Positive prostate biopsy following radiotherapy can predict metastasis-free survival in localized prostate cancer.

BACKGROUND/AIMS: To determine the impact of post-treatment biopsy results on 10-year metastasis-free survival (MFS), overall survival (OS) and cause-specific survival (CSS) in localized prostate cancer (PCa) patients treated with high-dose radiotherapy (RT). MATERIALS/METHODS: Retrospective analysis of 232 patients with T1c-T3bN0M0 PCa who underwent a prostate biopsy 24-36 months after high-dose RT. Biopsies were categorized as positive biopsy (PB) if H&E staining showed evidence of residual malignancy and negative biopsy (NB) if no malignant cells were present. Kaplan-Meier estimates of 10-year MFS, OS and CSS rates were calculated for each group and Cox proportional-hazards models were used to estimate the hazard ratios. The median follow-up was 124 months (range 26-267). RESULTS: Sixty-two of 232 (26.7%) patients had post-treatment positive biopsies (PB). A positive post-treatment biopsy was significantly associated with a lower 10-year MFS (78.4% vs. 95.4%, p = 0.001, HR: 3.9, 95% CI: 1.8-8.3). Although patients with PB had worse outcomes that those with NB, we could not show a statistically significant difference in OS (81.0% vs. 87.9%, p = 0.282, HR: 1.3, 95% CI: 0.7-2.3) or CSS (96.2% vs. 99.4% (p = 0.201, HR. 2.4, 95% CI: 0.6-9.7). After multivariate analysis, the strongest predictor of MFS was the post-treatment biopsy status (p < 0.001, HR: 5.4, 95% CI 2.26-12.85) followed by Gleason score (p = 0.002, HR: 2.24, 95% CI 1.33-3.79). CONCLUSION: A positive biopsy following RT can predict MFS in localized prostate cancer. These data highlight the relevance of achieving a local control and support the use of aggressive local therapeutic interventions for PCa.

Reduced late urinary toxicity with high-dose intensity-modulated radiotherapy using intra-prostate fiducial markers for localized prostate cancer

Background/purpose. To evaluate the impact of intensity-modulated radiotherapy (IMRT) with intra-prostate fiducial markers image-guided radiotherapy (IGRT) on the incidence of late urinary toxicity compared to 3D conformal radiotherapy (3DCRT) for patients with prostate cancer (PC). Methods and materials. We selected 733 consecutive patients with localized PC treated with dose-escalation radiotherapy between 2001 and 2014. Eligibility criteria were radiation dose >72.0 Gy, no pelvic RT and minimum follow-up 24 months. 438 patients were treated with 3DCRT and 295 with IMRT. Acute and late urinary complications were assessed using the EORTC/RTOG and CTCAEs v3.0 definition. The Cox regression model was used to compare grade ≥2 urinary toxicity between both techniques. The median follow-up was 75 months (range 24-204). Results. The median isocenter radiation dose was 78.7 Gy for 3DCRT and 80.7 Gy for IMRT/IGRT (p < 0.001). The 5-year incidence of late grade ≥2 urinary toxicity was 6.4% for IMRT and 10.8% for 3DCRT [hazard ratio (HR) 0.575, p = 0.056]. The corresponding 5-year estimates of late grade ≥2 hematuria were 2% for IMRT and 5.3% for 3DCRT (HR 0.296, p = 0.024). On multivariate analysis, the antecedent of prior transurethral resection of the prostate was also a strong predictor of a higher risk of urinary complications (HR 2.464, p = 0.002) and of hematuria (HR 5.196, p < 0.001). Conclusion. Compared with 3DCRT, high-dose IMRT/IGRT is associated with a lower rate of late urinary complications in spite of higher radiation dose (AU)

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Reduced late urinary toxicity with high-dose intensity-modulated radiotherapy using intra-prostate fiducial markers for localized prostate cancer.

