Dietary biomarkers-an update on their validity and applicability in epidemiological studies

The aim of this literature review was to identify and provide a summary update on the validity and applicability of the most promising dietary biomarkers reflecting the intake of important foods in the Western diet for application in epidemiological studies. Many dietary biomarker candidates, reflecting intake of common foods and their specific constituents, have been discovered from intervention and observational studies in humans, but few have been validated. The literature search was targeted for biomarker candidates previously reported to reflect intakes of specific food groups or components that are of major importance in health and disease. Their validity was evaluated according to 8 predefined validation criteria and adapted to epidemiological studies; we summarized the findings and listed the most promising food intake biomarkers based on the evaluation. Biomarker candidates for alcohol, cereals, coffee, dairy, fats and oils, fruits, legumes, meat, seafood, sugar, tea, and vegetables were identified. Top candidates for all categories are specific to certain foods, have defined parent compounds, and their concentrations are unaffected by nonfood determinants. The correlations of candidate dietary biomarkers with habitual food intake were moderate to strong and their reproducibility over time ranged from low to high. For many biomarker candidates, critical information regarding dose response, correlation with habitual food intake, and reproducibility over time is yet unknown. The nutritional epidemiology field will benefit from the development of novel methods to combine single biomarkers to generate biomarker panels in combination with self-reported data. The most promising dietary biomarker candidates that reflect commonly consumed foods and food components for application in epidemiological studies were identified, and research required for their full validation was summarized.

Mycotoxin Exposure and Renal Cell Carcinoma Risk: An Association Study in the EPIC European Cohort

BACKGROUND

Mycotoxins have been suggested to contribute to a spectrum of adverse health effects in humans, including at low concentrations. The recognition of these food contaminants being carcinogenic, as co-occurring rather than as singularly present, has emerged from recent research. The aim of this study was to assess the potential associations of single and multiple mycotoxin exposures with renal cell carcinoma risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.

METHODS

Food questionnaire data from the EPIC cohort were matched to mycotoxin food occurrence data compiled by the European Food Safety Authority (EFSA) from European Member States to assess long-term dietary mycotoxin exposures, and to associate these with the risk of renal cell carcinoma (RCC, n = 911 cases) in 450,112 EPIC participants. Potential confounding factors were taken into account. Analyses were conducted using Cox's proportional hazards regression models to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs) with mycotoxin exposures expressed as µg/kg body weight/day.

RESULTS

Demographic characteristics differed between the RCC cases and non-cases for body mass index, age, alcohol intake at recruitment, and other dietary factors. In addition, the mycotoxin exposure distributions showed that a large proportion of the EPIC population was exposed to some of the main mycotoxins present in European foods such as deoxynivalenol (DON) and derivatives, fumonisins, Fusarium toxins, Alternaria toxins, and total mycotoxins. Nevertheless, no statistically significant associations were observed between the studied mycotoxins and mycotoxin groups, and the risk of RCC development.

CONCLUSIONS

These results show an absence of statistically significant associations between long-term dietary mycotoxin exposures and RCC risk. However, these results need to be validated in other cohorts and preferably using repeated dietary exposure measurements. In addition, more occurrence data of, e.g., citrinin and fumonisins in different food commodities and countries in the EFSA database are a prerequisite to establish a greater degree of certainty.

Mycotoxin exposure and human cancer risk: A systematic review of epidemiological studies

