Is there room for luminal-basal urothelial cell population quantification? / ¿Hay lugar para la cuantificación de la población de células uroteliales luminales basales?

PURPOSE: Three cell layers compose the urothelium: basal, intermediate and luminal ("umbrella cells") and different diseases might arise from different cell populations. The aim of this study is to analyze the quantification ability of such cell populations by using four different protocols. METHODS: Twenty male rats (Wistar) were randomized in four groups of five animals: scraping, enzymatic 30, 45 and 60minutes. The cells were isolated, analyzed by flow cytometer and data processed by BD FACSDIVA™ software. RESULTS: The urothelium was separated in two cell populations that are different in size and complexity. The group that showed more efficiency in cells dissociation and cells separation was enzymatic protocol 45minutes. CONCLUSIONS: Enzymatic protocol 45minutes was able to isolate urothelial cell populations and might be explored as potential prognostic tool, patient selection and therapeutic target in urothelial diseases. Future studies should validate the potential clinical application to the proposed rational of luminal-basal paradigm in the urothelial cancer as hope for individualized approach.

Idiopathic fibrosing pancreatitis associated with ulcerative colitis.

Idiopathic fibrosing pancreatitis has been associated with Sjögren's syndrome, primary biliary cirrhosis and primary sclerosing cholangitis. This condition frequently develops in childhood and youth, and has also been related to ulcerative colitis and pericholangitis. Pancreatic complications have been rarely described as systemic complications of ulcerative colitis. A 25-year-old man presented with epigastric pain and jaundice. Abdominal ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) revealed a diffuse enlargement of the pancreas, filiform distal stenosis of the common bile duct and intrahepatic bile ducts, and pancreatic duct dilatation. At operation, a rock-hard and nodular pancreas was noted. Cholecystectomy and Roux-en-Y hepaticojejunostomy, with an access loop, was successfully performed. Idiopathic fibrosing pancreatitis should be considered in young patients with obstructive jaundice, especially those affected with chronic inflammatory or autoimmune diseases. Glucocorticoid therapy would be the first-line treatment, although many patients require operation.

Transfusion timing and postoperative septic complications after gastric cancer surgery: a retrospective study of 179 consecutive patients.

BACKGROUND: Immunosuppression associated with homologous blood transfusion was first observed in renal allograft transplantation. Clinical effects of transfusion-induced immunosuppression in surgical patients have been debated in the literature for more than a decade with contradictory results. OBJECTIVE: To investigate whether homologous blood transfusions significantly affect postoperative septic morbidity and mortality in patients undergoing elective surgery for gastric cancer. DESIGN: Case series. SETTING: Hospitalized care. PATIENTS: The hospital records of 209 patients who underwent elective surgery for gastric cancer at the Department of Surgery of the Hospital del Mar, Autonomous University of Barcelona in Spain, and at the Department of Surgery of the Catholic University of Rome in Italy from April 1984 to December 1990 were reviewed, and 179 patients were included in the study. MAIN OUTCOME MEASURES: The following variables were entered into univariate and multivariate analyses to identify factors potentially affecting postoperative septic morbidity: demographic data, weight loss, preoperative serum albumin level and lymphocyte count, type and duration of operative procedure, amount and timing of blood transfusion, and stage of disease. RESULTS: Univariate analysis showed that a large quantity of blood transfused (> 1500 mL) and transfusion in the postoperative period (group C) were associated with a worse clinical outcome. Postoperative transfusion was an independent predictor of septic morbidity in multivariate analysis. CONCLUSIONS: Despite transfusion-induced immunomodulation, homologous blood transfusion should not be considered a risk factor for postoperative septic morbidity in patients undergoing elective major abdominal surgery. The timing-response relationship between transfusions and septic morbidity in multivariate analysis may be the effect of uncontrolled confounders such as variation of volemia induced by stress response in patients who were developing or had just developed infectious complications.

Response of severely malnourished patients to preoperative parenteral nutrition: a randomized clinical trial of water and sodium restriction.