BACKGROUND/PURPOSE: To evaluate the impact of intensity-modulated radiotherapy (IMRT) with intra-prostate fiducial markers image-guided radiotherapy (IGRT) on the incidence of late urinary toxicity compared to 3D conformal radiotherapy (3DCRT) for patients with prostate cancer (PC). METHODS AND MATERIALS: We selected 733 consecutive patients with localized PC treated with dose-escalation radiotherapy between 2001 and 2014. Eligibility criteria were radiation dose >72.0 Gy, no pelvic RT and minimum follow-up 24 months. 438 patients were treated with 3DCRT and 295 with IMRT. Acute and late urinary complications were assessed using the EORTC/RTOG and CTCAEs v3.0 definition. The Cox regression model was used to compare grade ≥2 urinary toxicity between both techniques. The median follow-up was 75 months (range 24-204). RESULTS: The median isocenter radiation dose was 78.7 Gy for 3DCRT and 80.7 Gy for IMRT/IGRT (p < 0.001). The 5-year incidence of late grade ≥2 urinary toxicity was 6.4% for IMRT and 10.8% for 3DCRT [hazard ratio (HR) 0.575, p = 0.056]. The corresponding 5-year estimates of late grade ≥2 hematuria were 2% for IMRT and 5.3% for 3DCRT (HR 0.296, p = 0.024). On multivariate analysis, the antecedent of prior transurethral resection of the prostate was also a strong predictor of a higher risk of urinary complications (HR 2.464, p = 0.002) and of hematuria (HR 5.196, p < 0.001). CONCLUSION: Compared with 3DCRT, high-dose IMRT/IGRT is associated with a lower rate of late urinary complications in spite of higher radiation dose.

Genetic position of Valencia (Spain) in the Mediterranean basin according to Alu insertions.

In this work, eight human-specific Alu insertion polymorphisms (ACE, TPA25, PV92, APO, FXIIIB, D1, A25, and B65) were typed in 106 unrelated healthy individuals born in the province of Valencia (Spain), with the aim of analyzing the genetic relationships between this region of the Iberian Peninsula and other Mediterranean populations. To that end, Alu data on Eastern European, Western European, and North African populations were compiled from previous studies. The genetic information was stressed by means of genetic distances (R matrix method), nonmetric multidimensional scaling (MDS) and analyses of molecular variance (AMOVA). In Valencia, the most common Alu insertion was APO (0.940), and the least frequent was A25 (0.104). The average gene diversity (GD) computed for the sample examined was comparatively high (0.382). The insertion frequencies estimated for the eight Alu markers were very similar to the mean frequencies calculated for the whole set of populations included in the study, suggesting the hybrid nature of the Valencia's gene pool. MDS and AMOVA results generated from Alu data reveal that the Mediterranean has acted as a strong genetic boundary between the north (Europe) and the south (Northern Africa), resulting in significant gene diversity between the populations of the two regions. Restricted exclusively to the European scope, we suggest the possibility that the Mediterranean could have also acted as a migratory passageway, propitiating the dissemination of cultures and genes between the east and west of Europe and giving rise to some homogenization of gene frequencies among coastal dwelling populations.

Presente y futuro de la hormonoterapia adyuvante en cáncer de mama: evidencia clínica y ensayos clínicos / Present and future of adjuvant hormone therapy in breast cancer: clinical evidence and clinical trials

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Utilidad del Bifidobacterium lactis en la prevención de la translocación bacteriana en el intestino corto experimental / Probiotic suplementation reduces the risk of bacterial translocation in experimental short bowel syndrome

La translocación bacteriana (TB) constituye el principal foco de atención en los procesos infecciosos que acompañan al síndrome del intestino corto (SIC). La pérdida de tejido intestinal inmunocompetente, la alteración de la motilidad y el sobrecrecimiento bacteriano, favorecen la aparición de TB. El empleo de probióticos ha sido recomendado en diversas situaciones patológicas, como el tratamiento y prevención de diarreas agudas, alergia alimentaria, alteraciones inmunitarias, procesos inflamatorios intestinales, aumento de los niveles séricos de colesterol y prevención de la formación de tumores intestinales .El objetivo de este trabajo ha sido estudiar el posible efecto beneficioso de un probiótico en el intestino a corto experimental. Treinta y dos ratas Wistar fueron divididas en dos grupos: Grupo A (n=14): Grupo control con resección del 80 por ciento del intestino delgado, libre acceso a comida y agua, y 10 días de seguimiento. Grupo B (n=18), como el grupo A, incluyendo la administración oral diaria de 7,8 x 10 9 UFC de Bifidobacterium lactis en 1 ml de agua estéril. Tras el sacrificio, se recogieron muestras de sangre portal, sangre periférica y ganglio linfático mesentérico (GGLL) para cultivo microbiológico. Se consideró la existencia de TB ante la presencia de microorganismos gram (-) en algunos de los cultivos. La incidencia TB ha sido del 93 por ciento en el grupo A, y del 44 por ciento en el grupo B (p<0,001). La reducción del riesgo relativo (RRR) es 0,52 (IC al 95 por ciento de 0,23-0,81) y el número necesario a tratar (NNT) es 2 (IC al 95 por ciento de 1-5).En conclusión, la resección intestinal está asociada a una alta incidencia de TB y ésta incidencia se ve disminuida por la administración oral diaria de Bifidobacterium lactis (AU)

Probiotic supplementation reduces the risk of bacterial translocation in experimental short bowel syndrome.

