Chyloperitoneum due to gastric carcinoma: a case report

Chyloperitoneum is a rare manifestation of gastric carcinoma, generally occurring late in the course of the disease with a poor prognosis. We report an unusual case of chyloperitoneum in a patient with gastric carcinoma. A 61-year-old male patient presented with postprandial fullness, nausea and weight loss. The upper gastrointestinal endoscopy demonstrated a stenosing lesion of the esophagogastric junction. A biopsy was made and revealed a signet-ring cell gastric adenocarcinoma. The staging CT scan showed multiple abdominal lymphadenopathies and mild ascites. The patient underwent a staging laparoscopy that revealed a large carcinoma of the gastric cardia and a milky-appearing peritoneal fluid. A peritoneal washing and abdominal drainage were performed. The fluid analysis showed a high concentration of triglycerides, compatible with a chyloperitoneum. The patient started medium chain triglycerides-based diet with good response. This case report emphasizes that chyloperitoneum should be considered when assessing patients with gastric carcinoma.

Levobupivacaine plus fentanyl versus racemic bupivacaine plus fentanyl in epidural anaesthesia for lower limb surgery

BACKGROUND

To compare the anaesthetic epidural effects of levobupivacaine plus fentanyl versus bupivacaine plus fentanyl in patients undergoing lower limb surgery.

METHODS

A single blind, randomised, prospective, multicentre study was designed to compare both therapies. The study was conducted in 10 tertiary hospitals. A total of 96 patients who were ASA I or II, who required at least a 24-hour-stay in the hospital and who were subjected to surgery of lower limbs with epidural anaesthesia were enrolled in this study. Treatments were administered at a dosage of 1.2 ml per metamera,including a test dose (3 mL) and the dose of fentanyl (100 mg). Patients were then randomly allocated to receive either Levobupivacaine (n = 49) or bupivacaine (N.= 47). The primary endpoint was sensory blockade (SB) duration. Secondary evaluations included motor blockade (MB), post-surgery analgesic medication usage, safety and the investigator global evaluation.

RESULTS

SB duration was similar for both interventions: 195 min (165-205) in the bupivacaine group versus 170 min (140-185) in the levobupivicaine group (log-rank test, P=0.884). However, the lack of MB as evaluated by the modified Bromage scale was significantly higher in the levobupivacaine group than in the bupivacaine group (39% vs 13%, P=0.017). Although no significant differences in MB duration were observed between the groups, a trend was observed in the levobupivacaine group, which had a lesser MB (P=0.093). Investigator satisfaction was high and was assessed to a similar extent for both interventions. Forty-one adverse events were detected in 28 patients, with no differences between groups: 15 (33%) with bupivacaine and 13 (27%) with levobupivacaine, P=0.516.

CONCLUSION

Although both interventions showed similar anaesthetic effects, a higher proportion of patients receiving levobupivacaine lacked MB.

Design and validation of a scale to assess preferences of type 2 diabetic patients towards different nutritional supplements

OBJECTIVES

To design and validate a scale to evaluate preferences of type 2 diabetic patients towards nutritional supplements (Madrid scale) and to discover those taste attributes that are more discriminating.

CONTEXT

ambulatory patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

18 controls and 106 type 2 diabetic patients received 2 of the 7 stimuli studied (6 nutritional supplements and a differential salty stimulus) and then completed both scales and a criterion question. Two weeks later, 30 diabetic patients received a retest. The psychometric properties of the Madrid scale were studied and the relative importance of each stimuli attribute was assessed.

RESULTS

Feasibility: The Madrid scale consists of 8 questions and is completed in less than five minutes; Dimensionality: A single dimension which explains 45.1% of the variance. Reliability: Cronbach's , 0.806; intraclass correlation coefficient, 0.835 (95% confidence interval: 0.653-0.922). Concurrent validity: Correlation indexes of the corrected total score with the criterion question and the Modified Wine-Tasting Scale, 0.731 (p < 0.0005) and 0.774 (p < 0.0005), respectively. The scale discriminated between subjects younger and older than 75 years and between supplements and the differential stimulus. Preferences: Glucerna SR chocolate, Glucerna SR strawberry, Glucerna SR vanilla, Diasip vanilla, Clinutren vanilla and Resource diabet vanilla.