In recent years, there has been an increasing interest in investigating the carcinogenicity of mycotoxins in humans. This systematic review aims to provide an overview of data linking exposure to different mycotoxins with human cancer risk. Publications (2019 and earlier) of case-control or longitudinal cohort studies were identified in PubMed and EMBASE. These articles were then screened by independent reviewers and their quality was assessed according to the Newcastle-Ottawa scale. Animal, cross-sectional, and molecular studies satisfied criteria for exclusion. In total, 14 articles were included: 13 case-control studies and 1 longitudinal cohort study. Included articles focused on associations of mycotoxin exposure with primary liver, breast, and cervical cancer. Overall, a positive association between the consumption of aflatoxin-contaminated foods and primary liver cancer risk was verified. Two case-control studies in Africa investigated the relationship between zearalenone and its metabolites and breast cancer risk, though conflicting results were reported. Two case-control studies investigated the association between hepatocellular carcinoma and fumonisin B1 exposure, but no significant associations were observed. This systematic review incorporates several clear observations of dose-dependent associations between aflatoxins and liver cancer risk, in keeping with IARC Monograph conclusions. Only few human epidemiological studies investigated the associations between mycotoxin exposures and cancer risk. To close this gap, more in-depth research is needed to unravel evidence for other common mycotoxins, such as deoxynivalenol and ochratoxin A. The link between mycotoxin exposures and cancer risk has mainly been established in experimental studies, and needs to be confirmed in human epidemiological studies to support the evidence-based public health strategies.

Mycotoxin exposure assessments in a multi-center European validation study by 24-hour dietary recall and biological fluid sampling

The European Food Consumption Validation (EFCOVAL) project includes 600 men and women from Belgium, the Czech Republic, France, the Netherlands, and Norway, who had given serum and 24-hour urine samples, and completed 24-hour dietary recall (24-HDR) interviews. Consumption, according to 24-HDR, was matched against the European Food Safety Authority (EFSA) databases of mycotoxin contaminations, via the FoodEx1 standard classifications, producing an indirect external estimate of dietary mycotoxin exposure. Direct, internal measurements of dietary mycotoxin exposure were made in serum and urine by ultra-performance liquid chromatography coupled to tandem mass spectrometry. For the first time, mycotoxin exposures were thoroughly compared between two 24-HDRs, and two 24-hour urine samples collected during the same days covered by the 24-HDRs. These measurements were compared to a single-time point serum measurement to investigate evidence of chronic mycotoxin exposure. According to 24-HDR data, all 600 individuals were exposed to between 4 and 34 mycotoxins, whereof 10 found to exceed the tolerable daily intake. Correlations were observed between two time points, and significant correlations were observed between concentrations in serum and urine. However, only acetyldeoxynivalenol, ochratoxin A, and sterigmatocystin were found to have significant positive correlations between 24-HDR exposures and serum, while aflatoxin G1 and G2, HT-2 toxin, and deoxynivalenol were associated between concurrent 24-HDR and 24-hour urine. Substantial agreements on quantitative levels between serum and urine were observed for the groups Type B Trichothecenes and Zearalenone. Further research is required to bridge the interpretation of external and internal exposure estimates of the individual on a time scale of hours. Additionally, metabolomic profiling of dietary mycotoxin exposures could help with a comprehensive assessment of single time-point exposures, but also with the identification of chronic exposure biomarkers. Such detailed characterization informs population exposure assessments, and aids in the interpretation of epidemiological health outcomes related to multi-mycotoxin exposure.

[Dyspnea and cardia cancer, an unusual etiology]

CASE REPORT

a 63-year old man, followed for a metastatic cardia cancer, develop a pericardial effusion with sign of pre-tamponade. A CT scanner suggests the presence of a gastro- esophageal-pericardial fistula. A surgical drainage brings a purulent fluid, infected by a polymicrobial flora. Despite early antibiotics with vancomycin and piperacillin-tazobactam, the patient dies five days after the drainage.

DISCUSSION

purulent pericarditis associated with gastrointestinal neoplasia may be due to sepsis or a proximity invasion . The diagnosis is based on ultrasound and pericardiocentesis. The most commonly involved organism is Streptococcus pneumoniae. The treatment involves intravenous antibiotics, pericardial drainage and intrapericardial instillation of antibiotics. The mortality rate remains high, especially in cases associated with gastrointestinal neoplasia.

