Nausea and vomiting in a colorectal ERAS program: Impact on nutritional recovery and the length of hospital stay.

BACKGROUND & AIMS: Postoperative nausea and vomiting (PONV) and its impact on the hospital length of stay (LOS), have been extensively studied. However, most previous publications focused their studies on PONV during the first 24 h, and less is known about this complication during the ensuing days, its impact on nutritional recovery or its relation to other complications and the course of care. METHODS: An observational study involving 806 consecutive patients in a colorectal Enhanced Recovery After Surgery (ERAS) programme was performed. The primary objective was to analyse the incidence of early PONV on the day of surgery and the following 2 postoperative days (late PONV). Secondary objectives included evaluation of the influence of late PONV over the LOS and the nutritional recovery adjusted for confounding factors. RESULTS: PONV tended to increase over time (7% vs 7% and 10%, postop days 0, 1 and 2, respectively; p < 0.05). PONV on day 2 was associated in an adjusted analysis with poor oral intake, delayed solid food tolerance and an average increase in LOS of 2 nights. Risk factors for the presence of PONV on day 2 were the use of opioids on the same day, PONV on the day of the surgery and rectal procedures. CONCLUSIONS: PONV continues to be frequent after the first 24 h in colorectal surgery despite high compliance to current anti emetic recommendations. PONV during day 2 negatively affects the nutritional postoperative recovery and independently prolongs the hospital stay. The findings of the current study highlight the adverse effects of opioids and the need of further discussion on how to best audit, prevent and treat late PONV in ERAS colorectal programmes.

No lower bacterial adhesion for ceramics compared to other biomaterials: An in vitro analysis.

BACKGROUND: Although there is some clinical evidence of ceramic bearings being associated with a lower infection rate after total hip arthroplasty (THA), available data remains controversial since this surface is usually reserved for young, healthy patients. Therefore, we investigated the influence of five commonly used biomaterials on the adhesion potential of four biofilm-producing bacteria usually detected in infected THAs. HYPOTHESIS: Ceramic biomaterials exhibit less bacterial adherence than other biomaterials. MATERIAL AND METHODS: In this in vitro research, we evaluated the ability of Staphylococcus aureus, Staphylococcus epidermidis ATCC 35984, Escherichia coli ATCC 25922 and Pseudomonas aeruginosa to adhere to the surface of a cobalt-chromium metal head, a fourth-generation ceramic head, a fourth-generation ceramic insert, a highly-crossed linked polyethylene insert and a titanium porous-coated acetabular component. After an initial washing step, bacterial separation from the surface of each specimen was done with a vortex agitator. The colony-forming units were counted to determine the number of viable adherent bacteria. RESULTS: We found no differences on global bacterial adhesion between the different surfaces (p=0.5). E. coli presented the least adherence potential among the analysed pathogens (p<0.001). The combination of E. coli and S. epidermidis generated an antagonist effect over the adherence potential of S. epidermidis individually (58±4% vs. 48±5%; p=0.007). The combination of P. aeruginosa and S. aureus presented a trend to an increased adherence of P. aeruginosa independently, suggesting an agonist effect (71% vs. 62%; p=0.07). DISCUSSION: Ceramic bearings appeared not to be related to a lower bacterial adhesion than other biomaterials. However, different adhesive potentials among bacteria may play a major role on infection's inception. LEVEL OF EVIDENCE: IV, in vitro study.

Influence of single-dose intravenous tranexamic acid on total hip replacement : A study on transfusions, collateral complications, and readmissions.

INTRODUCTION: To determine the effects of tranexamic acid (TXA) on transfusions in patients undergoing hip replacement with a hybrid or cementless prosthesis. METHODS: A group of 172 consecutive patients aged 18 years or older who underwent elective hip replacement with uncemented or hybrid prostheses, undergoing surgery between January 2012 and January 2014 by the same primary surgeon and anesthesiologist, were retrospectively included. TXA (1 g) was administered immediately before incision in the TXA group. Primary variables included number of red blood cell transfusions and the influence of TXA for each type of prosthesis. Secondary variables included hematocrit at discharge, length of hospital stay, thrombosis or pulmonary embolism, seizures, and death. RESULTS: Average transfusion was 1.53 units/patient in the control group compared to 0.6 units/patient in the TXA group (z = 6.29; U = 1640.5; p < 0.0001). TXA use was significantly correlated with the number of units transfused (p < 0.0001, 95% CI -1.24 to -0.68). Odds risk reduction for transfusion was observed during surgery (OR: 0.14; CI 0.06-0.29; p < 0.0001) and during the rest of hospital stay (OR: 0.11; CI 0.01-0.96; p = 0.046). Both hybrid and cementless prostheses that received TXA were transfused less than control groups (0.57 ± 1 vs. 1.7 ± 1 p < 0.01 and 0.65 ± 1 vs. 1.24 ± 1 p < 0.01). No difference was observed between the groups regarding adverse effects. Hematocrit values at discharge and length of hospital stay were similar between groups. No deaths were observed during hospital stay. CONCLUSIONS: TXA reduced transfusions without increasing the prevalence of adverse effects. This reduction was observed during surgery and the following days of hospital stay for both for hybrid and cementless prosthesis.

