Registered Replication Report: Schooler and Engstler-Schooler (1990)

Trying to remember something now typically improves your ability to remember it later. However, after watching a video of a simulated bank robbery, participants who verbally described the robber were 25% worse at identifying the robber in a lineup than were participants who instead listed U.S. states and capitals-this has been termed the "verbal overshadowing" effect (Schooler & Engstler-Schooler, 1990). More recent studies suggested that this effect might be substantially smaller than first reported. Given uncertainty about the effect size, the influence of this finding in the memory literature, and its practical importance for police procedures, we conducted two collections of preregistered direct replications (RRR1 and RRR2) that differed only in the order of the description task and a filler task. In RRR1, when the description task immediately followed the robbery, participants who provided a description were 4% less likely to select the robber than were those in the control condition. In RRR2, when the description was delayed by 20 min, they were 16% less likely to select the robber. These findings reveal a robust verbal overshadowing effect that is strongly influenced by the relative timing of the tasks. The discussion considers further implications of these replications for our understanding of verbal overshadowing.

Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients

Background

A trial in selected men suggested that antibiotic therapy could be an alternative to appendicectomy in appendicitis. This study aimed to evaluate antibiotic therapy in unselected men and women with acute appendicitis.

Methods

Consecutive patients were allocated to study (antibiotics) or control (surgery) groups according to date of birth. Study patients received intravenous antibiotics for 24 h and continued at home with oral antibiotics for 10 days. Control patients had a standard appendicectomy. Follow-up at 1 and 12 months was carried out according to intention and per protocol.

Results

Study and control patients were comparable at inclusion; 106 (52·5 per cent) of 202 patients allocated to antibiotics completed the treatment and 154 (92·2 per cent) of 167 patients allocated to appendicectomy had surgery. Treatment efficacy was 90·8 per cent for antibiotic therapy and 89·2 per cent for surgery. Recurrent appendicitis occurred in 15 patients (13·9 per cent) after a median of 1 year. A third of recurrences appeared within 10 days and two-thirds between 3 and 16 months after hospital discharge. Minor complications were similar between the groups. Major complications were threefold higher in patients who had an appendicectomy (P < 0·050).

Conclusion

Antibiotic treatment appears to be a safe first-line therapy in unselected patients with acute appendicitis. Registration number: NCT00469430 (http://www.clinicaltrials.gov).

Ethical and legal aspects of enteral nutrition

European ethical and legal positions with regard to EN vary slightly from country to country but are based on a common tradition derived from Graeco Roman ideas, religious thought and events of the 20th century. The Hippocratic tradition is based on 'beneficience' (do good) and 'non-maleficience' (do no harm). Religious thinking is based upon the presumption of providing food and drink by whatever means unless burden outweighs benefit. The concept of 'autonomy' (the patients right to decide) arose following in the decades after the Second World War and is enshrined in Human Rights law. The competent patient has the right to participate in decision making and to refuse treatment although the doctor is not obliged to give treatment which he or she considers futile or against the patient's interests. The incompetent patient is protected by law. The fourth principle is that of 'justice' i.e. equal access to healthcare for all. The law regards withholding and withdrawing treatment as the same. It also defines the provision of food and drink by mouth as basic care and feeding by artificial means as a medical treatment. It requires doctors to act in the best interests of the patient.

Collagen degradation products modulate matrix metalloproteinase expression in cultured articular chondrocytes

Destruction of collagen within osteoarthritic cartilage depends in part on collagen-degrading matrix metalloproteases (MMP). Degradative fragments of type II collagen (Col II) occur in normal and in osteoarthritic cartilage, and may contribute to regulation of matrix turnover by interfering with normal cell-matrix communication pathways. Therefore, the effects of different types of collagen fragments on mRNA and protein levels of MMP-2, MMP-3, MMP-9, and MMP-13 in cultured bovine articular knee chondrocytes and explants were examined. Primary chondrocytes and explants were incubated with fragments from whole cartilage collagen matrix (Colf) and from purified type II collagen (Col2f), or with a synthetic 29-mer peptide representing the amino-terminal domain of type II collagen (Ntelo). Gelatin zymography revealed increases of proMMP-2, a shift towards active MMP-2 and increases in proMMP-9, depending on the type of fragment. In situ hybridization of cartilage sections displayed MMP-3 mRNA in virtually all cells. Moderate to strong increases in MMP-2, MMP-3, MMP-9, and MMP-13 mRNA levels were detected by quantitative PCR. The results demonstrate stimulating effects of collagen fragments on both mRNA and/or protein from MMP -2, -3, -9, and -13, and suggest a novel mechanism of MMP induction and activation that includes a particular role for N-telo in controlling catabolic pathways of matrix turnover.

Relationships between self-reported health related quality of life and measures of standardized exercise capacity and metabolic efficiency in a middle-aged and aged healthy population

BACKGROUND

The purpose of this study was to evaluate to what extent self-reported health related quality of life (HRQL), assessed by the Swedish standard version of the Medical Outcome Study Short-Form 36 (SF-36), is related to measured exercise capacity and metabolic efficiency in a cohort of healthy subjects from the Gothenburg area of Sweden.