Orbital wall infarction in child with sickle cell disease

We present the case of a 17-year-old boy, known with homozygous sickle cell disease, who was admitted because of generalised pain. He developed bilateral periorbital oedema and proptosis, without pain or visual disturbances. In addition to hyperhydration, oxygen and analgesia IV antibiotics were started, to cover a possible osteomyelitis. Patients with sickle cell disease are at risk for vaso-occlusive crises, when the abnormally shaped red blood cells aggregate and block the capillaries. Such a crisis typically presents at a location with high bone marrow activity, as the vertebrae and long bones. At an early age, the bone marrow is still active at other sites, for example the orbital wall, and thus infarction can also occur there. Thus, in young persons with sickle cell disease, it is important to consider orbital wall infarction in the differential diagnosis, since the approach is different from osteomyelitis. If the disease is complicated by an orbital compression syndrome, corticosteroids or surgical intervention may be necessary to preserve the vision. In our patient, an MRI of the orbitae demonstrated periorbital oedema with bone anomalies in the orbital and frontal bones, confirming orbital wall infarction. Ophthalmological examination revealed no signs of pressure on the nervus opticus. The patient recovered gradually with conservative treatment.

Fast determination of haptoglobin phenotype and calculation of hemoglobin binding capacity using high pressure gel permeation chromatography

A new and fast method for haptoglobin (Hp) phenotyping was developed based on high pressure gel permeation chromatography of hemoglobin-supplemented serum. Haptoglobin phenotypes 1-1, 2-1, and 2-2 are resolved on the difference in size of their hemoglobin-haptoglobin complexes. Results are available in less than 15 min. Results of the chromatographic typing correspond to those obtained by conventional starch gel electrophoresis. Next to the phenotyping of haptoglobin, the method allows reproducible calculation of the hemoglobin binding capacity (HBC) of human serum. Using this methodology, reference values for HBC were found to be 0. 75+/-0.25 g/l, with the lowest HBC in Hp 2-2 subjects and the highest in Hp 1-1 subjects (P<0.05). In contrast to earlier findings, the ratio HBC:Hp concentration was found to be comparable for the three Hp types. In conclusion, this method allows a rapid phenotyping in critical clinical conditions where Hp phenotyping can be useful, e.g. determining the donor's phenotype in liver transplantation.

Associations between haptoglobin polymorphism, lipids, lipoproteins and inflammatory variables

The haptoglobin allele frequencies and the phenotype distribution were determined in 741 male Caucasian workers, aged 35 to 59 years. The association of the haptoglobin polymorphism with various clinical and biochemical parameters was investigated. Furthermore a possible interaction with the apo E polymorphism on lipid and lipoprotein traits was analysed. The frequency of Hp1 and Hp2 was found to be 0.401 and 0.599, respectively. The observed distribution of Hp types (Hp 1-1, 15.5%; Hp 2-1, 49.3%; Hp 2-2, 35.2%) was in Hardy-Weinberg equilibrium. Age, body mass index, smoking, alcohol intake and blood pressure were comparable between the three Hp groups. Subjects with Hp 2-2 had significantly higher serum total and free cholesterol concentration compared to those in other haptoglobin types (P = 0.006 and P = 0.003). Similarly, apo B levels were significantly higher among Hp 2-2 individuals (P = 0.02). No significant differences were demonstrated between the Hp phenotypes in HDL cholesterol, apo A-I, apo E, Lp(a), cholesteryl esters, fibrinogen and C-reactive protein concentrations, although for the latter an increase was noticed in Hp 2-2. The effects of Hp type and apo E type on Lp(a) and on free cholesterol levels were found to be significantly multiplicative, with the highest free cholesterol values observed in subjects having Hp 2-2 and the apo epsilon4 allele. Significantly lower Lp(a) levels were observed in individuals carrying Hp 1-1 and an epsilon2 allele than in subjects without the epsilon2 allele. In conclusion, haptoglobin polymorphism may play an important role in the regulation of lipoprotein metabolism and could contribute to the risk of coronary heart disease. Larger samples are needed to clarify the clinical relevance of the gene-gene (Hp-apo E) interaction on lipids and lipoproteins.