CONCLUSION

The Madrid scale has adequate psychometric properties for its use in research and daily clinical practice.

[Effects of NSAID on blood pressure among hypertensive patients with a high cardiovascular risk]

BACKGROUND

An elevation in the risk of cardiovascular (CV) events and blood pressure (BP) levels in patients treated with COX-2 inhibitors compared to non selective NSAID has been shown previously.

OBJECTIVES

To compare the effects of NSAID (COX-2 inhibitors and non-selective) on BP levels and control of HT. To determine the association between NSAID use and coronary heart disease in HT patients with elevated CV risk.

METHODS

Cross sectional epidemiological study in 8126 ambulatory HT patients, older than 40, with a high CV risk. We obtained data on personal variables, CV risk factors, previous CV history, CV medication, analgesic and anti inflammatory drugs (AID). Control of HT was classified: optimal, suboptimal and no control. Absolute CV risk was calculated according to the WHO-ISH score.

RESULTS

44.2% of subjects took ASA and 3.7% another NSAID. SBP was 5.90 mmHg (95%CI: 2.53-9.27 mmHg) higher (p < 0.05) in patients treated with NSAID than in those with no AID medication. Patients having ASA, both SBP and DBP were 5.89 mmHg (p < 0.01) and 2.25 mm Hg (p < 0.05) respectively, lower than in patients with NSAID. However, mean SBP was similar in the ibuprofen group compared to without AID; 11.12 mmHg lower (95%CI: 3.66-18.58) than in the group on NSAID (p < 0.05) and 8.82 mmHg (95%CI: 0.27-17.38) (p < 0.05) lower than in those on COX-2 inhibitors.

CONCLUSIONS

Among HT patients, NSAID therapy (selective or not) is associated with a higher level of SBP than in those without such medication. However, patients treated exclusively with Ibuprofen show similar levels of SBP than without NSAID treatment. Frequency of ischemic disease was significantly higher in the group treated with COX-2 inhibitors than in the non-selective NSAID treated group or in patients without NSAID treatment.

[IV Debate Forum of the SENPE: questions on nutrition research]

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers

Effect of antibodies on the expression of Plasmodium falciparum circumsporozoite protein gene

Antibodies are known to play an important role in the control of malaria infection. However, they can modulate parasite development enhancing infection. The effect of anti-Plasmodium antibodies on the expression of circumsporozoite protein gene (csp) was investigated. Plasmodium falciparum 3D7 in vitro cultures were submitted to: i) anti- circumsporozoite protein monoclonal antibody (anti-CSP-mAb) [1microg/ml, 0.1microg/ml, 0.01microg/ml and 0.001microg/ml] and ii) purified IgG Fab fragment from a pool of malaria patients [1mg/ml and 1microg/ml]; and compared to control cultures. After 24h the number of ring infected erythrocytes was determined in order to calculate invasion efficacy. At 48h culture supernatant was collected, and the amount of circumsporozoite protein determined by ELISA, parasitaemia was calculated and cells were processed for RNA preparation. Expression of csp gene was quantified using Real time RT-PCR. There was an increase in parasite growth when treated with lower anti-CSP-mAb concentration, which was associated with lower csp expression, while 1mug/ml anti-CSP-mAb treatment presented a growth inhibitory effect accompanied by high csp expression.

[Evaluation of palatability of two special oral diets for institutionalized elderly diabetics, Glucerna SR vs Resource Diabet]

OBJECTIVES

To evaluate the organoleptic characteristics of two specific nutritional supplements for diabetes (Glucerna SR and Resource Suport) and compare them.

SETTING

An evaluation was made of 456 patients with Type 2 diabetes (most of them receiving OADs or insulin) from 34 centers. They were non-smoking elderly patients (mean age 73 to (71-78) admitted to nursing homes or homes for the aged distributed all over the Spanish territory.