MATERIAL AND METHODS

Individuals were invited to take part in the evaluation where HRQL was compared with the maximal power output expressed in Watts assessed during a standardized treadmill test with incremental work loads. Whole body respiratory gas exchanges (CO2/O2) were simultaneously measured. Estimate of metabolic efficiency was derived from oxygen uptake per Watt produced (ml O2/min/W) near maximal work.

RESULTS

The health status profile in the current population largely agreed with normative data from an age- and gender-matched reference group, although some measured scores were slightly better than reference scores. Males and females had a similar relationship between energy cost (ml O2/min) for production of maximal work (W), while the regressions for maximal exercise power and age were significantly different between males and females (p < 0.01). The overall metabolic efficiency was the same in individuals between 40 and 74 years of age (10.4 +/- 0.07 ml O2/min/ Watt). Maximal exercise power was only related to the SF-36 subscale physical functioning (PF), but unrelated to other physical subscales such as role limitations due to physical problems, good general health and vitality. There was also a discrepancy between measured maximal power and PF in many subjects, particularly in males who experienced either intact or severely reduced PF.

CONCLUSIONS

Our results demonstrate that simultaneous measurements of self-reported and objective measures of PF should add a more integrated view for evaluation of therapeutic effectiveness, since the overall correlation was poor between objective and subjective scores among individuals.

Heparan sulfates and coxsackievirus-adenovirus receptor: each one mediates coxsackievirus B3 PD infection

Amino acid exchanges in the virus capsid protein VP1 allow the coxsackievirus B3 variant PD (CVB3 PD) to replicate in decay accelerating factor (DAF)-negative and coxsackievirus-adenovirus receptor (CAR)-negative cells. This suggests that molecules other than DAF and CAR are involved in attachment of this CVB3 variant to cell surfaces. The observation that productive infection associated with cytopathic effect occurred in Chinese hamster ovary (CHO-K1) cells, whereas heparinase-treated CHO-K1 cells, glucosaminoglycan-negative pgsA-745, heparan sulfate (HS)-negative pgsD-677, and pgsE-606 cells with significantly reduced N-sulfate expression resist CVB3 PD infection, indicates a critical role of highly sulfated HS. 2-O-sulfate-lacking pgsF-17 cells represented the cell line with minimum HS modifications susceptible for CVB3 PD. Inhibition of virus replication in CHO-K1 cells by polycationic compounds, pentosan polysulfate, lung heparin, and several intestinal but not kidney HS supported the hypothesis that CVB3 PD uses specific modified HS for entry. In addition, recombinant human hepatocyte growth factor blocked CVB3 PD infection. However, CAR also mediates CVB3 PD infection, because this CVB3 variant replicates in HS-lacking but CAR-bearing Raji cells, infection could be prevented by pretreatment of cells with CAR antibody, and HS-negative pgsD-677 cells transfected with CAR became susceptible for CVB3 PD. These results demonstrate that the amino acid substitutions in the viral capsid protein VP1 enable CVB3 PD to use specific modified HS as an entry receptor in addition to CAR.

Tetracycline residues in meat and bone meals. Part 2: the effect of heat treatments on bound tetracycline residues

The stability of bound tetracycline residues during heat treatments at 133 degrees C and 100 degrees C for up to 45 min was investigated. An intermediate product from a rendering plant was mixed with bone splinters that contained bound tetracycline (TC) and chlortetracycline (CTC) residues. The mixture was heated in an autoclave at 133 degrees C for 20, 30 and 45 min and at 100 degrees C for 20 and 30 min and subsequently dried at 103 degrees C for 4 h. Two different extraction procedures with hydrochloric acid were used, one with and one without the previous sedimentation of bone particles. Tetracycline concentrations were determined by HPLC analysis before and after the heat treatment. A complete destruction of tetracyclines during heat treatment at 133 degrees C could not be demonstrated, but there was a significant decrease of TC by about 50%. CTC was less resistant to the same temperature, which brought about a reduction of 90-100%. Treatment at 100 degrees C did not bring about any reduction, except for CTC after extraction without sedimentation. The possible toxicological relevance of the findings is discussed. Further research has to be done on possible degradation products of the tetracycline derivatives.

The effect of glutamine on protein balance and amino acid flux across arm and leg tissues in healthy volunteers

BACKGROUND

Glutamine is important in nitrogen transportation and the physiological control of acid-base regulation. In addition, it has been assumed that glutamine regulates protein balance in skeletal muscles based on findings in both experimental and clinical studies. However, little information on glutamine and its effect on protein dynamics in normal individuals is available. Therefore, the aim of this study was to evaluate whether glutamine improves protein balance and uptake of various indispensable amino acids across peripheral tissue in healthy individuals.