Preoperative parenteral nutrition (PPN) may be beneficial for severely malnourished patients who are candidates for a major elective surgical procedure. The response to PPN, however, has not been thoroughly investigated. Expansion of the extracellular water compartment may occur in some patients, producing a further decrease in the serum albumin concentration and increasing the postoperative complications. Our aims were to investigate the occurrence of and factors associated with water and sodium retention during PPN and its impact on postoperative respiratory complications. Forty-one patients with gastrointestinal cancer and severe malnutrition (weight loss > 15% and/or serum albumin < 35 g/L) were randomly allocated to two groups receiving isocaloric isonitrogenous PPN for 10 d. The Standard PPN Group (SG, n = 19) received 70% of nonprotein calories as glucose, 45 cc of water.kg-1.d-1, and 140 mEq/d of sodium chloride; and the Modified Group (MG, n = 22) received 70% of calories as fat, 30 cc of water.kg-1.d-1, and no sodium. Weight and albumin changes, diuresis, sodium and water balances, and postoperative complications were recorded. At the end of PPN, the SG showed a higher weight gain (0.8 versus -1.5 kg, P = 0.0001) and albumin decrease (-0.7 versus 2.3 g/L, P = 0.006). Diuresis and sodium balance were greater in the SG (1,230 versus 959 mL/d, P = 0.003 and 40 versus -27 mEq/d, P = 0.001). Weight changes correlated with water (r2 = 0.46, P = 0.001) and sodium (r2 = 0.62, P = 0.0001) balances. Inappropriate responses to PPN in both groups (expansion or depletion of the extracellular water compartment) were associated with a significant increase in pulmonary postoperative complications. During PPN, extracellular water expansion--as determined by increasing weight and lowering of the serum albumin concentration--and aggressive fluid therapy to treat water and sodium depletion seem crucial to the development of postoperative respiratory complications.

Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula.

Somatostatin and octreotide both enhance closure of gastrointestinal fistulas. The present trial was undertaken to test whether early combined treatment with parenteral nutrition and octreotide 100 micrograms every 8 h by subcutaneous injection had a beneficial effect compared with parenteral nutrition plus placebo. Thirty-one patients with post-operative gastrointestinal or pancreatic fistula were randomly assigned to receive parenteral nutrition plus octreotide (14 patients) or placebo (17) within 8 days of fistula onset. The percentage reduction in output and rate of spontaneous closure within 20 days were analysed. Mean(s.d.) reduction in output was similar after octreotide and placebo at 24 h (66(43) versus 68(47) per cent, P = 0.9), 48 h (60(46) versus 57(43) per cent, P = 0.8) and 72 h (62(50) versus 66(49) per cent, P = 0.9) after starting the combined treatment. Closure within 20 days was observed in eight of 14 fistulas in patients given octreotide and in six of 17 in those receiving placebo (P = 0.4). Administration of octreotide, within 8 days of fistula onset, associated with parenteral nutrition does not significantly increase the spontaneous fistula closure rate compared with parenteral nutrition plus placebo.

Extracellular volume, nutritional status, and refeeding changes.

ECW, and particularly its interstitial component, expands easily with malnutrition, sepsis, and trauma and after aggressive intravenous fluid therapy. In this scenario, hypoalbuminemia is usually the result of both an increased capillary escape rate due to leaky endothelium and increased distribution volume; this can be worsened by artificial intravenous nutrition with sodium, water, and glucose. Monitoring ECW is essential during TPN. Short-term changes in weight and serum albumin concentration are helpful to control ECW volume and prevent ECW expansion. Tetrapolar bioimpedance analysis is a promising technique for accurate bedside measurement of changes in body fluid compartments.

[A randomized prospective study of antibiotic prophylaxis compared to lavage of the surgical wound in nonperforating appendicitis]. / Estudio prospectivo aleatorizado de la profilaxis antibiótica comparada con el lavado de la herida quirúrgica en apendicitis no perforada.