Flujo retrógrado diastólico. Comunicación preliminar / Diastolic retrograde arterial flow: preliminary report

No disponible

[Diastolic retrograde arterial flow: preliminary report]. / Flujo retrógrado diastólico. Comunicación preliminar.

OBJECTIVE: Holodiastolic arterial blood flow is associated with pathological conditions. Nevertheless, we have observed that lifting the arm at an angle greater than the horizontal causes holodiastolic arterial blood flow in the brachial artery in normal patients. Thus, we decided to assess the frequency and characteristics of this phenomenon. MATERIAL AND METHODS: Ten volunteers (7 women) aged 43 ± 17 years participated in the study. We used an ultrasound scanner with a 12 MHz probe to analyze the brachial artery. The examination included: a) Baseline measurements in the supine position; b) measurements during three minutes with the arm raised, and c) a measurement sixty seconds after lowering the arm to the supine position in which the baseline measurements had been obtained. RESULTS: We observed mid- and end-diastolic retrograde flow in 8/10 patients when their arms were raised. No mid- or end-diastolic retrograde flow was observed in the baseline measurements or after the arm was lowered to the supine position (p=0.0007). The minimum diastolic velocity was significantly higher in the measurements obtained with the arm raised than in the supine position before or after arm raising (-13.5 ± 4.9 cm/s vs. -2.38 ± 7.5 cm/s, p<0.05 and -13.5 ± 4.9 cm/s vs. -4.6 ± 5.2 cm/s, p<0.05, respectively). The modified resistance index was significantly higher when the arm was raised (1.20 ± 0.07 vs. 1.04 ± 0.15; p<0.05); moreover, the modified resistance index was significantly lower in the measurements obtained after the arm was lowered than in the baseline measurements (1.20 ± 0.07 vs 1.07 ± 0.08; p<0.05). CONCLUSION: We conclude that holodiastolic reflux occurs in healthy patients. This physiological phenomenon merits further investigation and can help elucidate previous observations in different pathological conditions.

Complex population history of two Anopheles dirus mosquito species in Southeast Asia suggests the influence of Pleistocene climate change rather than human-mediated effects.

Anopheles dirus and Anopheles baimaii are closely related species which feed on primates, particularly humans, and transmit malaria in the tropical forests of mainland Southeast Asia. Here, we report an in-depth phylogeographic picture based on 269 individuals from 21 populations from mainland Southeast Asia. Analysis of 1537 bp of mtDNA sequence revealed that the population history of A. baimaii is far more complex than previously thought. An old expansion (pre-300 kyr BP) was inferred in northern India/Bangladesh with a wave of south-eastwards expansion arriving at the Thai border (ca 135-173 kyr BP) followed by leptokurtic dispersal very recently (ca 16 kyr BP) into peninsular Thailand. The long and complex population history of these anthropophilic species suggests their expansions are not in response to the relatively recent (ca 40 kyr BP) human expansions in mainland Southeast Asia but, rather, fit well with our understanding of Pleistocene climatic change there.

High levels of population structure caused by habitat islands in the malarial vector Anopheles scanloni.

The genetic structure of four populations of the malarial vector Anopheles scanloni in Thailand was studied using mitochondrial DNA sequences. Four highly divergent lineages were observed, all with signals of population expansion. Since An. scanloni is restricted to 'islands' of limestone karst habitat, this suggests there is a metapopulation-type dynamic in this species, with restricted gene flow, extinctions and drift all contributing to lineage divergence. Historical environmental change and marine transgressions may also have contributed to population extinction, expansion and divergence. Although there is some current gene flow inferred between nearby populations, it is extremely restricted between the northern and southern populations, which also differed by one fixed polymorphism at the ITS2 rDNA locus. Crossing experiments showed no post-mating barriers existing between the north and the south, but the lack of gene flow between these populations could ultimately result in speciation and has implications for malaria control strategies.

Molecular identification of mosquito species in the Anopheles annularis group in southern Asia.