MATERIAL AND METHODS

Standard primed constant infusions of L-[ring-2H5]phenylalanine and [ring 3,3-2H2]tyrosine (2 micromol kg(-1) h(-1)) were performed after overnight fast in five healthy male volunteers before and during infusions of a standard and a glutamine/tyrosine enriched amino acid solution. Flux measurements of amino acids (AA) including 3-methylhistidine, glucose, lactate and free fatty acids (FFA) were performed across arm and leg tissues.

RESULTS

Infusion of the standard AA solution (0.2 g N kg(-1) day(-1)) increased the net uptake of individual amino acids, but provision of the enriched solution (0.4 g N kg(-1) day(-1)) with increased amounts of glutamine and tyrosine seemed to compete unfavourably with the net uptake of other key amino acids as methionine and phenylalanine, which are indispensable in muscles for protein synthesis. Increased flux of amino acids across peripheral tissues did not influence on flux of glucose, free fatty acid and lactate.

CONCLUSIONS

Glutamine provision did neither stimulate protein synthesis nor attenuate breakdown of either globular or myofibrillar proteins in skeletal muscles of healthy volunteers.

Tetracycline residues in meat and bone meals. Part 1: methodology and examination of field samples

The incidence of tetracycline residues in commercially available samples of meat meals and meat and bone meals was investigated. Four different methods were used on each of the 87 samples from nine different rendering plants in Germany: examination using a screening fluorescence test; examination by high performance liquid chromatography analysis using three different extraction procedures (succinate buffer, hydrochloric acid, hydrochloric acid after sedimentation of bone particles). Tetracyclines were found in 100% of the samples by one or more of the extraction procedures. The highest concentrations found in meat meals were 2048 microgkg(-1), 1393 microgkg(-1) and 608 microgkg(-1) for oxytetracycline, tetracycline and chlortetracycline, respectively. In meat and bone meals the highest concentrations were 2295 microg oxytetracycline kg(-1) 848 microg tetracycline kg(-1) and 1274 microg chlortetracycline kg(-1). The extraction after sedimentation was the most effective of the applied extraction procedures and exposed the highest total tetracycline concentrations. The results of this investigation showed that considerable amounts of tetracyclines have to be expected in field samples. Further research has to be done on the heat stability of bound tetracycline residues.

Oxygen consumption in patients with hyperthyroidism before and after treatment with beta-blockade versus thyrostatic treatment: a prospective randomized study

OBJECTIVE

To evaluate randomly the effect of thyrostatic treatment (tiamazole) versus selective (metoprolol) and nonselective beta-blockade (propranolol) on whole-body energy metabolism in women with hyperthyroidism.

SUMMARY BACKGROUND DATA

beta-blockade is used as an alternative to thyrostatic drugs in the preoperative treatment of patients with hyperthyroidism. beta-blockers have well-established symptomatic effects, but in contrast to antithyroid drugs beta-blockade is thought to lack direct effects on the increased metabolism in hyperthyroidism.

METHODS

Whole-body oxygen consumption and carbon dioxide production was measured in a semiopen canopy system with paramagnetic O2 and infrared CO2 sensors. A constant flow generator and the gas-dilution method for calculation of gas flow were used. Anabolic parameters were body weight, triceps skinfold, and arm muscle circumference.

RESULTS

Tiamazole normalized oxygen consumption and induced signs of anabolism with improved nutritional state. Metroprolol did not affect oxygen consumption. Propranolol reduced elevated oxygen consumption by 54%. Body weight and other anthropometric assessments were stable after specific and nonspecific beta-blockade, which also led to symptomatic relief in approximately 90% of the patients.

CONCLUSION

Tiamazole was the most effective drug to oppose the adverse effects of hyperthyroidism. Therefore, thyrostatic agents are recommended for preoperative treatments of patients with severe catabolic hyperthyroidism. Whenever beta-blockers are chosen for treatment of hyperthyroidism, propranolol (beta 1 + beta 2) has an advantage because it reduces the metabolic rate, whereas selective beta 1-blockade seemed to provide only symptomatic relief, related to the normalization of heart rate.

Beta-adrenoceptor activity and resting energy metabolism in weight losing cancer patients

This study was aimed at comparing the blocking of beta-adrenoceptor activity to changes in the resting energy metabolism of 10 cancer patients with progressive weight loss due to solid malignant tumours. Resting energy expenditure (REE) as well as whole body carbohydrate and fat oxidation were investigated and related to plasma substrate levels (glucose, glycerol, free fatty acids (FFA)) before and after 5 days of oral administration of specific beta1 receptor blocker (atenolol, 50 mg/day) and non-specific beta1,beta2-adrenoceptor (propranolol, 80 mg/day) blockade. The administration order of the drugs was random, and a 3-day washout period was used in all individuals between the provision of the first and the second drug in order to minimise the risk of carry-over effects. Resting measurements in the morning after an overnight fast were performed by indirect calorimetry. Atenolol treatment reduced REE by 77+/-14 kcal/day and propranolol by 48+/-13 kcal/day, respectively (P<0.05 versus pretreatment values). Whole body oxygen uptake and carbon dioxide production were decreased similarly by both atenolol and propranolol treatment (P<0.05). Carbohydrate oxidation was increased by atenolol and decreased by propranolol, whilst fat oxidation was decreased by atenolol and unchanged by propranolol. The decrease in REE, accounting for the decline in heart rate, was significantly more pronounced following treatment with propranolol compared with atenolol (P<0.05). Atenolol and propranolol had no effect on blood glucose, plasma glycerol and FFA. We conclude that wastage in cancer patients is in part explained by increased beta(1) and beta(2)-adrenoceptor activity, in part secondary to elevated cardiovascular activity as a result of anaemia, loss of cardiac contractile capacity and altered host metabolism.

