Tinción de Gram intraoperatoria en bilis para la prevención de complicaciones infecciosas en la duodenopancreatectomía / Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

Introducción Las complicaciones infecciosas presentan un papel destacado en la duodenopancreatectomía. Su incidencia aumenta en casos con drenaje biliar preoperatorio (DBP), por el mayor riesgo de bacterobilia. Se presenta un estudio con el objetivo de valorar un protocolo de antibioterapia guiado por una tinción de gram intraoperatoria de líquido biliar. Métodos Estudio retrospectivo en el que se analiza la incidencia de complicaciones infecciosas entre dos grupos de 25 pacientes, consecutivos en el tiempo, intervenidos de duodenopancreatectomía. En el grupo 1 se administró profilaxis con cefazolina en pacientes sin DBP y antibioterapia durante cinco días con piperacilina-tazobactam en casos con DBP. En el grupo 2 se realizó tinción de gram intraoperatoria de bilis de forma sistemática. Si no se detectaban microorganismos, la antibioterapia se limitaba a profilaxis con cefazolina. Si se apreciaba bacterobilia, se administraba antibioterapia dirigida durante cinco días. Resultados La incidencia de infección órgano-cavitaria fue del 24% en el grupo 1 y del 4% en el 2 (p=0,04) y la incidencia de sepsis fue del 32% en el primer grupo y del 4% en el segundo (p=0,01). No se apreciaron diferencias en el resto de variables de morbimortalidad. Los microorganismos más prevalentes en bilis fueron Enterococcus spp y Klebsiella spp. En cultivos postoperatorios, aunque también fueron los más frecuentes en el grupo 1 (28 y 24%), solo aparecieron en el 4% de los casos del grupo 2 (p<0,05) Conclusión La tinción de gram intraoperatoria de bilis podría ser útil para dirigir la antibioterapia en la duodenopancreatectomía y contribuir a reducir las complicaciones infecciosas (AU)

Introduction Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications. Methods A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days. Results The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively). Conclusion Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications (AU)

Antimicrobial activity of binary combinations of natural and synthetic phenolic antioxidants against Enterococcus faecalis.

This study investigated the antimicrobial activity of 3 natural (thymol, carvacrol, and gallic acid) and 2 synthetic [butylated hydroxyanisole (BHA) and octyl gallate] phenolic compounds, individually and in binary combinations, on 4 dairy isolates of Enterococcus faecalis with different virulence factors (ß-hemolytic, gelatinase, or trypsin activities; acquired resistance to erythromycin or tetracycline; and natural resistance to gentamicin). A checkerboard technique and a microdilution standardized method were used. All compounds individually tested exhibited antimicrobial activity against E. faecalis, with minimal inhibitory concentrations (MIC) ranging from 30 µg/mL (octyl gallate) to 3,150 µg/mL (gallic acid), although no significant differences were detected among strains to each phenolic compound. Carvacrol in combination with thymol or gallic acid, and gallic acid combined with octyl gallate showed partial synergistic inhibition of all E. faecalis strains. The most effective combinations were thymol+carvacrol and gallic acid+octyl gallate, as the MIC for each of these compounds was reduced by 67 to 75% compared with their respective individual MIC. These results highlight the possibility of using combinations of these phenolic compounds to inhibit the growth of potential virulent or spoilage E. faecalis strains by reducing the total amount of additives used in dairy foods.

Characterization of certain bacterial strains for potential use as starter or probiotic cultures in dairy products.

The present work was aimed at characterizing 12 strains of lactic acid bacteria (LAB) to obtain improved potential starter or probiotic cultures that could be used for making dairy products from ewe's milk and cow's milk. Eight strains with antimicrobial properties, isolated from ewe's milk and from cheese made from ewe's and/or cow's milk, were studied. They were identified as Enterococcus faecalis (five strains), Lactococcus lactis subsp. cremoris, Leuconostoc mesenteroides, and Lactobacillus paracasei subsp. paracasei (one strain of each species). Additionally, four strains were obtained from the American Type Culture Collection: Lactobacillus casei 393 (isolated from cheese), L. lactis subsp. lactis 11454 (origin nonspecified and a producer of nisin), and two strains isolated from human feces (L. paracasei subsp. paracasei 27092 and Lactobacillus rhamnosus 53103, antibacterial agent producer). All E. faecalis strains showed at least one virulence factor (either hemolysin or gelatinase), which emphasizes the importance of these studies in this species. Both L. lactis strains and most Lactobacillus spp. were good acidifiers in ewe's milk and cow's milk at 30°C. High ß-galactosidase activity, as well as aminopeptidase activities that favor the development of desirable flavors in cheese, were detected in all Lactobacillus spp. strains. Furthermore, L. rhamnosus ATCC 53103 showed α-fucosidase activity (thought to help colonization of the intestine) and lack of α-glucosidase activity (a trait considered positive for diabetic and obese humans). This last enzymatic activity was also lacking in L. lactis ATCC 11454. L. mesenteroides was the only strain D(2)-lactic acid producer. The selection of any particular strain for probiotic or dairy cultures should be performed according to the technological and/or functional abilities needed.