Monitoring of median nerve somatosensory evoked potentials in carotid surgery

The purpose of this study was to compare median somatosensory evoked potentials (SEP) in patients undergoing carotid endarterectomy (CEA) with routine shunting and nonshunting (excluding the option of selective shunting) and to evaluate the significance of a decrease in the amplitude of the cortically generated waveforms of the SEP and/or an increase in the central conduction time (CCT) on the one hand, and that of a loss of the cortical SEP, on the other. Somatosensory evoked potentials were recorded in 32 patients before, during, and after CEA with routine shunting or nonshunting. The N13 and N20 latency, the CCT, and the N20/P25 amplitude were evaluated. In addition, a meta-analysis of 15 previous studies was performed comprising a total of 3,136 patients. The intraoperative cortical SEP showed no differences between shunted and nonshunted patients, apart from the preclamping value of the N20/P25 amplitude which was lower in the nonshunted subjects. The number of patients with decreased and/or delayed cortical SEP (findings frequently used as criterion for selective shunting) was similar in the two study groups. A loss of the cortical SEP occurred in one patient operated on without an indwelling shunt. None of these patients had a new neurologic deficit after surgery. In the meta-analysis, the positive predictive value of decreased and/or delayed cortical SEP was extremely poor, that of absent cortical SEP was poor to moderate and the prevalence of new neurologic deficits was similar in patients undergoing CEA with routine shunting-nonshunting and those with selective shunting-nonshunting. Our study suggests that decreased and/or delayed cortical SEP are unreliable predictors of the neurological outcome of CEA patients and consequently an unsuitable criterion for selective shunting. The meta-analysis confirms this finding and shows that the neurologic outcome is not improved by using an indwelling shunt selectively based on SEP monitoring.

[Acute mesenteric ischemia]

Acute mesenteric ischemia is a life-threatening vascular emergency. A retrospective analysis of our patients was performed to describe the development of the various procedures of diagnostic assessment and treatment between 1970 and 1996, to show the influence on survival and to define recent standards.

PATIENTS

Between 1970 and 1996, 145 patients, 75 male and 70 female, suffering from acute mesenteric ischemia, have been treated at the Department of Surgery-University Hospital Vienna.

RESULTS

In most cases AMI was caused by arterial embolism (64.1%, n = 93) followed by arterial thrombosis (27.6%, n= 40). Venous thrombosis (3.5%, n = 5) and non-occlusive AMI (4.8%, n = 7) were rare events. Serum lactate level has been determined routinely in all patients having been admitted with acute abdomen since 1984 and turned out to be positive in 81.2% (mean value 9.81 (3.21-22.3) mmol/l). Abdominal x-ray gave only in some individual cases special hints to the advanced intestinal gangrene. Abdominal sonography led to the correct diagnostic assessment in 52 patients (= 35.8%). Angiography was in 92% conclusive for the diagnosis. Abdominal CT led to establish the correct diagnosis in > 80%. Our series with revascularisation (thrombectomy/embolectomy or bypass) has resulted in 73.8% patient survival with intestine having been maintained in the most favourable cases.

CONCLUSIONS

Early diagnostic assessment and treatment are decisive for survival. Abdominal-CT, angiography and serum-lactate constitute quick and reliable means to provide diagnosis and to judge the stage of AMI in addition to meticulous examination of patients' history, symptoms and physical conditions.

Thromboembolic complications in a patient with heparin-induced thrombocytopenia (HIT) showing cross-reactivity to a low molecular weight heparin-treatment with Org 10172 (Lomoparan)

Heparin-induced thrombocytopenia is an immuno-mediated life-threatening side effect of heparin therapy which poses difficulties in diagnosis and major therapeutic problems. Heparin must be instantly discontinued. We describe the case of a 60-year-old male patient with type II heparin-induced thrombocytopenia, complicated by progressive deep venous thrombosis and pulmonary embolism. He failed to improve when therapy was continued with a low molecular weight heparin (Fragmin) and high doses of intravenous immunoglobulins were administered. The test for heparin-dependent platelet aggregation was positive for unfractionated heparin and low molecular weight heparin, but negative for the heparinoid Org 10172. During subsequent anticoagulant therapy with Org 10172 for seven days the number of platelets increased rapidly and the patient recovered. Nine months later Org 10172 was used again in this patient for thrombosis prophylaxis without any adverse effects. In patients with heparin-induced thrombocytopenia requiring immediately acting anticoagulant therapy, Org 10172 can be considered as an effective alternative drug to unfractionated and low molecular weight heparins.