A model of computation in neocortical architecture

We propose that the specific architecture of the neocortex reflects the organization principles of neocortical computation. In this paper, we place the anatomically defined concept of columns into a functional context. It is provided by a large-scale computational hypothesis on visual recognition, which includes both, rapid parallel forward recognition, independent of any feedback prediction, and a feedback controlled refinement system. Short epochs of periodic clocking define a global reference time and introduce a discrete time for cortical processing which enables the combination of parallel categorization and sequential refinement. The presented model differs significantly from conventional neural network architectures and suggests a novel interpretation of the role of gamma oscillations and cognitive binding.

The role of glucose, long-chain triglycerides and amino acids for promotion of amino acid balance across peripheral tissues in man

The role of amino acids, glucose and lipids in improving amino acid balance in peripheral tissues was evaluated. Primed constant infusion of L-[ring-2H5]phenylalanine in combination with flux measurements of glucose, free fatty acids (FFA) and amino acids across arm and leg tissues were applied in male volunteers after an overnight fast with subsequent primed constant infusions of amino acids (0.2 g N kg-1 body weight day-1), long-chain triglycerides (0.98-1.079 g kg-1 day-1) and glucose (3.13-3.62 g kg-1 day-1). Amino acids and phenylalanine tracer infusion continued for 6 h; the lipid infusion was provided during 2-6 h from the start, and glucose infusion was provided between 4 and 6 h. Flux measurements were performed at steady state before the next infusion started. Arterial concentrations of infused substrates increased during provision, but remained constant thereafter. Plasma insulin increased when glucose was provided, whereas insulin-like growth factor (IGF) I was unchanged during all infusions. Blood flow was unchanged in arm tissue during all infusions, while leg blood flow increased during fat and glucose infusion. FFA and glucose balance were unchanged during amino acid infusion but improved during lipid and glucose infusions. Amino acid balance was negative across arm and leg tissues in the fasted state, but reached balance during amino acid infusion. This effect was equally dependent on protein synthesis and protein degradation without any contribution from lipids and glucose. 3-Methylhistidine release from tissues was not influenced by any substrate. Our results suggest that extracellular amino acid concentrations determine amino acid balance across peripheral tissues independently of non-protein calories, insulin and IGF-I.

Protection of metabolic and exercise capacity in unselected weight-losing cancer patients following treatment with recombinant erythropoietin: a randomized prospective study

This study was aimed at evaluating whether anemia could be prevented in unselected weight-losing cancer patients on anti-inflammatory treatment by early and prophylactic treatment with recombinant human erythropoietin (rhEPO) and whether such a benefit could be translated into improved physical function and metabolic efficiency. One hundred eight cancer patients who experienced progressive cachexia due to solid, mainly gastrointestinal tumors were randomized to receive twice daily a cyclo-oxygenase inhibitor (controls; indomethacin, 50 mg twice a day) or indomethacin and erythropoietin, provided on individual basis to prevent development of progressive anemia (study patients; indomethacin, 50 mg twice a day plus rhEPO; range, 12,000-30,000 units per week). All patients were treated and followed up until death or to preterminal stage. Biochemical tests (blood, liver, kidney, and thyroid), nutritional state assessment (food intake and body composition), and exercise testing with simultaneous measurements of respiratory gas exchanges before and during exercise were performed before institution of treatments and then at regular intervals during the treatment period (2-30 months after start). Study and control patients did not differ in survival. rhEPO prevented development of anemia during the entire observation period. This was associated with a significantly more preserved maximum exercise capacity in study patients compared to control patients during the follow-up period (101 +/- 10 versus 66 +/- 6 W; P < 0.0001), based on more effective ventilation and whole-body respiratory gas exchanges. These improvements were also evident when exercise performance was normalized to lean body mass, an indirect measure of the skeletal muscle mass. The metabolic efficiency, expressed as oxygen uptake per watt produced, was also significantly preserved in rhEPO-treated patients compared to controls (14.1 +/- 1.1 versus 16.3 +/- 0.9 ml O2/W, P < 0.05). Our results demonstrate that institution of early and prophylactic rhEPO treatment to patients with progressive cancer prevents development of tumor-induced anemia. This achievement was associated with a better preserved exercise capacity, which is explained in part by improved whole-body metabolic and energy efficiency during work load.