INTERVENTIONS

Palatability was studied using a modified wine tasting scale assessing 6 parameters (appearance, smell, body, sweetness, aftertaste and taste) that were scored individually, with a total score ranging from 0 (most unfavorable) to 20 (most favorable). Each brand was evaluated in two flavors (vanilla and strawberry) according to a crossover, double-blind design.

RESULTS

A total of 906 evaluable observations were made, and highly statistically significant differences favorable to Glucerna RS were found in all parameters considered both absolutely and relatively, exception for sweetness, for which statistical significance was not reached because it was relatively evaluated. No statistical differences were found between the two flavors (vanilla and strawberry). The only significant confusing factor found was age; the older the age, the more the differences were noted between the two brands.

CONCLUSIONS

Glucerna SR has a better flavor than Resource Suport for institutionalized elderly diabetic patients.

Conventional stepwise vs. vital capacity rapid inhalation induction at two concentrations of sevoflurane

BACKGROUND AND OBJECTIVE

A multicentre study was conducted to compare three methods of inhalation induction with sevoflurane in adult premedicated patients.

METHODS

One-hundred-and-twenty-five adult patients of ASA I-II were scheduled for short elective surgical procedures (< 90 min) under general anaesthesia with spontaneous ventilation of the lungs via a laryngeal mask airway. Patients were randomly assigned to one of three groups: conventional stepwise inhalation induction group (Group C) or vital capacity rapid inhalation induction groups at 4.5% (Group VC4.5) or at 8% sevoflurane (Group VC8). Before anaesthetic induction, fentanyl 1 micro kg(-1) was given and the face mask applied with the anaesthetic breathing system primed with sevoflurane 4.5% or 8% in the respective vital capacity groups. Loss of eyelash reflex, time to cessation of finger tapping, laryngeal mask insertion, side-effects and adequacy of induction were recorded.

RESULTS

The time to loss of eyelash reflex was significantly shorter in both vital capacity groups vs. the control group: VC8: 68 +/- 7 s; and VC4.5: 94 +/- 6.5 s vs. C: 118 +/- 6.4s (P < 0.0001). Significant differences were found in all pairwise comparisons for time to cessation of tapping: Group VC8 (62 +/- 7 s), Group VC4.5 (85 +/- 6 s) and Group C (116 +/- 6 s; P < 0.0001). The time to laryngeal mask insertion was significantly shorter in the Group VC8 (176 +/- 13 s) compared with the other two groups, Group VC4.5 (219 +/- 13 s) and Group C (216 +/- 9 s). There were no significant differences in the incidence of side-effects between the three groups.

CONCLUSIONS

Inhalation induction of anaesthesia with sevoflurane with the three techniques tested is safe, reliable and well accepted by the patients. The vital capacity rapid inhalation group primed with sevoflurane 8% was the fastest method with no relevant side-effects.

Detection of atovaquone and Malarone resistance conferring mutations in Plasmodium falciparum cytochrome b gene (cytb)

Clinical treatment failures of the hydroxynaphthoquinone atovaquone or its combination with proguanil (Malarone) in Plasmodium falciparum malaria has been recently documented. These events have been associated to single nucleotide polymorphisms (SNPs) in the parasite cytochrome b gene (cytb). In this report we describe a set of nest PCR-RFLP methods developed for the fast detection of all known cytb mutations associated to resistance to these drugs. The methods were successfully applied for the analysis of phenol-chloroform extracted DNA samples from patients not cured by Malarone, and from an established parasite clone. Further, the protocol for the detection of the A803C mutation was applied to 164 DNA field samples extracted through crude methanol-based protocols, originated from several malaria settings. The PCR-RFLP methods here presented can be used as a valuable for the clinical detection and study of Malarone and atovaquone P. falciparum resistance.