BACKGROUND: There are many doubts as to the efficacy of systemic antibiotic prophylaxis versus the methods of local treatment in the prevention of infection of the contaminated surgical wound. A controlled prospective study was designed to compare the effectiveness of a combination of parenteral antibiotics with lavage with physiologic serum of the surgical wound to prevent infection of the postappendectomy wound. METHODS: The patients in group A (antibiotic, n = 70) received a sole preoperative dose of methronidazol and gentamicin while in those in group I (irrigation, n = 71) the wounds were irrigated with physiologic serum prior to and following closure of aponeurosis. The patients were controlled at one week and one month after the intervention. RESULTS: The global rate of infection was 9.3%. Six patients of group A and five of group I developed wound infection (p = 0.06), The age and length of the intervention were significantly higher in the infected patients (41 vs 23 years, p = 0.0001 and 53 vs 41 minutes, p = 0.03, respectively). Intraperitoneal culture was positive in 70% of the patients who posteriorly developed wound infection, being positive in only 9.4% of the uninfected patients (p = 0.0001). Eight of the infections (73%) were detected following discharge from hospital. The cost of prophylaxis in group A was seven-fold higher than that of group I. CONCLUSIONS: Lavage of the surgical wound with physiologic serum may be an effective, safe and inexpensive method to prevent infection of the wound following appendicectomy for unperforated appendicitis.

Influence of calorie source on the physiological response to parenteral nutrition in malnourished rabbits.

The present study was designed to investigate whether calorie source influences sodium and water metabolism and sympathetic activity during parenteral nutrition (PN). 20 New Zealand rabbits were starved until a mean weight loss of 18% was achieved and then re-fed for 6 days with 2 formulae of PN with different glucose-fat proportions. In the Glucose group (n = 9), 70% of non-protein calories were given as glucose while in the Lipid group (n = 11), 70% of non-protein calories were administered as lipids. Rabbits with a high glucose intake showed significantly higher weight gain (151 +/- 87 vs. 52 +/- 7 g, P = 0.01), water cumulative balance (542 +/- 132 vs. 411 +/- 87 ml; P = 0.02) and urinary metanephrine excretion (0.42 +/- 0.12 vs. 0.30 +/- 0.1 mumol/d, P = .03). Only in this group, urinary metanephrines correlated positively with water and sodium balances (r2 = 0.6; P = 0.02 and r2 = 0.7; P = 0.009 respectively). The Glucose group showed 2 different responses and in a second experiment 10 additional rabbits were added to this group to allow a statistical analysis of the response pattern: half of the animals increased their extracellular water (ECW) compartment while the remaining animals did not. The former group had higher sodium balance (13.9 +/- 8 vs. 4.3 +/- 5; P = 0.004) and wet lung weight (8.9 +/- 0.9 vs. 7.9 +/- 0.8; P < 0.05) after re-feeding and, at the beginning of PN, their serum aldosterone concentration were also higher (221 +/- 11 vs. 130 +/- 47 pmol/l; P < 0.05). In conclusion, glucose based PN appears to increase sympathetic activity and induce spurious weight gain due to markedly positive wate and sodium balances. Plasma aldosterone concentration at the end of starvation period influences sodium retention and ECW expansion during high glucose re-feeding.

Body water compartments in patients with obstructive jaundice.

To elucidate the pathogenesis of renal dysfunction associated with obstructive jaundice, body water compartments were measured using a multi-isotope dilution technique in ten patients with biliary tract obstruction and in ten control subjects matched for age, sex, weight, height and body surface area. Expressed as a fraction of body-weight, total body water was reduced in jaundiced patients (41.8 versus 46.2 per cent, P less than 0.02). Extracellular water volume was also reduced in patients with jaundice (20.3 versus 24.3 per cent, P less than 0.003) owing to a reduction of the interstitial space (16.1 versus 19.5 per cent, P less than 0.004) and, to a lesser degree, of the plasma volume (4.2 versus 4.8 per cent, P = 0.1). There was a close correlation in jaundiced patients between plasma volume and the creatinine clearance rate (r2 = 0.56, P less than 0.02) and between plasma volume and extracellular volume (r2 = 0.77, P less than 0.0001). Extracellular volume in such patients also correlated with the percentage weight loss (r2 = 0.42, P = 0.04). Obstructive jaundice is associated with a contracted extracellular water compartment, although extracellular water, as a percentage of body-weight, increased in proportion to the body-weight lost. Reduction of the interstitial volume and a marginally reduced plasma volume may be determinant factors in the pathogenesis of the renal and haemodynamic disturbances observed in patients with biliary tract obstruction.