The Anopheles annularis group of subgenus Cellia Theobald (Diptera: Culicidae) includes five currently recognized species in southern Asia: An. annularis Van der Wulp, Anopheles nivipes (Theobald) and Anopheles philippinensis Ludlow, which are widespread in the region, Anopheles pallidus Theobald, which is known in Sri Lanka, India and Myanmar, and Anopheles schueffneri Stanton, which occurs in Java and Sumatra. Identification of the four mainland species based on morphology is problematic. In view of the fact that the three widespread species are variously involved in malaria transmission in different parts of the region, we developed a species-specific polymerase chain reaction assay based on rDNA internal transcribed spacer 2 (ITS2) sequences to facilitate entomological and epidemiological studies of the four species. The method proved to be reliable when tested over a wide geographical area.

Mycosis fungoides--a review of the management of 28 patients and of the recent literature.

BACKGROUND: Mycosis fungoides is an uncommon cutaneous T-cell lymphoma characterized by malignant monoclonal proliferation of T-helper lymphocytes. Its course is variable with a potential for lymphatic and hematogenous involvement. We report the investigations, staging, treatment, follow-up, and outcome of 28 patients. This is the first such study reported from Ireland. METHODS: Twenty-eight patients with mycosis fungoides (14 women, 14 men; average age, 52.5 years) were reviewed over 12 years in the dermatology clinic which assesses an average of 4500 patients per year. All mycosis fungoides patients were referred from their family physicians. The diagnosis was made in all cases from a combination of clinical findings, histology, and immunohistochemistry. TNM staging revealed 11 patients at diagnosis stage IA (T1), 12 at stage IB (T2), four at stage IIB (T3), and one at stage III (T4). RESULTS: The usual male preponderance was not found. Eight patients needed multiple biopsies to establish the diagnosis. Detailed investigations were not useful in the early stages. Patients were followed up over a 12-year period. Thirteen patients died as a result of cutaneous lymphoma. Two patients with stage IA disease progressed rapidly and died, a feature reported in only 10% of patients at this stage. Five patients showed unusual features, including a long history prior to presentation, the development of the rarely reported bullous mycosis fungoides, and aggressive disease beginning at a young age. CONCLUSIONS: Mycosis fungoides is rare; we reviewed 28 patients over 12 years. The prognosis is poor at the later stages; 13 patients died. Two patients who died were unusual in that they rapidly progressed from stage IA disease; however, in the majority of patients with this stage, the prognosis is excellent. Detailed investigations were unhelpful in early stage disease. Close clinical follow-up is essential to identify disease progression.

Genetic diversity and molecular identification of mosquito species in the Anopheles maculatus group using the ITS2 region of rDNA.

The species diversity and genetic structure of mosquitoes belonging to the Anopheles maculatus group in Southeast Asia were investigated using the internal transcribed spacer 2 (ITS2) of ribosomal DNA (rDNA). A molecular phylogeny indicates the presence of at least one hitherto unrecognised species. Mosquitoes of chromosomal form K from eastern Thailand have a unique ITS2 sequence that is 3.7% divergent from the next most closely related taxon (An. sawadwongporni) in the group. In the context of negligible intraspecific variation at ITS2, this suggests that chromosomal form K is most probably a distinct species. Although An. maculatus sensu stricto from northern Thailand and southern Thailand/peninsular Malaysia differ from each other in chromosomal banding pattern and vectorial capacity, no intraspecific variation was observed in the ITS2 sequences of this species over this entire geographic area despite an extensive survey. A PCR-based identification method was developed to distinguish five species of the group (An. maculatus, An. dravidicus, An. pseudowillmori, An. sawadwongporni and chromosomal form K) to assist field-based studies in northwestern Thailand. Sequences from 187 mosquitoes (mostly An. maculatus and An. sawadwongporni) revealed no intraspecific variation in specimens from Thailand, Cambodia, mainland China, Malaysia, Taiwan and Vietnam, suggesting that this identification method will be widely applicable in Southeast Asia. The lack of detectable genetic structure also suggests that populations of these species are either connected by gene flow and/or share a recent common history.

Multidimensional analysis of the insoluble sub-proteome of Oceanobacillus iheyensis HTE831, an alkaliphilic and halotolerant deep-sea bacterium isolated from the Iheya ridge.