[Ethical questions and marginal problems in assisted reproduction]

Assisted reproduction is subject of ethical controversies as it depends very much on our understanding of both the human being and of individual dignity. The ethical and technical boundaries have changed very much over the last decades. The main focus of the debate until the eighties was to avert manipulation and hazards to human health (surrogate mothers, chimeras). Speculations which exceeded the real possibilities of biomedicine were common. Finally the technology was restrained by an ethical and legal framework: in Germany the parliament passed the "Embryo protection act" (Embryonenschutzgesetz). Since the beginning of the nineties the focus of ethical problems has shifted towards the legal overregulation, which is in fact hampering the application of helpful and humane technology, like for instance preimplantation diagnosis. Ethical discussion and analysis should be directed at regulations that promote the dignity of the individual as well as the search of consensus positions, which can live up to the realities of a pluralistic society.

Effects of amino acids on synthesis and degradation of skeletal muscle proteins in humans

Synthesis and degradation of globular and myofibrillar proteins across arm and leg muscles were examined during stepwise increased intravenous infusion of amino acids (0.1, 0.2, 0.4, and 0.8 g N.kg-1.day-1) to healthy volunteers. Protein dynamics were measured by a primed constant infusion of L-[ring-2H5]phenylalanine and the release of 3-methylhistidine from skeletal muscles. Arterial concentrations and flux of glucose, lactate, and free fatty acids were unchanged despite increasing concentrations of plasma amino acids from 2.6 to 5.7 mM. Plasma insulin, insulin-like growth factor I (IGF-I), and plasma concentrations of IGF-I-binding proteins-1 and -3 remained at fasting levels throughout the investigation. Amino acid infusion caused a significant uptake of the majority of amino acids across arm and leg tissues, except tyrosine, tryptophan, and cysteine, probably due to low concentrations of these amino acids in the formulation. The balance of globular proteins improved significantly (P < 0.01) due to stimulation of synthesis and attenuation of degradation across arm and leg tissues, despite insignificant uptake of tyrosine, tryptophan, and cysteine. Degradation of myofibrillar proteins was uninfluenced by provision of amino acids. The results demonstrate that neither insulin nor circulating IGF-I explained improved protein balance in skeletal muscles after elevation of plasma amino acids. Rather, some amino acids in themselves trigger cellular reactions that initiate peptide formation. Limited availability of some extracellular amino acids was overcome by increased reutilization of the intracellular amino acid.

Structured triglycerides were well tolerated and induced increased whole body fat oxidation compared with long-chain triglycerides in postoperative patients

BACKGROUND

It has been proposed, on the basis of animal experiments, that medium-chain triglycerides (MCT) may exert more favorable effects on whole body metabolism of injured animals than long-chain triglycerides (LCT). Therefore, the present study was designed to evaluate whether structured triglycerides are associated with increased whole body fat oxidation without promotion of ketogenesis in postoperative patients.

METHODS

A structured lipid emulsion (73403 Pharmacia, Sweden) containing medium- and long-chain fatty acids, esterified randomly to glycerol in a triglyceride structure, was used. Whole body fat oxidation was determined by indirect calorimetry in the postoperative period. Patients were randomized to receive structured lipids 1 day followed by LCT (Intralipid, Pharmacia) the next day or vice versa during 6 postoperative days. In part 1 of the study patients received fat at 1.0 g/kg per day in the presence of 80% of the basal requirement of nonprotein calories. In part 2 patients received fat at 1.5 g/kg per day in the presence of 120% of the nonprotein caloric requirement. Amino acids were always provided at 0.15 g N/kg per day.

RESULTS

Structured lipids were not associated with any side effects, were rapidly cleared from the plasma compartment, and were rapidly oxidized without any significant hyperlipidemia or ketosis. Provision of structured lipids in the presence of excess of nonprotein calories (part 2) caused a significantly higher whole body fat oxidation (2.4 +/- 0.05 g/kg per day) compared with LCT provision (1.9 +/- 0.06 g/kg per day) (p < .0001) examined in the same patients.

CONCLUSIONS

The results demonstrated for the first time in man that provision of structured triglycerides were associated with increased whole body fat oxidation in stressed postoperative patients, which is in line with the original metabolic and biochemical concept for structured triglycerides. The study provided evidence to support that structured lipids may represent a next generation of IV fat emulsions that may be clinically advantageous compared with conventional LCT emulsions in certain clinical conditions.

The effect on energy and nitrogen metabolism by continuous, bolus, or sequential infusion of a defined total parenteral nutrition formulation in patients after major surgical procedures

BACKGROUND

The role of IV infusion kinetics to explain nutrition efficiency was investigated in patients after major surgical procedures.