[Etiopathogenic factors in colorectal cancer. Nutritional and life-style aspects. 2]

INTRODUCTION

Colorectal Cancer (CRC) is more prevalent in the countries that have an occidental type diet (rich in meat, animal fat, and refined carbohydrates and poor in fibre). Genetic differences among the various populations do not seem to be very important regarding this issue. Several geographic areas are suffering a growing rise in incidence that seems to be related to a greater local prosperity and a concomitant occidentalization of their diet.

NUTRITIONAL FACTORS

High fibre content in food has traditionally been considered as a protector factor against CRC because of multiple epidemiological studies; clinical trials have not been able to confirm it maybe due to methodological problems. Vegetables in general more than fruit, seem to have a certain protective effect, among the former, cruciferous vegetables and garlic should be highlighted. Red or processed meat seems to enhance risk, meanwhile it is not clear for white meat and fish seems to be protective. Ingestion of a high-calorie diet, overweight and the total contents of fat in diet seem to be related to a rise in the incidence of CRC; nowadays the possible protective effect of mono and polyunsaturated fatty acids (particularly the n-3) is starting to be considered. Among micronutrients calcium, vitamin D, folates, flavonoids, antioxidant vitamins (A, C and E) and selenium can be protective meanwhile iron may enhance risk.

STYLE OF LIFE FACTORS

Tobacco seems to be an important risk factor for CCRC even for those who use it moderately. Alcohol (specially liquors and beer) seems to be a direct risk factor also, in addition to its co-carcinogenic effect with tobacco. Physical exercise is increasingly been considered as a protective factor. Industrial workers who are in contact for many years with inorganic dust coming from plastic substances and fuel oil could have a greater risk of developing CRC.

CONCLUSIONS

A vegetable rich, red meat and fat poor diet seems to be ideal to avoid CRC. It is convenient to do exercise on a regular basis and to avoid overweight and the use of tobacco and alcohol. Protection against industrial waste substances is also important.

Follow-up of anti-Aspergillus IgG and IgA antibodies in bone marrow transplanted patients with invasive aspergillosis

A total of 89 patients at risk for, or with invasive aspergillosis (IA) were recruited from bone marrow transplantation (BMT) units in two Lisbon hospitals, and followed for 2(1/2) years to monitor their immune response. Of these patients, six developed probable IA, from which five died. The presence of serum IgG or IgA antibodies against seven Aspergillus recombinant antigens was assessed in patients with IA, using an enzyme-linked immunosorbent assay (ELISA). In parallel, the serum levels of galactomannan (GM) were also monitored, using the Platelia Aspergillus kit (Sanofi Pasteur, Marnes-la-Coquette, France). Superoxide dismutase (Sod) and 94 kDa were the most immunogenic antigens for IgA, while the IgG pattern of recognition changed from patient to patient. From our results we conclude that although follow-up of antibodies against these antigens should not be used as a diagnostic method, patients with IA do produce an immune response that may influence disease outcome.

[Etiopathogenic factors in colorectal cancer. Genetic and clinical features (first of 2 parts)]

INTRODUCTION

Colorectal Cancer (CRC) is the second cause of death in Spain, reaching the first place in non-smoking population. It is also the tumour with the greatest one-year incidence. The last few years some reduction in its incidence along with a greater 5-year average survival has been observed.

PATHOGENESIS

Most CRCs develop from benign polyps. Vogelstein's hypothesis suggests an orderly progression from normal mucosa, to a small polyp, to a large polyp and finally to a CRC. In this progression transforming cells will be increasingly charged with molecular alterations.