The influence of calorie source on water and sodium balances during intravenous refeeding of malnourished rabbits.

34 New Zealand rabbits were starved until a mean weight loss of 15% to 20% was achieved and then were parenterally re-fed with four different total parenteral nutrition (TPN) formulae for 6 days. Regimens were isocaloric (85 kcal/kg/day) and isonitrogenous (0.52 gN/kg/day) with the following formulae: group S-GLU-70 (water 100 ml/kg/day, Na 7 mEq/day and 70 30 % of calories as glucose/lipids, n = 9), group S-GLU-50 (water 100 ml/kg/day, Na 7 mEq/day and 50 50 % of calories as glucose/lipids, n = 9), group L-GLU-30 (water 70 ml/kg/day, no sodium and 30 70 % of calories as glucose/lipids, n = 8) and group L-GLU-50 (water 70 ml/kg/day, no sodium and 50 50 % of calories as glucose/lipids, n = 8). The group S-GLU-70 showed the highest water and sodium balances (p = 0.001 respectively, ANOVA test). Group S-GLU-70 showed also a greater weight gain (p = 0.0001) and, although not statistically significant, the lowest albumin at the end of the TPN. Glucose load appears to be responsible for the rapid weight gain and positive water and sodium balances during TPN in depleted non-stressed animals.

Water and sodium metabolism during intravenous re-feeding in the malnourished rabbit.

Twenty-three New Zealand rabbits were starved until a mean weight loss of 21% was achieved and then re-fed parenterally with two different total parenteral nutrition (TPN) formulae: a standard formula (Group SF, n = 12) containing 100 ml/kg/day of water, 7 mEq/day of sodium and 70% of non-protein calories as glucose; and a modified formula (Group MF, n = 11) containing 70 ml/kg/day of water, no sodium and 70% of non-protein calories as fat. After 6 days of parenteral nutrition, Group SF showed a higher weight gain than Group MF (10 +/- 5.8% vs. 1.4 +/- 5%; p = 0.001) and serum albumin concentration in Group SF was lower than in Group MF (25.9 +/- 4.2 vs. 32 +/- 4.5 g/l; p = 0.004). There was a close correlation between weight gain and water and sodium balances (r(2) = 0.714; p = 0.0001 and r(2) = 0.447; p = 0.0005, respectively). In Group SF, a close correlation was found between the free water clearance and water balance (r(2) = 0.711, p = 0.0006). In conclusion, in Group MF water and sodium restriction led to a better nutritional response in terms of improving serum albumin concentrations and minimising weight gain, probably due to less expansion of the extracellular fluid compartment in this group.

Assessment of a new hub design and the semiquantitative catheter culture method using an in vivo experimental model of catheter sepsis.

An in vivo model of hub-related catheter sepsis in rabbits is reported. The model was used to investigate the protection offered by a new hub design against external contamination by Pseudomonas aeruginosa or Staphylococcus epidermidis and to reassess the diagnostic value of the semiquantitative culture method in bacteremia of endoluminal origin. Contamination of conventional Luer-Lock connectors was followed by clinical sepsis, positive catheter segment cultures, or both, whereas contamination of the new hub was followed by complete protection. Clinical and bacteriological discrepancies observed between contamination with P. aeruginosa and S. epidermidis suggest that the virulence of microorganisms may account for differences in the natural history of hub-originated catheter sepsis. The semiquantitative extraluminal method for catheter culture yielded less than 15 CFU in three animals with proven bacteremia and should not be used as the "gold standard" to define catheter-related bacteremia.