We report the first proteomic analysis of the insoluble sub-proteome of the alkaliphilic and halotolerant deep-sea bacterium Oceanobacillus iheyensis HTE831. A multidimensional gel-based and gel-free analysis was utilised and a total of 4352 peptides were initially identified by automated MS/MS identification software. Automated curation of this list using PROVALT reduced our peptide list to 467 uniquely identified peptides that resulted in the positive identification of 153 proteins. These identified proteins were functionally classified and physiochemically characterised. Of 26 proteins identified as hypothetical conserved, we have assigned function to all but four. A total of 41 proteins were predicted to possess signal peptides. In silico investigation of these proteins allowed us to identify three of the five bacterial classes of signal peptide, namely: (i) twin-arginine translocation; (ii) Sec-type and (iii) lipoprotein transport. Our proteomic strategy has also allowed us to identify, at neutral pH, a number of proteins described previously as belonging to two putative transport systems believed to be of importance in the alkaliphilic adaptation of O. iheyensis HTE831.

Multidimensional proteomic analysis of the soluble subproteome of the emerging nosocomial pathogen Ochrobactrum anthropi.

We report the first large-scale gel-free proteomic analysis of the soluble subproteome of the emerging pathogen Ochrobactrum anthropi. Utilizing our robust offline multidimensional protein identification protocol, a total of 57 280 peptides were initially identified utilizing automated MS/MS analysis software. We describe our investigation of the heuristic protein validation tool PROVALT and demonstrate its ability to increase the speed and accuracy of the curation process of large-scale proteomic datasets. PROVALT reduced our peptide list to 8517 identified peptides and further manual curation of these peptides led to a final list of 984 uniquely identified peptides that resulted in the positive identification of 249 proteins. These identified proteins were functionally classified and physiochemically characterized. A variety of typical "housekeeping" functions identified within the proteome included nucleic acid, amino and fatty acid anabolism and catabolism, glycolysis, TCA cycle, and pyruvate and selenoamino acid metabolism. In addition, a number of potential virulence factors of relevance to both plant and human disease were identified.

A combined shotgun and multidimensional proteomic analysis of the insoluble subproteome of the obligate thermophile, Geobacillus thermoleovorans T80.

To further our understanding of the biology of the thermophilic bacterium Geobacillus thermoleovorans T80, we now report the first proteomic analysis of the insoluble subproteome of this isolate. A combination of both shotgun and multidimensional methodologies were utilized, and a total of 8628 peptides was initially identified by automated MS/MS identification software. Curation of these peptides led to a final list of 184 positive protein identifications. The proteins from this insoluble subproteome were functionally classified, and physiochemical characterization was carried out. Of 15 hypothetical conserved proteins identified, we have assigned function to all but four. A total of 31 proteins were predicted to possess signal peptides. In silico investigation of these proteins allowed us to identify four of the five bacterial classes of signal peptide, namely, (i) twin-arginine translocation; (ii) Sec-type; (iii) lipoprotein, and (iv) ABC transport. In addition, a number of proteins were identified that are known to be involved in the transport of compatible solutes, known to be important in microbial stress responses.

Regulation of Homer and group I metabotropic glutamate receptors by nicotine.

The present study focuses on the nicotine-induced modulation of mRNA and protein expression of a number of genes involved in glutamatergic synaptic transmission in rat brain over different time periods of exposure. A subchronic (3 days) but not the chronic (7 or 14 days) administration of nicotine resulted in the up-regulation of Homer2a/b mRNA in the amygdala while in the ventral tegmental area (VTA) no change in expression of either Homer2a/b or Homer1b/c was observed. Although the increase in Homer2a/b mRNA was not translated into the protein level in the amygdala, a slight but significant up-regulation of Homer1b/c protein was observed in the same region at day 3. Both Homer forms were up-regulated at the protein level in the VTA at day 3. In the nucleus accumbens, 14 days of nicotine treatment up-regulated mRNA of Homer2b/c by 68.2% (P < 0.05), while the short form Homer1a gene was down-regulated by 65.0% at day 3 (P < 0.05). In regard to other components of the glutamatergic signalling, we identified an acute and intermittent increase in the mRNA and protein levels of mGluR1 and mGluR5 in the amygdala. In the VTA, however, the effects of nicotine on mGluR mRNA expression were long-lasting but rather specific to mGluR1. Nevertheless, mGluR1 protein levels in the VTA area were up-regulated only at day 3, as in the amygdala. These data provide further evidence for the involvement of nicotine in the glutamatergic neuronal synaptic activity in vivo, suggesting a role for the newly identified Homer proteins in this paradigm.

Immunological and genetic analysis of 65 patients with a clinical suspicion of X linked hyper-IgM.