GENETIC FACTORS

20% of CRCs have a genetic background although only a fourth of these are genetically based. The APC (or FAP) gene mutation is one of the earlier events that can be seen in tumour progression. When this mutation appears in the germ line it renders Familial Adenomatose Polyposis Syndrome (that evolves to CRC in a 100% of cases) or to the Gardner Syndrome (if it has extracolonic expressions). The p53 mutation is a late event in cellular transformation but it makes a rapid accumulation of mutations an easier process and it confers advantages for survival of the tumour cells. Mutations in the genes implicated in microsatellite instability are related to DNA error repair; their clinical correlates are the Lynch I and II syndromes. Other important genes related to CRC are DCC and ras. CLINICAL FACTORS: Inflammatory Bowel Disease (particularly Crohn's disease) is the most important clinical factor, it may enhance basal risk 30 times. Other risk factors are: previous malignant conditions, pelvic irradiation and previous surgery (cholecystectomy and ureterosigmoidostomy). The endocrinologic factors have a rising importance and so hormonal substitution therapy for menopause and multiparity can provide some protection. The use of NSAIDs can also be protective (specially COX-2 inhibitors).

CONCLUSIONS

It is important that people who are identified as having a high risk for developing a CRC are subjected to a strict clinical and endoscopic follow-up in order to be able to identify an incipient tumour or to practice prophylactic surgery. The use of hormonal substitution therapy or anti COX-2 NSAIDs can be future useful chemoprophylactic agents.

[Nutritional and metabolic status and dietetic evaluation in institutionalized elderly patients with non-insulin-dependent diabetes mellitus]

OBJECTIVE

To evaluate nutritional status and blood glucose level according to type of diet followed by elderly (> 65 years old) institutionalised patients with non insulin dependent diabetes mellitus (NIDDM).

METHODS

A data collection questionnaire was administered to the staff of 80 Spanish geriatric facilities participating in this one-day cross-sectional study. Data collected included: age, gender, history of previous glucose control, type of antidiabetic treatment, body mass index (BMI), nutritional risk index (NRI), type of diet with patient's preference, nutritional status evaluation and biochemical parameters.

RESULTS

Data from a total of 486 institutionalised elderly people (66.5% female) were collected with a mean +/- SD age of 80.8 +/- 7.5. Had a diabetic diet 93.3% of patients with no gender differences 55.7% were on oral antidiabetic treatment (53.9% females and 58.9% males, ns) and 24.7% on insulin therapy (24.5% females and 26.4% males, ns). Physical activity was presented in 86% of people with no gender differences. Exercise was practiced by people younger, 78.8 +/- 7.9 years, versus walking, 80.4 +/- 7.6 years or resting 82.1 +/- 7.3 years, p < 0.05. Both nutritional indexes, BMI and NRI, were equivalent in men and in women; 28.5 +/- 10.7 vs 28.1 +/- 7.6 and 103.5 +/- 12.9 vs 104.1 +/- 11.4, respectively. History glucose control was good in 68.8% of the sample with a trend towards significance between sexes (62.7% males, 71.7% females, p = 0.07) and significant differences according to type of diet; 70.7% diabetic versus 37.0% free diet, p = 0.0006). Eating behaviors (appetite and meal completeness) were similar in both males and females and in diabetic or free diet groups. Also, no differences were observed in patient preferences about diet according to type of diet (71% of diabetic patients always or almost always liked their food versus 82% of free diet patients) and either nutritional status (9.3% vs 15.6% in status I, 10.9% vs 12.5% in level II and 79.9% vs 71.9% in status III, respectively). The NRI, cholesterol, albumin and triglyceride levels were significantly higher in patients with high fat rate supplemented dietary intake than other supplemented diets.

CONCLUSIONS

A high proportion of patients on a diabetic diet was observed in this study with no gender differences. Elderly NIDDM institutionalised patients on a diabetic diet showed a greater good history glucose control than patients on a free diet. Diabetic diet preference by these subjects is similar than free diet. A better nutritional risk control was shown in patients with high fat rate supplemented diet.

[Evaluation of nutritional risk in ambulatory elderly patients]

OBJECTIVE

The purpose of this study was to evaluate the nutritional risk in ambulatory elderly people (> or = 65 years old) and determine influential factors.

METHODS

A questionnaire was provided to 400 Spanish pharmacists to gather data from ambulatory elderly people in a one-visit prospective study. Data collected included: age, gender, body mass index, environment and nutritional assessment using the Nutrition Screening Initiative panel, a subjective nutritional evaluation and nutritional therapy. ANOVA and Mann-Whitney tests were used to evaluate differences and correlations. Logistic regression analysis was used to calculate association with risk factors.