METHODS

IV nutrition was provided as three different infusion kinetic regimens in a randomized fashion. All patients received nonprotein calories (100% of predicted preoperative REE, 60% D-glucose, 40% fat) and amino acid nitrogen (0.2 g N/d). Group A: Nutrition was provided by sequential infusion with combined fat and amino acids during daytime and glucose alone during nighttime ("sequential infusion"). Group B: Patients received 24-hour combined infusion with fat, amino acids, and glucose (all in one mixture) ("continuous infusion"). Group C: Nutrition was provided by bolus infusions during 1 hour followed by 2 hours without any infusion ("bolus infusion").

RESULTS

The daily energy balance was negative in all groups (-318 +/- 25 kcal/d, sequential infusion; -368 +/- 25 kcal/d continuous infusion; -292 +/- 20 kcal/d, bolus infusion). Significantly different excretion patterns of nitrogen in urine occurred among the groups despite an almost identical provision of nitrogen. Continuously infused patients retained nitrogen significantly better (-0.2 +/- 0.6 g/d) compared with sequentially (-3.4 +/- 1.0 g/d) and bolus-infused patients (-2.8 +/- 0.3 g/d) (p < .01), whereas their cumulative urinary glucose excretion was significantly larger. Continuously infused patients were in cumulative nitrogen balance during the entire postoperative period, whereas the other groups were in a significantly negative nitrogen balance. Urinary 3-methylhistidine excretion was similar in all groups.

CONCLUSIONS

The breakdown of muscle proteins was not sensitive to alterations in nutrient and substrate supply. Thus improved nitrogen retention reflected entirely improved synthesis. "All-in-one" IV nutrition with prolonged infusion periods is at present the most favorable regimen considering both the nutritional efficiency and its metabolic load on the organism after major surgery.

[Confocal microscopy of the cornea in patients with diabetes]

PURPOSE

To investigate with confocal microscopy the cornea of diabetics type I and II.

MATERIAL AND METHODS

Thirty eyes of 10 patients with diabetes mellitus type I, 10 with d.m. type II, and 10 of controls were entered in the study. Eyes with corneal or anterior segments pathologies were excluded. In-vivo corneal morphology was studied using a confocal microscope.

RESULTS

Cell density of basal epithelial cells, anterior stromal keratocytes, and endothelial cells did not differ significantly between the groups. In the diabetic groups polymorphy of both epithelial and endothelial cells was noted. Abnormal stromal nerves were also noted in 2 cases.

DISCUSSION

Our findings support previous studies on corneal epithelial and endothelial morphology in diabetic patients. The corneal stroma appears to be affected only in its nerves, although in few cases.

[Sarcoidosis of the optic nerve]

BACKGROUND

Rarely an affection of the optic nerve is seen as the initial or only manifestation of sarcoidosis. Therefore the disease is often diagnosed late. The aim of systemic corticosteroid therapy is to prevent progression though it cannot yield a cure.

PATIENT AND METHOD

Despite a high-dose corticosteroid therapy in suspected optic neuritis a 25-year-old woman developed unilateral amaurosis. When visual acuity continuously decreased in the second eye a computerized tomography was performed, which suggested a tumor of the optic nerve. A biopsy of this lesion lead to the diagnosis of Boeck's disease. A long-term corticosteroid therapy was initiated. Over the following 9-year period corticosteroids were dosed according to the results of regular clinical and perimetrical examinations (200 examinations with Octopus-Perimeter 201, program G1). In case of deterioration of the visual field higher oral doses were applied. When no improvement was achieved by this, corticosteroids were given intrathecally. Under this therapeutic regime no systemic side effects were seen.

CONCLUSION

In unilateral visual loss Boeck's disease should be considered as a rare etiology. In case of clear optical media frequent computerized perimetry allows the neurologist to adjust the dosage of cortisone and minimize its side effects.

Anti-inflammatory treatment may prolong survival in undernourished patients with metastatic solid tumors

Eicosanoids may be important factors for tumor cell proliferation, metastatic formation, and development of cancer cachexia. The present study has evaluated the effect of anti-inflammatory treatment on tumor progression in clinical cancer. Patients (n = 135) with insidious or overt malnutrition due to generalized malignancy (various kinds of solid tumors) and an expected survival of more than 6 months were randomized by a computer-based algorithm to receive placebo, prednisolone (10 mg twice daily), or indomethacin (50 mg twice daily) p.o. until death. Patient groups were stratified in the randomization procedure for sex, tumor type, stage, nutritional state, and previous tumor treatment, and biochemical, physiological, and some functional variables (Karnowsky index, fatigue and pain score). A majority of these variables was then registered during the follow-up. Indomethacin and prednisolone treatment maintained Karnowsky index, while placebo-treated patients experienced a decreased index. Indomethacin-treated patients suffered less pain and consumed less additional analgetics compared to the other patient groups. Indomethacin prolonged mean survival compared to placebo-treated patients from 250 +/- 28 days to 510 +/- 28 days (P < 0.05). Survival analysis on observations from all patients treated with either indomethacin or prednisolone demonstrated a significantly prolonged survival by anti-inflammatory treatment compared to placebo treatment (log rank, P < 0.03). The results suggest that not only may prostaglandin synthesis inhibition offer palliative support to patients with solid advanced cancer, but it may also impact on pathways that ultimately determine outcome.