BACKGROUND/PURPOSE: Probiotics are live organisms that survive passage through the gastrointestinal tract and have beneficial effects on the host. Lactobacillus and Bifidobacterium have been recommended for cholesterol lowering, acute diarrhea, prevention of cancer, or inflammatory bowel disease. On the other hand, after massive bowel resection, bacterial overgrowth is frequent and favors bacterial translocation (BT). The possible beneficial effects of Bifidobacterium lactis (BL) administration on BT in experimental short bowel syndrome (SBS), have not been investigated. The aim of this study was to test the hypothesis that BL administration decreases BT in SBS in animals fed orally. METHODS: One hundred twenty-eight adult Wistar rats fed orally with standard rat chow and tap water "ad libitum" were maintained in individual metabolic cages for 10 days and divided into 3 groups: control group (n = 71): nonmanipulated animals; RES group (n = 39): 80% gut resection from 10 cm beyond the angle of Treitz to 10 cm above the cecum; RES-PRO group (n = 18): same resection and daily 7.8 x 10(8) CFU B Lactis administration, after orogastric intubation. At the end of the experiment they were killed, and mesenteric lymph nodes (MLN) and peripheral and portal blood specimens were recovered and cultured. Bacterial identification in blood was made by conventional methods, and MLN culture was considered positive with a growth over 100 CFU/g. RESULTS: Bacterial translocation was detected in 6% of control group rats. The incidence of BT in the RES group was 87% (34 of 39), whereas only 50% (9 of 18) of RES-PRO animals had BT (P <.05). The relative risk reduction (RRR) was 0.43 (95% Cl 0.14 to 0.72), and the number needed to treat (NNT) was 3 (95% Cl 2 to 8). In other words, animals that received BL had the risk of BT reduced by 43% (RRR of 0.43), and of every 3 animals treated, 1 is expected to be free of BT (NNT of 3). CONCLUSION: Administration of B Lactis reduces the incidence of BT in adult Wistar rats after 80% gut resection.

Microsatellite DNA markers from HLA region (D6S105, D6S265 and TNFa) in autochthonous Basques from Northern Navarre (Spain).

BACKGROUND: The extent of the genetic polymorphism of the HLA complex is becoming well characterized in Basque population and their subpopulations. This level of knowledge mainly concerns HLA class I loci. However, Basque population surveys dealing with HLA class II genes and/or microsatellites in the HLA region are still very scarce. AIM: The population genetics of three highly polymorphic short tandem repeat (STR) loci, D6S105, D6S265 and TNFa, from HLA region has been analysed in autochthonous (indigenous) Basques from Northern Navarre (Spain). The same blood samples have been typed for HLA class II genes from DQ/DR/DP regions and some findings from that information can be found therein. SUBJECTS AND METHODS: Blood samples were taken from 107 unrelated autochthonous Basques from Northern Navarre. The criterion used to define Northern Navarrese identity was that of three generations of Basque surnames and birthplaces. RESULTS: The main features observed in Navarrese Basques were the rather high frequencies of alleles D6S105*4 and D6S265*7. A novel allele has been detected at the D6S265 locus (13: 145 bp). The most frequent haplotype was D6S105*8-D6S265*4 with a highly significant linkage disequilibrium being presented. The high frequency of allele TNFa*1 in Basques is noteworthy and this characteristic is not shared by other European populations, where TNFa*1 is absent or shows negligible values. The multidimensional scaling analysis (MDS) for TNFa allele frequencies has shown a high variability among populations and that alleles TNFa*1 (F(ST) = 0.0615) and TNFa*12 (F(ST) = 0.0424) seem to have significant influence over the spatial population configuration. TNFa*2 showed the lowest FST value (0.0077) because of its conspicuous homogeneous distribution all over the European populations. CONCLUSIONS: Findings shown here on HLA microsatellites and their relationships with other HLA class I and class II genes in Basques can be helpful for those studies mainly addressed at detecting associations between HLA genes and diseases in the Basque area as a whole, and particularly in its autochthonous population, settled there since remote times.

[Beneficial effects of Bifidobacterium lactis in the prevention of bacterial translocation in experimental short bowel syndrome]. / Utilidad del Bifidobacterium lactis en la prevención de la translocación bacteriana en el intestino corto experimental.