¿Constituye la cirugía mayor ambulatoria una opción de tratamiento adecuado en la enfermedad de Crohn perianal? / No disponible

Introducción: El tratamiento quirúrgico de las fístulas perianales en pacientes con enfermedad de Crohn (EC) ha sufrido algunos cambios con la llegada de las terapias biológicas. Material y método: Se han evaluado 25 pacientes con EC perianal entre diciembre de 2005 y septiembre de 2007. Todos los pacientes se trataron en régimen ambulatorio siguiendo un protocolo diagnóstico-terapéutico consensuado con la Unidad de Inflamatoria de nuestro hospital. El tratamiento consistió en el drenaje de abscesos con colocación de sedales y/o histerotomía junto con el tratamiento con anti-TNF. El objetivo de este trabajo ha sido valorar los resultados de los primeros pacientes tratados en régimen de cirugía mayor ambulatoria (CMA).Resultados: El número medio de fístulas fue de 2,31 ± 1,22(1-5), siendo en el 84% fístulas complejas y la más frecuente la transesfinteriana alta. La colocación de sedales fue el procedimiento más aplicado en un 60%, con una permanencia media de21,1 ± 7,9 semanas. Se administraron biológicos en un 84% (21pacientes). Ningún paciente preciso ingreso hospitalario derivado de complicaciones quirúrgicas o anestésicas. Conclusiones: La CMA puede ser un abordaje seguro en el manejo de la enfermedad perianal en la EC (AU)

Background: The surgical management of perianal fistulas in patients with Crohn’s disease (CD) has experienced some changes since the appearance of biological therapies. Material and method: Twenty-five patients with perianal CD were analyzed from December 2005 to September 2007. All these patients were treated as ambulatory surgery following a diagnostic-therapeutic protocol developed by the Inflammatory Bowel Disease Unit of our hospital. The treatment was based on the drainage of the abscesses with Seton placement and/or fistulotomy associating anti-TNF. The aim of this study is to evaluate the results of the first patients who underwent this treatment in ambulatory surgery. Results: The mean number of fistulas was 2.31 ± 1.22 (1-5),84% of which were complex. The most frequent type was a hightrans-sphincteric fistula. Insertion of set on was the most common procedure (60%) with a mean time placement of 21.1 ± 7.9weeks. Biological therapies were used in 84% (21 patients). No patients required further hospitalization due to surgical or anesthetic complications. Conclusions: Ambulatory surgery can become a safe approach for the management of perianal disease in CD (AU)

Fisiopatología de la degeneración y del dolor de la columna lumbar / Physiopathology of lumbar spine degeneration and pain

La lumbalgia es una patología muy frecuente en nuestro medio, con una enorme repercusión sanitaria y sociolaboral. Con la edad, se inicia una cascada degenerativa en la columna lumbar, que comienza en el disco intervertebral, continuando por las facetas articulares y demás elementos vertebrales. Esta degeneración del raquis forma parte del envejecimiento normal del individuo, aunque en ocasiones puede causar dolor y/o alteraciones neurológicas. Para comprender la fisiopatología del dolor lumbar, será preciso conocer que la inervación de la columna lumbar se hace fundamentalmente por tres ramos nerviosos: ramo dorsal de los nervios espinales lumbares (o rami dorsal), nervio sinuvertebral de Luschka y ramos ventrales de la cadena simpática. Existen dos tipos de patrones de dolor en la columna lumbar: el dolor irradiado y el dolor referido. La cascada de la degeneración consta en tres estadios. El primer estadio sería la disfunción. El anillo fibroso se fisura y pierde la capacidad de contener al núcleo pulposo. Esto ocasiona primero el síndrome de disrupción discal y, si el núcleo supera el contorno del annulus, las hernias discales. El segundo estadio de Kirkaldy-Willis es el de inestabilidad. En este estadio la movilidad en el segmento móvil aumenta de forma patológica. En esta revisión describiremos los signos radiológicos asociados a esta inestabilidad. La tercera fase es la de estabilización, caracterizada por la estenosis, asociada o no a inestabilidad