Prognostic factors in vitreous surgery for proliferative diabetic retinopathy

A total of 25 proliferative diabetic eyes of 24 patients scheduled for vitrectomy were examined. The overall preoperative visual acuity was below 0.1, corresponding to hand movement in most patients because of intravitreal hemorrhage. Hence, funduscopy was not possible. The following tests were performed in addition to standard clinical examination: Purkinje entoptic phenomenon, laser interferometry, perception of color flashes, and flicker-VEP using 1.8, 7.6, 15, and 30 Hz as stimulating frequencies. Only the flicker-VEP revealed results predicting reliably the functional visual outcome at 6 months after vitrectomy. Patients with a positive preoperative response to 15 or 30 Hz had a significantly (P < 0.05) better visual outcome at 6 months after vitrectomy (mean postoperative visual acuity 0.11; 95% confidence interval, 1/25-0.32) as compared with patients showing a positive preoperative VEP-response to only 1.8 and 7.6 Hz (mean postoperative visual acuity, hand movement; 95% confidence interval, light without projection--1/35). The flicker-VEP can give additional information about the integrity of the retina and the function of the optic nerve and can therefore help the surgeon to predict the functional result after vitrectomy.

Insulin selectively attenuates breakdown of nonmyofibrillar proteins in peripheral tissues of normal men

The role of insulin to control protein synthesis and degradation in the human leg and forearm was investigated in eight healthy individuals. The glucose clamp technique with simultaneous infusion of crystalline amino acids were used to create hyperinsulinemia (100-120 mU/l) in combination with euglycemia and elevated plasma concentrations of amino acids (> 4 mmol/l). A primed constant infusion with L-[U-14C]tyrosine and L-[phenyl-2H5]phenylalanine was used for simultaneous measurements of the disposal (protein synthesis) and the release (protein degradation) of tyrosine and phenylalanine, respectively, across the leg and forearm before and during hyperinsulinemia. The balance of 3-methylhistidine was also determined as a measure of muscle breakdown. Insulin stimulated tissue glucose and net amino acid uptake across the arm and leg tissues, whereas the disposal of both tyrosine and phenylalanine (protein synthesis) was not stimulated across the arm and the leg during hyperinsulinemia. The release of tyrosine and phenylalanine was significantly decreased from both leg and arm tissues (protein degradation) in response to insulin. However, the release of 3-methylhistidine from skeletal muscles was totally unaffected by hyperinsulinemia. We conclude that it is unlikely that insulin contributes to the normal stimulation of protein synthesis during feeding in humans and that insulin has no effect on breakdown of the large myofibrillar protein pool in skeletal muscles in unstressed individuals.

Metabolic rate and nitrogen balance in patients receiving bolus intermittent total parenteral nutrition infusion

The present study investigated whether infusion principles are significant factors that influence the nutritional efficiency of complete intravenous nutrition. For this purpose, three infusion modalities were evaluated in patients who underwent elective and uncomplicated cholecystectomy. The nutrition regimens were as follow: group 1, sequential infusion of fat plus amino acids at a constant rate over 12 hours during daytime followed by glucose infusion at a constant rate for 12 hours during nighttime; group 2, simultaneous infusion of all substrates at a constant rate over 24 hours; and group 3, simultaneous infusion of all substrates with bolus-based intermittent infusions during 60 minutes six times per day (24 hours). Nonprotein calories corresponded to 160% of the individually measured resting need and were provided as 60% carbohydrate and 40% fat. Nitrogen was provided as crystalline amino acids in solution at 0.2 g of nitrogen per kilogram per day. All patients were randomized into three comparable groups. Intermittent nutrition (group 3) was associated with a significantly higher thermic effect, which led to a significantly lower although still positive energy balance than either sequential nutrition (group 1) or constant nutrition (group 2). The mean daily nitrogen balance was, however, significantly improved in patients receiving intermittent nutrition, and this was accompanied by much higher plasma insulin levels as well as higher plasma amino acid concentrations. This study demonstrates that all substrates should be given simultaneously and that supplementation of intravenous nutrition in boluses, similar to meal feeding, gave the most pronounced protein accretion when compared with either sequential administration of total parenteral nutrition or administration of all admixtures with constant infusion over 24 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Structured triglycerides to postoperative patients: a safety and tolerance study

Long-chain triglycerides are still the standard in fat emulsions, although medium-chain triglycerides have been suggested to have metabolic advantages even though pure medium-chain triglycerides are toxic in large doses. The next generation of fat emulsions may be structured triglycerides, which are assumed to provide a higher oxidation rate, faster clearance from blood, improved nitrogen sparing, and less of a tendency to accumulate in the reticuloendothelial system compared with long-chain triglyceride emulsions. This study was designed to evaluate the safety and tolerance of structured triglyceride fat emulsion 73403 (Kabi Pharmacia Parenterals, Stockholm, Sweden) compared with that of a standard long-chain triglyceride emulsion (Intralipid 20%) in postoperative patients requiring total parenteral nutrition after major surgery. The study was randomized and of the double-blind, parallel group type. Twenty patients were included and treated for 5 to 7 days. Safety and tolerance variables demonstrated no major differences between the study and control groups. Physiologic and biochemical variables suggested that structured lipids were rapidly cleared and metabolized. This study represents the first report of administration of structured triglycerides to postoperative patients. The structured triglyceride emulsion (73403) demonstrated no difference in safety and tolerance compared with Intralipid 20%. Therefore, it will now be possible to follow up with studies on metabolic efficiencies of structured triglycerides in postoperative patients.

