of receptor tyrosine phosphatases is responsive to sciatic nerve crush

Given the importance of phosphotyrosine signaling in growth cone dynamics, we have examined the embryonic and adult expression of receptor-like protein tyrosine phosphatases in sensory neurons and studied their responsiveness to nerve lesions in young adult animals. The phosphatases LAR, PTPsigma, and PTPalpha are expressed in most neurons of E14 and E18 rat embryo dorsal root ganglia, while BEM-1 is expressed in a more restricted subset of these neurons. These phosphatases continue to be expressed in young adult animals, suggesting that they have roles in mature as well as in developing dorsal root ganglia neurons. After an experimental sciatic nerve crush, the expression of the phosphatase genes was significantly and differentially altered in these neurons. PTPsigma mRNA was increased by 50% after 3 days, while LAR and PTPalpha expression dropped by 50 and 20%, respectively. BEM-1 mRNA levels were unaltered. These data show that mRNA levels of specific tyrosine phosphatase genes are highly responsive to nerve damage and may be reset to a new and potentially optimal pattern of expression more conducive for nerve regeneration. We propose that tyrosine phosphatases are not only involved in primary axonogenesis but can also now be implicated in the molecular control of adult nerve repair.

Protein tyrosine phosphatases and neural development

During neural development, cells interact dynamically with each other and with the extracellular matrix, using cell signaling to control differentiation, axonogenesis, and survival. Enzymes that regulate protein tyrosine phosphorylation often lie at the core of such cell signaling. Protein tyrosine phosphatases (PTPases) are recognized as being of central importance here, and a growing family of PTPases are now known to be expressed in embryonic neurons and glia. Both receptor-like and cytoplasmic enzymes have been identified. The receptor family includes immunoglobulin superfamily members that influence cell-cell adhesion, proteoglycans that control neurite growth, and enzymes in Drosophila that regulate axon guidance and target cell recognition. Cytoplasmic PTPases are implicated in nerve cell commitment and potentially in the regulation of cell survival. This review outlines what we currently know about PTPases in the nervous system and presents concepts concerning their possible modes of action.

Don't forget prostatic carcinoma in abdominal carcinomatosis

An incarcerated hernia containing peritoneal secondaries from carcinoma of the prostate is presented. Abdominal carcinomatosis may be due to a prostatic primary and will benefit from hormonal treatment.

A novel Bacillus thuringiensis gene encoding a Spodoptera exigua-specific crystal protein

Only one of the four lepidoptera-specific crystal protein subclasses (CryIC) Bacillus thuringiensis was previously shown to be highly toxic against several Spodoptera species. By using a cryIC-derived nucleotide probe, DNA from 25 different strains of B. thuringiensis was screened for the presence of homologous sequences. A putative crystal protein gene, considerably different from the cryIC gene subclass, was identified in the DNA of strain 4F1 (serotype kenyae) and cloned in Escherichia coli. Its nucleotide sequence was determined and appeared to contain several features typical for a crystal protein gene. Furthermore, the region coding for the N-terminal part of the putative toxic fragment showed extensive homology to subclass cryIA sequences derived from gene BtII, whereas the region coding for the C-terminal part appeared to be highly homologous to the cryIC gene BtVI. With an anti-crystal protein antiserum, a polypeptide of the expected size could be demonstrated in Western immunoblots, onto which a lysate of E. coli cells harboring the putative gene, now designated as BtXI, had been transferred. Cells expressing the gene appeared to be equally toxic against larvae of Spodoptera exigua as recombinant cells expressing the BtVI (cryIC)-encoded crystal protein. However, no toxicity against larvae of Heliothis virescens, Mamestra brassicae, or Pieris brassicae could be demonstrated. The nucleotide sequence analysis and the toxicity studies showed that this novel crystal protein gene falls into a new cryl gene subclass. We propose that this subclass be referred to as cryIE.

Perceived family relationships in drug abusing adolescents

A group of 15- to 16-year-old adolescents were asked to report on their perception of their own family relationships, previous family experiences and their perceptions of their relationships with their fathers and with their mothers. They were also asked to report on their use of psychoactive drugs. Drug users were more likely than non-users to perceive their families as distant and less involved, with poor communications, mistrusting and punitive. Fathers were more likely perceived to be ineffective, and less significant than mothers. Drug users reported more parental separation, divorce, re-marriage and bereavement.

Pharmaceuticals and health policy: an Indian example

The production and consumption of allopathic medicines in less developed countries has far-reaching effects. In particular, the legitimization of allopathic medicine endows professional groups and sectors of industry with a special status, supports some patterns of healthcare, and neglects others. Research in India demonstrates that people equate "more drugs' with "a better situation' and this is seen as the most "appropriate' solution to India's pharmaceuticals problems. The belief is expressed in matters such as Government policy on the pharmaceutical industry and the development of health services. However, these dominant assumptions, and the equation of drug prescription with medical practice, have a negative effect on health.