BACKGROUND: X linked hyper-IgM (XHIM) is a primary immunodeficiency caused by mutations in the tumour necrosis factor superfamily 5 gene, TNFSF5, also known as the CD40 ligand (CD40L) gene. Patients often present with recurrent infections, and confirmation of a diagnosis of XHIM enables appropriate therapeutic interventions, including replacement immunoglobulin, antibiotics, and bone marrow transplantation. AIM: To review and optimise the institution's diagnostic strategy for XHIM. METHOD: Samples from 65 boys were referred to this centre for further investigation of suspected XHIM. The results, which included a flow cytometric whole blood assay for CD40L expression followed by mutation analysis in selected patients, were reviewed. RESULTS: Twenty one patients failed to express CD40L and TNFSF5 mutations were found in 20 of these patients. In contrast, no TNFSF5 mutations were found in 16 patients with weak expression of CD40L. Interestingly, one quarter of patients with confirmed XHIM who had TNFSF5 mutations had low concentrations of IgG, IgA, and IgM. Most of the remaining patients with XHIM had the classic pattern of normal or raised IgM with low concentrations of IgA and IgG. CONCLUSIONS: This study demonstrates the usefulness of the whole blood staining method as a rapid screen to select patients for subsequent TNFSF5 mutation analysis, and shows the benefits of a unified protein/genetic diagnostic strategy.

Mucor mycosis infection presenting as a non-healing ulcer in an immunocompromised patient.

Mucor mycosis is an uncommon saprophytic opportunistic fungus causing localized cutaneous infection associated with high morbidity and, on dissemination, high mortality. We report the case of an immunocompromised patient with an aggressively progressing, painful non-traumatic ulceration, unresponsive to standard treatment. Deep biopsies for haematoxylin and eosin staining and fungal culture revealed the characteristic broad non-septate irregular hyphae of mucor allowing introduction of the appropriate treatment. Infection with mucor mycosis must be considered in today's medical environment as the number of immunocompromised patients increases.

Protein tyrosine phosphatase genes downregulated in melanoma.

Phospho-tyrosine levels are increased in melanoma, apparently consistent with reports of elevated protein tyrosine kinase activity. Some protein tyrosine kinases are encoded by oncogenes and have been implicated in melanoma genesis. Decreased protein tyrosine phosphatase activity may also increase phospho-tyrosine. Protein tyrosine phosphatase genes are candidate tumor suppressors and loss of expression may contribute to melanoma genesis. Here we survey protein tyrosine phosphatase expression in pigment cells. Protein tyrosine phosphatase genes were cloned by reverse transcriptase polymerase chain reaction using degenerate primers based upon conserved sequences within the phosphatase catalytic domain. Reaction products were cloned and sequenced: 118 and 113 partial protein tyrosine phosphatase products were isolated from normal melanocytes and melanoma cells, respectively. Northern blotting analysis was used to study expression of 15 protein tyrosine phosphatase genes. Expression of PTP-kappa and PTP-pi was absent or downregulated in more than 20% of melanoma cell lines and in some unmanipulated melanoma biopsies. These closely related enzymes are members of the 2B receptor protein tyrosine phosphatase family previously implicated in contact inhibition. Loss of protein tyrosine phosphatase expression may contribute to the abnormal tyrosine phosphorylation seen in melanoma; these genes are candidate tumor suppressors.

Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients.

BACKGROUND: In the Irish health system, dermatology patients present to their family practitioner for diagnosis and treatment, and are referred to a dermatologist for a second opinion where diagnosis is in doubt or when there has been therapeutic failure. The level of expertise in dermatology amongst family practitioners varies considerably. AIM: To compare the diagnoses of general practitioners and dermatologists over a selected period in patients with a possible diagnosis of skin cancer. METHODS: Four hundred and ninety-three patients were seen by one of two dermatologists over a 1-year period at a rapid referral clinic for patients suspected by their family practitioners of having unstable or possibly malignant skin lesions; 213 of these patients had a diagnosis made on clinical examination by the dermatologist, while 264 had diagnostic or therapeutic biopsies performed; 16 patients defaulted on surgery. RESULTS: The diagnoses of the family practitioners agreed with the diagnoses of the dermatologists on patients diagnosed clinically in 54% of cases. Thirty-eight patients had histologically proven skin malignancy. These were diagnosed accurately by the referring family practitioner in 22% of patients, while the dermatologists made the correct diagnosis prior to biopsy in 87%. CONCLUSIONS: In over 50% of cases diagnosed clinically, the dermatologist and family practitioner agreed. Histologically proven skin cancers were diagnosed accurately in only 22% of cases by family practitioners, compared to 87% of cases by dermatologists. Specific areas of diagnostic difficulty for family practitioners include benign pigmented actinic and seborrheic keratoses, squamous cell carcinoma, and melanoma. Postgraduate education for family practitioners should be directed towards these areas of deficiency. Dermatologists had difficulty distinguishing pigmented actinic keratoses from melanoma.