Low back pain is a very frequent condition in our country and has great social and occupational repercussions. With advancing age, a degenerative cascade occurs in the lumbar spine, which starts at the intervertebral disc and subsequently involves the facet joints and other vertebral elements. This spinal degeneration is part of the normal ageing process, although it can sometimes cause pain and/or neurological alterations. To understand the physiopathology of lumbar pain, it is necessary to know that the innervation of the lumbar spine occurs mainly through three nerve rami: dorsal ramus of the lumbar spine nerves (or «dorsal rami»), Luschka's sinuvertebral nerve and the ventral rami of the sympathetic chain. There are two types of pain pattern in the lumbar spine: irradiated pain and referred pain. The degeneration cascade is divided up into three stages. The first is that of dysfunction, whereby the annulus fibrosus is fissured and can no longer contain the nucleus pulposus. This leads, first to the so-called disc disruption syndrome and, if the nucleus exceeds the contour of the annulus, to disc herniations. The second stage, also called the Kirkaldy-Willis stage, is that of instability. At this stage, the mobility of the mobile segment increases pathologically. We describe the radiological signs associated to this instability. The third phase is that of stabilization and is characterized by stenosis, which may or may not be associated to instability

Evaluation of the spiral plating system for the routine assessment of indicator microorganisms in raw ewe's milk.

The numbers of members of different microbial groups in bulk raw ewe's milk used for cheesemaking (46 samples, taken on receipt at the dairy over 1 year) were assayed by the spiral plating system to determine the effectiveness of this method compared with that of widely accepted conventional methods in providing counts. The results indicated that for ewe's milk, the suitability of the spiral plating system depends to a great extent on the microbial group studied. Although "spiral" counts of mesophiles, psychrotrophs, coliforms, and Enterobacteriaceae could be considered equivalent to those obtained by conventional techniques (r > or = 0.90; variance between replicate platings approximately 0.005), the automated method was found not to be suitable for the assessment of other groups of indicator bacteria (thermodurics and enterococci). Counts of lactic acid bacteria and yeasts and molds were affected significantly (P < 0.05) by the plating method, although other statistical parameters were more favorable (r = 0.88 and r = 0.82, respectively; 95% confidence limits within 0.5 log units). Finally, counts of staphylococci, particularly on Baird-Parker medium, showed less variation and higher reproducibility with the spiral method. Nevertheless, for the routine microbiological analysis of ewe's milk, the spiral plating system, with its time-, effort-, and material-saving advantages, is preferred over the conventional method.

Effect of pH on the role of Mg2+ and Mn2+ on Phycomyces isocitrate lyase kinetics.

Mg2+ and Mn2+ function with the same partial mixed-type activation/inhibition mechanism, in which the metal isocitrate complex is the true substrate of Phycomyces isocitrate lyase. Binding of Mg2+ or Mn2+ to the activation site normally contributes significantly to the mechanism of catalysis. Whereas both ions activate catalysis at pH 7.3, at pH 8.5, Mg2+ ions behaved as inhibitors (beta < 1) and Mn2+ ions continued to function as activators. The binding of Mg2+ or Mn2+ to the activator site is virtually independent of the pH value. The affinity of the non-activated form of the enzyme for the Mg(2+)-isocitrate complex decreased (Ksa increased 20-fold) as pH was raised, but for Mn2+ ions the affinity of the activated enzyme for the Mn(2+)-isocitrate complex decreased 86-fold. The ion moiety of the metal-ion-isocitrate complex appears to be involved in the formation of the active enzyme-substrate complex from the non-activated enzyme.

[Emphysematous pyelonephritis]. / Pielonefritis enfisematosa.

OBJECTIVE: To present an uncommon but startling case of a urinary tract infectious disease such as renal emphysematous pyelonephritis. METHOD/RESULTS: We report the case of a decompensated diabetic female patient who presented an intrarenal infectious picture with gas formation compatible with emphysematous pyelonephritis that showed good evolution following medical treatment and simple nephrectomy surgery. CONCLUSIONS: Emphysematous pyelonephritis is a serious infective disease that occurs almost exclusively in diabetic patients and requires a fast and correct diagnosis differentiating between diffuse from focused processes in order to advise conservative or aggressive therapy on the renal unit (percutaneous drainage/nephrectomy), based on immediate hemodynamic and antibiotic medical support, due to its serious prognosis such as is described in the literature.

The pH dependence and modification by diethyl pyrocarbonate of isocitrate lyase from Phycomyces blakesleeanus.