BACKGROUND: Probiotics are live organisms that survive passage through the gastrointestinal tract and have beneficial effects on the host. Lactobacillus and Bifidobacterium have been recommended in cholesterol lowering, acute diarrhea, prevention of cancer or inflammatory bowel disease. On the other hand, after massive bowel resection bacterial overgrowth is frequent and favours the occurrence of bacterial translocation (BT). The possible beneficial effects of Bifidobacterium lactis (BL) administration on BT in experimental short bowel syndrome (SBS), have not been investigated. AIM: To test the hypothesis that BL administration decreases BT in SBS in animals fed orally. METHODS: Thirty-two adult Wistar rats fed orally with standard rat chow and tap water "ad libitum" were maintained individual metabolic cages for ten days after 80% gut resection from the duodeno-jejunal angle to 10 cm above the cecum and divided in two groups: -Group A (n = 14): served as control. -Group B (n = 18): daily 7.8 x 109 CFU Bifidobacterium lactis administration, after orgastric intubation. At the end of the experiment they were sacrificed and mesenteric lymph nodes (MLN), and peripheral and portal blood specimens were recovered and cultured. Bacterial identification in blood was made by conventional methods and MLN culture was considered positive with a growth over 100 CFU/g. RESULTS: Bacterial translocation was detected in 93% of Group A rats. The incidence of BT in Group B was 44%. The relative risk reduction (RRR) was 0.52 (95% confidence interval 0.23-0.81) and the number needed to treat (NNT) was 2 (95% confidence interval between 1-5). CONCLUSION: Administration of Bifidobacterium lactis reduces the incidence of BT in adult Wister rats, after 80% gut resection.

Glioblastoma multiforme recidivado tratado con temozolomida oral, un agente activo y con perfil toxicológico favorable / Treatment of gliobastoma multiforme at first relapse with oral temozolomide: an active and weli tolerated treatment

Propósito: Estudio clínico, analítico, radiológico, histológico y terapéutico de un caso de glioblastoma multiforme recidivado tratado con temozolomida, un nuevo agente quimioterápico oral. Métodos: Tras documentación de recidiva tumoral se administró temozolomida a una dosis de 200 mg/m2/día x 5 días cada 28 días. Resultados: Con un seguimiento hasta la fecha de 22 meses y una supervivencia libre de progresión de 17 meses, se ha analizado la actividad antitumoral mediante RM objetivándose respuesta completa, mantenimiento en los parámetros de calidad de vida según cuestionario EORTC QLQ-C30 y buena tolerancia al tratamiento. Conclusiones: Temozolomida es un agente activo y con perfil toxicológico favorable para el tratamiento de gliomas malignos (AU)

Invasive bladder cancer: a single-institution experience with bladder-sparing approach.

Our objective was to assess the efficacy and safety of a selective bladder-preserving approach by transurethral resection and sequential chemoradiotherapy in patients with muscle-invasive bladder cancer. From 1989 through 1997, 40 patients with biopsy-confirmed bladder cancer, clinical stages T2-4NxM0, were treated with induction by aggressive transurethral resection (TUR) and three cycles of methotrexate, cisplatin, and vinblastine (MCV) chemotherapy. Tumor response was evaluated by cystoscopy and biopsy. In complete responders, the treatment was continued by radiotherapy (60 Gy to the bladder and 50 Gy to pelvic lymph nodes). Radical cystectomy was recommended to patients with residual tumor. Clinical complete response rate to TUR and MCV chemotherapy was 70%. The 4-year actuarial overall survival rate for the whole series was 80.5%. Among 36 patients who completed chemotherapy and radiotherapy, the 4-year actuarial survival was 84%, with 82.6% surviving with their bladders intact. Freedom from local failure in complete responders to TUR-chemotherapy was 84%. Multivariate analysis revealed that the extent of initial TUR and status after TUR-chemotherapy were independent prognostic factors associated with survival and disease-free survival. This study confirms that the combination of aggressive TUR and sequential chemoradiotherapy with bladder preservation is an alternative treatment option to primary cystectomy for selected patients with invasive bladder carcinoma.

The genetic position of the autochthonous subpopulation of Northern Navarre (Spain) in relation to other basque subpopulations. A study based on GM and KM immunoglobulin allotypes.