Evaluation of mechanisms behind elevated energy expenditure in cancer patients with solid tumours

The aim of this study was to demonstrate significant factors behind elevated resting energy expenditure in weight-losing cancer patients. Therefore, weight-losing cancer patients (n = 60), with normal liver and kidney function tests, were randomized to receive one of four drug treatments for 5 days: (a) Propranolol 80 mg x 2 (beta-adrenoceptor blockade); (b) Indomethacin 50 mg x 2 (prostaglandin synthesis inhibition); (c) Morphine 5 mg x 3 (pain relief) or (d) Placebo x 2. A reference group of healthy well-nourished individuals were examined outside the formal randomization protocol and they received Propranolol 80 mg x 2. The cancer patients were randomized by a computer based algorithm stratifying for measured resting energy expenditure (REE), body composition, biochemical tests, previous therapy, tumour type and tumour stage. Resting energy expenditure was measured by indirect calorimetry in the morning after an overnight fast before and after drug treatment. beta-blockade reduced REE significantly in cancer patients from 1416 +/- 95 kcal day-1 to 1160 +/- 63 kcal day-1 (P < 0.02) and from 1472 +/- 69 vs, 1398 +/- 63 kcal day-1 (P < 0.01) in the well-nourished reference individuals. The reduction found in cancer patients (10%) was significantly larger than that in the group of reference patients (5%), (P < 0.01). Indomethacin, morphine or placebo did not induce any significant alteration in energy expenditure in our cancer patients. Propranolol treatment was associated with a significant reduction in plasma concentrations of free fatty acids (FFA), but not in plasma glycerol.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect on body composition and exercise performance of home parenteral nutrition when given as adjunct to chemotherapy of testicular carcinoma

This study has evaluated whether long-term and permanent total parenteral nutrition (TPN) can protect body composition and exercise capacity during iterated courses of chemotherapy (PVB) in men with testicular carcinoma. Thirty-three men were randomly allocated by means of a computer based algorithm to receive either TPN (at hospital and home) during the entire chemotherapy period or to rely on spontaneous oral intake only. Nutrition status was assessed by measurements of whole body nitrogen (neutron activation), total body potassium, body water, urine creatinine excretion, loco-regional body nutrition indexes (AMC, TSF) and biochemical plasma concentrations (albumin, thyroid hormones). Whole body respiratory gas exchanges were measured during resting, submaximal and maximal exercise. TPN was prescribed on an individual basis in all study patients to cover 150% of their measured caloric need; nitrogen was given as 0.2 g N kg-1 day. All individuals were allowed to eat freely throughout the study. TPN patients were in overall positive energy balance (+850 Kcal day-1), while the control group was in negative balance (-532 Kcal day-1). This led to weight gain in the TPN group (+2.2 +/- 1.0 kg) while the control group lost significant weight (-4.2 +/- 1.1 kg). The average spontaneous oral caloric intake was 1014 +/- 153 Kcal day-1 in the TPN group and 1484 +/- 200 Kcal day-1 in the control group; total protein intake corresponded to 1.5 g protein kg day-1 in the TPN group and 0.7 kg day-1 in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated energy expenditure in cancer patients with solid tumours

Cancer patients (n = 106) and non-cancer subjects (n = 96) were classified as weight stable (n = 70) or weight-losing (n = 132). Cancer patients had elevated resting energy expenditure (REE) compared with either weight-losing (23.6 [0.4] vs. 20.5 [0.5] kcal/kg per day, P less than 0.001) or weight-stable controls (22.0 [0.6] vs. 17.9 [0.4], P less than 0.001). Cancer patients had increased fat oxidation irrespective of weight loss (1.24 [0.07] vs. 0.87 [0.04] mg/kg per min; 1.07 [0.04] vs. 0.78 [0.04], P less than 0.001). Elevated energy expenditure was counter-regulated by a decrease in thyroid hormones. Abnormal liver function had no impact on REE in either group. Heart rate was the most powerful factor for prediction of high energy expenditure in both patients and controls. Elevated energy expenditure was related to the increased heart rate in cancer patients in a significantly higher proportion than that in controls. Increased metabolic rate is a significant component behind weight loss in cancer disease, independent of malnutrition and an elevated adrenergic state may be a likely explanation.