We determined the variation with pH of the kinetic parameters for the isocitrate cleavage reaction catalyzed by Phycomyces isocitrate lyase, with the aim of elucidating the role played by ionising amino acid residues in binding and catalysis. The log VmaxpH profile shows that the enzyme possesses two ionising groups with pK values of 6.1 and 8.3. The first group is also observed in the VmaxpH/KmpH and pKmpH profiles, so this group is involved in catalysis. The last two profiles exhibit a similar pK value of 16 on the basic side, which represents the sum of the pK values for two ionising groups with pK values that differ by less than two pH units. Diethyl pyrocarbonate inactivated isocitrate lyase from Phycomyces with a second-order rate constant of 18.58 M-1 s-1 (at pH 6.0 and 20 degrees C). The difference spectra of the modified enzyme revealed an absorption maximum at 242 nm, characteristic of N-carbethoxyhistidine isocitrate lyase. No trough at around 280 nm due to O-carbethoxytyrosine is observed. Quantification of the increase in absorbance to 242 nm due to N-carbethoxyhistidine showed that ten histidine residues/active site were modified during total inactivation. However, only one of them was essential for catalysis. Treatment of the partially inactivated enzyme with hydroxylamine led to recovery of a substantial part of the original activity. The reactivity of isocitrate lyase towards diethyl pyrocarbonate declined with pH, following a titration curve for a group of pK 6.1. The presence of substrate decreased the rate of inactivation. Data-protection analyses indicate that the reactive histidine residues are within the active site of the enzyme.

Identification of the histidine residue in Escherichia coli isocitrate lyase that reacts with diethylpyrocarbonate.

Escherichia coli isocitrate lyase was inactivated by diethylpyrocarbonate in a pseudo-first-order process. The enzyme was completely inactivated by modification of a single histidine residue, but slower modification of further residues also occurred. The substrate, isocitrate, and products, glyoxylate and succinate, protected against inactivation by diethylpyrocarbonate but this was not simply due to binding at the active site. Treatment of the inactivated enzyme with hydroxylamine led to only partial recovery of activity. Diethylpyrocarbonate also reacted with sulphydryl groups in isocitrate lyase, as judged by titrations with Nbs2, but this reaction was not responsible for the failure of hydroxylamine to reactivate the enzyme fully. The reactivity of isocitrate lyase to diethylpyrocarbonate declined with pH, following a titration curve for a group of pKa 6.1. Isolation and sequencing of ethoxyformylated peptides showed that the major site of modification by diethylpyrocarbonate was histidine residue 306.

Inactivation of Phycomyces isocitrate lyase by thiol-reactive reagents. Evidence for an essential thiol group.

Isocitrate lyase from the mycelium of Phycomyces blakesleeanus was inactivated with thiol-reactive reagents, 5,5'-dithiobis-(2-nitrobenzoic)acid, p-hydroxymercuribenzoic acid, N-ethylmaleimide or iodoacetate, at pH 6.8 and 25 degrees C. In all cases the inactivation is characterized by a biphasic kinetic profile. The rapid initial phase of inactivation does not increase linearly with increasing reagent concentration, but exhibits an apparent saturation effect, suggesting the formation of a reversible complex between the enzyme and the reagent prior to the inactivation step. Re-activation of the enzyme was observed under thiol excess treatment. The pH dependence of the initial phase of inactivation suggests that a group on the enzyme with pKa = 6.8 is being modified. The effect of ligands was tested on the inactivation reaction. Mg(2+)-Ds-isocitrate and Ds-isocitrate provided total protection, whereas Mg2+ ions, succinate and oxalate provided only partial protection of the enzyme against inactivation. On the basis of these results, we would suggest that the thiol-reactive reagents modify at least one thiol group crucial for the enzymatic activity and probably located in the interface between succinate and glyoxylate subsite.

Isocitrate lyase from Phycomyces blakesleeanus. The role of Mg2+ ions, kinetics and evidence for two classes of modifiable thiol groups.

Isocitrate lyase was purified from Phycomyces blakesleeanus N.R.R.L. 1555(-). The native enzyme has an Mr of 240,000. The enzyme appeared to be a tetramer with apparently identical subunits of Mr 62,000. The enzyme requires Mg2+ for activity, and the data suggest that the Mg2(+)-isocitrate complex is the true substrate and that Mg2+ ions act as a non-essential activator. The kinetic mechanism of the enzyme was investigated by using product and dead-end inhibitors of the cleavage and condensation reactions. The data indicated an ordered Uni Bi mechanism and the kinetic constants of the model were calculated. The spectrophotometric titration of thiol groups in Phycomyces isocitrate lyase with 5.5'-dithiobis-(2-nitrobenzoic acid) gave two free thiol groups per subunit of enzyme in the native state and three in the denatured state. The isocitrate lyase was completely inactivated by iodoacetate, with non-linear kinetics. The inactivation data suggest that the enzyme has two classes of modifiable thiol groups. The results are also in accord with the formation of a non-covalent enzyme-inhibitor complex before irreversible modification of the enzyme. Both the equilibrium constants for formation of the complex and the first-order rate constants for the irreversible modification step were determined. The partial protective effect of isocitrate and Mg2+ against iodoacetate inactivation was investigated in a preliminary form.