[Abdominal aortic aneurysm: surgery, indications, technique, outcome]

The fate of a patient with an abdominal aortic aneurysm] (AAA) is influenced by the risk of rupture and embolism. When the indication for operation is considered, individual associated risk factors have to be taken into account. With regard to the literature, the following recommendations concerning indication for surgery can be given: emergency surgery for symptomatic or ruptured aneurysm; elective surgery: aneurysms 5 cm diameter or growing AAA 5 mm/year, patient with acceptable individual risk for operation; asymptomatic aneurysms less than 5 cm in diameter, without growth in patients aged over 75 years and/or considerable perioperative risk should not be operated on: sonography should be done 3-monthly as a continuing control. Finally the results in our institution are presented for elective surgery: 30-day mortality 3.5%, AAA with rupture, no shock: 20%, ruptured AAA with shock 47%, respectively.

Significance of radiological diagnosis for detection and staging of inflammatory abdominal aortic aneurysm

Operative morbidity and mortality are elevated in patients with inflammatory abdominal aortic aneurysm. Preoperative identification of inflammatory abdominal aortic aneurysm. the detection of the proximal level and of adhesions to adjacent structures are important for surgical management. The sensitivity and specificity of ultrasonography and computed tomography (CT) for identification and staging in 13 patients with inflammatory abdominal aortic aneurysm were studied. Preoperative radiological diagnoses were validated by intraoperative findings. Correct identification of inflammatory abdominal aortic aneurysm could be achieved in 85% by the use of CT and in 62% by ultrasonography. The proximal level of inflammatory abdominal aortic aneurysm was correctly determined by CT in all patients and by ultrasonography in 62%. Using a transperitoneal approach, the condition was considered inoperable in two patients as a result of the suprarenal extent of the aneurysm and because of unremovable adhesions in two other cases. In the latter pair, it was impossible to predict inoperability by radiological findings. Sensitivity (85%) and specificity (100%) of standard radiological techniques to identify inflammatory changes are high. Inoperability caused by suprarenal extent could be detected correctly by routine radiological procedures. However, identification of dense adhesions appears uncertain.

F.P. Weber syndrome associated with a brachial artery aneurysm. A case report

Klippel-Trenaunay syndrome is characterized by the triad of unilateral port-wine hemangiomas, varicose veins, and hypertrophy of bone and soft tissue affecting one or more limbs. The rare F.P. Weber syndrome describes the mentioned entity and additional arteriovenous malformations. The association of an arterial aneurysm with the F.P. Weber syndrome has never been described in the current literature. A case of a brachial artery aneurysm in a patient with F.P. Weber syndrome is presented and the etiology of arterial aneurysm combined with congenital vascular abnormalities is discussed.

[Epidural electrostimulation of the spinal cord in obliterating diseases of the peripheral arteries]

Under study was the efficiency of epidural electrical stimulation of the spinal cord (ESSC) of 237 patients with obliterating diseases of the peripheral arteries. Reconstructive operations proved to be impossible in all the patients, and conservative treatment was not successful. The clinical status of 169 patients was determined as the 3rd stage, in 68 patients as the 4th stage after Fontain. The period of observation was 35.6 months at an average. High amputation was performed in 64 patients in spite of ESSC. In the other cases when the extremity could be kept safe, the intensity of pain was considerably relieved (more than 75%). We believe that ESSC can considerably relieve the intensity of the pain syndrome and improve the quality of life in patients with critical ischemia of the extremities when traditional methods of treatment are not possible.