RESULTS

Data were collected from 1320 elderly subjects (60.0% female, mean +/- SD, age = 75.6 +/- 7.4). Moderate to high nutritional risk was present in 79.1%, without gender differences, and 18.6% were undergoing nutritional therapy of whom 93% consumed a complementary enteral diet. The following nutritional risk factors were identified (Odds ratio -95% confidence interval-): having three or more glasses of beer or wine in men (10.70, -6.11 to 18.70-), eating usually alone for women (1.96, -1.52 to 2.52-) and physical weakness for cooking, shopping or feeding in women (1.7, -1.34 to 2.16-). The assessment of nutritional status with the Nutrition Screening Initiative panel showed a linear significant correlation with age (p < 0.01). There was poor correlation between the objective (panel) and subjective evaluations (kappa index, 0.0822). The environment was not associated with nutritional status, but women showed a poorer subjective nutritional valuation than men (p < 0.001). Although chronic diseases and drug therapy are usually the most frequent risk factors, in our subjects, alcohol consumption was the most frequent risk factor. Poor fitness showed a very close association with a moderate to high nutritional risk. There is a high rate of elderly people at risk and a very low percentage of subjects undergoing nutritional therapy.

CONCLUSIONS

The moderate to high nutritional risk rate in ambulatory Spanish elderly persons is higher than expected. Both physical and social issues influence nutritional status. Awareness of the high rate of nutritional risk, should prompt consideration of early, appropriate therapy to prevent malnutrition and deteriorating quality of life.

Risks and benefits of replacing protease inhibitors by nevirapine in HIV-infected subjects under long-term successful triple combination therapy

OBJECTIVE

To analyse the safety and efficacy of replacing the protease inhibitor (PI) by nevirapine (NVP) in subjects experiencing a long-term control of virus replication under a triple PI-containing antiretroviral combination.

DESIGN

Prospective evaluation of 138 HIV-positive subjects with plasma viral load below 50 HIV-RNA copies/ml for the last 6 months under a triple PI-containing regimen, who were randomly assigned to either replace the PI by NVP (n = 104) or continue on the same treatment (n = 34).

METHODS

Viral load, CD4 count, lipid profile, body-shape features, and quality of life parameters were all assessed at the time of randomization and every 3 months thereafter.

RESULTS

In an intent-to-treat analysis, a rebound in viral load occurred in 11% of subjects during the first 6 months after replacing the PI by NVP, whereas it appeared in 29% of those who remained on PI (P = 0.007). Treatment failure was related to lack of adherence in 90% of subjects on PI, but only in 22% of those receiving NVP (P = 0.006). The CD4 cell count outcome did not differ significantly comparing both groups at 6 months, although in patients receiving NVP an average reduction of 35 x 10(6) cells/l was observed, whereas in those on PI a positive trend was still recorded (+54 x 10(6) cells/l). At the time of randomization, 77.5 and 57.5% of subjects had cholesterol and triglyceride values above 200 mg/dl, respectively. No significant changes in the lipid profile were observed in any of the groups thereafter. Body-shape abnormalities were recorded in 70% of persons at the time of randomization, and partially reversed at 6 months in 50% of subjects who replaced the PI by NVP. A quality of life score recorded a significant improvement in subjects who switched to NVP compared with those who continued on PI.

CONCLUSIONS

The replacement of PI by NVP seems to be safe both virologically and immunologically, provides a significant improvement in the quality of life and in half of patients ameliorate lipodystrophic body-shape changes at 6 months, although serum lipid abnormalities still remain unmodified.

Chylopericardium of neoplastic aetiology

Here we present the case of a 30-year-old man diagnosed with a dysgerminoma with mediastinal involvement, who developed an isolated chylopericardium during treatment. The purpose of this paper is to review the etiology, diagnosis and new approaches to the treatment of chylopericardium.