Effect of glucose on isocitrate lyase in Phycomyces blakesleeanus.

Repression of the synthesis of isocitrate lyase by glucose and/or induction of the synthesis of isocitrate lyase by acetate in Phycomyces blakesleeanus were demonstrated. Both glycerol and ethanol failed to induce isocitrate lyase activity. Furthermore, glucose appeared to cause an in vivo catabolite inactivation of the derepressed enzyme. Isocitrate lyase was inactivated both reversibly and irreversibly by glucose.

[Comparative study of adriamycin and thiotepa in the chemoprophylaxis of superficial bladder tumors]. / Estudio comparativo entre adriamicina y thiotepa en la quimioprofilaxis de los tumores vesicales superficiales.

We present a comparative study of the evolution of 250 patients with primary surface tumour, analysing the percentages of relapses and period free of illness according to the type of endovesical chemoprophylactic treatment administered. In 103 cases no chemotherapy treatment at all was administered, whilst in 90 cases thiotepa was applied and in 57 adriamycin. We have studied the evolution of these patients in accordance with the number of tumours, location, cell grade and stage, assessing the progression in grade and state of the primary tumours. After analysing the results, we observe that relapses are significantly more numerous and more precocious in patients receiving no chemotherapy treatment at all, and differences may be seen on an overall basis between adriamycin and thiotepa. In grade 1, stage 0 and single tumours, though they displayed a longer period free of illness in treated patients, the relapses were similar to those of non-treated patients. In this type of tumour thiotepa proved more effective than adriamycin, although the latter provides a longer period free of illness. Patients with high grade and stage tumours do indeed relapse significantly less and later when they receive treatment, and adriamycin achieves better results. As regards location, save in the case of tumours located on the cupula and front face, where relapses were the same between groups of treated and non-treated patients, in the rest the evolution of the tumours was better in treated patients irrespective of location.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of light on several metabolites of carbohydrate metabolism in Phycomyces blakesleeanus.

The concentrations of all metabolites studied, except fructose 1,6-bisphosphate from wild-type Phycomyces blakesleeanus, were light dependent. This photoregulation appears to be independent of the mad gene product(s) and also independent of carotene biosynthesis regulation. However, the photoregulation of glyceraldehyde 3-phosphate, 2-phosphoglycerate, and phosphoenolpyruvate may be assigned to these mad and car S gene products.

Detection of human cytomegalovirus in clinical specimens by DNA-DNA hybridization.

A diagnostic assay has been developed to detect human cytomegalovirus (HCMV) DNA in clinical specimens with 32P-labeled cloned fragments of HCMV strain AD169. The labeled probe can detect 10 pg of HCMV DNA and fails to hybridize to DNA from other herpesviruses or human DNA. The assay correctly identified 22 (92%) of 24 coded urine specimens culture positive for HCMV and 23 (88%) of 26 urine specimens culture negative for HCMV. In a prospective study of 67 buffy-coat specimens from recipients of bone marrow transplants HCMV DNA was detected in 13 (93%) of 14 culture-positive samples. Of 53 buffy-coat specimens culture negative for HCMV, 32 were hybridization negative for HCMV DNA. However, in 20 of 21 buffy-coat specimens positive for HCMV by hybridization but negative by culture there was evidence that the hybridization assay was correct and more sensitive than currently available tissue culture techniques.

[Evaluation of gammagraphy in the differential diagnosis of cysts and renal tumors]. / Valoración de la gammagrafía en el diagnóstico diferencial de quistes y tumores renales.

In view of the problems posed by the diagnosis of intrarenal masses, the authors review 16 cases of patients with this pathology who have undergone renographic and gammagraphic studies. They obtain a high level of coincidence between the gammagraphic diagnosis and its subsequent surgical confirmation, a fact which indicates that the kidney gammagraph is of great diagnostic value. This may be due to the different vascularization of the pathological area which would allow for a greater indication by the tracer, rejecting the theory of parenchymatous intoxication by toxic tumour substances.