Epidural spinal cord stimulation in the treatment of severe peripheral arterial occlusive disease

Epidural spinal cord stimulation (ESCS) has been suggested to improve microcirculatory blood flow and reduce amputation rates in patients with severe peripheral arterial occlusive disease (PAOD). Pain relief, limb salvage, and skin circulation were studied in 177 patients with ischemic pain caused by nonreconstructible PAOD who were receiving ESCS. Medical or surgical therapy had failed and vascular reconstruction was impossible in all cases. Clinical status was classified as Fontaine's stage III (chronic ischemic rest pain) in 114 patients and Fontaine's stage IV (ischemic pain and ulcers or dry gangrene) in 63 patients. PAOD was essentially due to arteriosclerosis, but 36 patients also had diabetic vascular disease. After a mean follow-up of 35.6 months, significant pain relief (> 75%) with limb salvage was achieved in 110 patients. In 11 patients with limb salvage, pain alleviation was determined to be between 50% and 70%. ESCS was ineffective in reducing pain, leading to major amputation in 56 patients. The cumulative limb salvage rate was 66% at 4 years. The systolic ankle/brachial blood pressure index did not change under stimulation. TcPO2 was assessed on the dorsum of the foot. Clinical improvement was associated with increased TcPO2, with limb salvage improving from 24.2 to 48.1 mm Hg in stage III (p < 0.02) and from 16.4 to 37.2 mm Hg in stage IV (p < 0.03) disease. A TcPO2 increase of more than 50% within the first 3 months after implantation was predictive of success. TcPO2 changes are correlated with the presence of adequate paresthesias in the painful area during the trial period.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative whole blood autotransfusion during venous thrombectomy

OBJECTIVE

Intraoperative autotransfusion is currently performed using two different systems, the relatively expensive cell-saving device washes and concentrates red cells and the more simple, economical total disposable device for whole blood collection and retransfusion. Some institutions prefer the cell-saving device because of previously documented side-effects of whole blood autotransfusion. As some investigators more recently reported the application of whole blood autotransfusion without clinical complications, the potential hazards of whole blood autotransfusion are now being controversially discussed.

MATERIALS AND METHODS

The potential side-effects using whole blood autotransfusion were studied in 100 patients prospectively undergoing venous thrombectomy. The effectiveness of homologous transfusion reduction was assessed in comparison with an historical patient group (n = 10, control group).

RESULTS

In the study population a mean of 1064 ml shed blood (67% of total blood loss) was retransfused. A mean of 247 +/- 292 ml of homologous blood was transfused in the study group. In contrast, homologous blood requirement was significantly higher (1056 +/- 659 ml, p < 0.006) in the control group. No hematologic, hemeostatic, renal or pulmonary complications occurred after intraoperative whole blood autotransfusion.

CONCLUSIONS

Whole blood autotransfusion is a safe, easy and economical procedure and highly effective in reducing homologous blood transfusions and costs.

[Hamartoma of the breast]

Two cases of hamartoma of the breast are presented. The clinical findings of this benign, rare lesion are not specific. It is characterized radiologically by its typical features of a clear or heterogeneous well defined picture with radiolucent zones on mammography. Echography provides no specific picture. Histologically, the tumor is composed of normal or dysplastic mammary tissue. Surgical treatment is mandatory, an enucleation can usually be performed.

Liver plasma membrane: the source of high molecular weight alkaline phosphatase in human serum

This study presents biochemical, histochemical, morphological and immunological evidence that part of the high molecular weight alkaline phosphatase observed in the serum of patients with liver disease and particularly in cases of intrahepatic cholestasis or focal-, extrahepatic obstruction originates from the liver plasma membrane. The high molecular weight protein alkaline phosphatase complex contains several plasma membrane enzymes and behaves like a plasma membrane fragment after isopycnic density gradient ultracentrifugation in sucrose, cesium chloride and metrizamide. Electron microscopic examination revealed a triple-layered vesicle which retained alkaline phosphatase activity. Incubation of human liver cells with anti-serum against purified high molecular weight multienzyme complex resulted in fixation of antibodies on the plasma membrane as shown by positive plasma membrane fluorescence. These plasma membrane fragments in the serum are not of biliary origin.