GM and KM immunoglobulin (Ig) allotypes were tested in 118 autochthonous Basques from northern Navarre. The results are compared to those obtained for the same genetic markers in 6 other Basque subpopulations, 3 from Spain (Guipúzcoa, Vizcaya, and Alava) and 3 from France: Macaye, Saint-Jean Pied de Port, and Mauleon. The northern Navarrese appear genetically closer to the Alava and Saint-Jean Pied de Port subpopulations. The Basques present 3 GM haplotypes that are uncommon in Caucasian populations, suggesting that they have not been completely isolated either from Asian or African populations. The GM*1,17 23' 10,11,13,15,16 north Asian haplotype was probably the first to be introduced into the Basque area. The GM*1,17 23' 5* haplotype, considered an African genetic marker although also detected in Central Asia, would have reached the Iberian Peninsula through consecutive historic migrations from North Africa. The rare haplotype GM*1,17 23 21,28 results probably from a genetic recombination or crossing-over between the 2 common haplotypes GM*1, 17 23' 21,28 and GM*3 23 5*. It is also found with a low frequency in other neighboring regions and countries; but the possibility of its having been introduced through the main passage connecting western France and Spain during the Roman Empire and Middle Ages cannot be ruled out.

Immunoglobulin allotypes (GM and KM) in Basques from Spain: approach to the origin of the Basque population.

GM and KM immunoglobulin (Ig) allotypes have been tested in 310 autochthonous Basques from the three subpopulations of Vizcaya, Guipúzcoa, and Alava, Spain. They are compared with allotypes occurring in autochthonous French Basques, some Pyrenean subpopulations in France, and European populations. The analysis suggests that the Basque subpopulations show noticeable genetic distances between them and with other European populations. The genetic similarity between Basques and European populations is greater in the Basques from France than in the Basques from Spain. The genetic distances between Basque subpopulations in Spain fit well with the different historical levels of the spatial implantation of the Basque language. Guipúzcoa, the Basque province with the highest number of Basque-speaking people, shows the most genetic distinctiveness. The main underlying cause of this spatial genetic pattern seems to be admixture with surrounding populations. Our results do not support the hypothesis that Basques are a relict population of ancient Europeans. They might be a consequence of the colonization of the Basque area by a long-distance migrating group, probably a small Neolithic North Caucasian population that introduced agriculture in the region. They experienced early, rapid demographic growth, and they did not breed with the few hunter-gatherers wandering throughout the area. The North Caucasian migrants could have admixed with North Asian groups dating from many centuries before. Furthermore, Basques present polymorphic frequencies of a common African haplotype, suggesting that they have not been completely isolated from populations of Africa. However, another focus of the African haplotype has been detected in Central Asia, and the Basque frequencies alternatively might be due to North Asian groups.

Successful bone marrow transplantation in sensitized aplastic anemia patients using total lymphoid irradiation for conditioning: long-term follow-up.

Between June 1986 and November 1994, 22 previously transfused patients with severe aplastic anemia (SAA) were treated with high-dose cyclophosphamide (CY) (50 mg/kg over 4 consecutive days) and 7 Gy total lymphoid irradiation (TLI) in two fractions before allogeneic bone marrow transplantation (BMT) from HLA-identical sibling. Graft-versus-host-disease (GVHD) prophylaxis included the combination of methotrexate and cyclosporine A in all cases. Actuarial survival at 5 years is 73 +/- 9 per cent for the entire group and 86 +/- 13 per cent for the seven patients < or = 18 years. The incidence of graft failure was 0 per cent, and of acute GVHD and chronic GVHD was 31.5 per cent and 24 per cent respectively. Prolonged interval from diagnosis to BMT adversely influenced survival (P = 0.03). No hypothyroidism or secondary malignancies have been documented in this series. Our findings indicate that survival with CY-TLI is comparable to that obtained using preparative regimens without radiation. The changing role of radiotherapy in pretransplant immunosuppression for SAA is discussed.

Prognostic factors affecting leukemia relapse after allogeneic BMT conditioned with cyclophosphamide and fractionated TBI.

Between June 1985 and May 1992, 94 consecutive patients with acute myeloid leukemia (AML = 28), acute lymphoblastic leukemia (ALL = 27) and chronic myelogenous leukemia (CML = 39), were transplanted using genotypically HLA-identical marrow donors. All were conditioned with cyclophosphamide (CY) plus 12 Gy fractionated TBI. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A alone in nine patients and methotrexate-cyclosporin A in 85 patients. Forty-eight patients developed grades II-IV acute GVHD and 24 of 68 patients who survived at least 100 days developed chronic GVHD. The 5-year actuarial probability of survival, event-free survival and relapse were 41 +/- 5%, 37 +/- 5% and 37 +/- 6%, respectively. In multivariate analysis, an increased risk of leukemia relapse was associated with (1) absence of chronic GVHD (P = 0.017), (2) advanced disease at transplant (P = 0.034) and (3) diagnosis of AML (P = 0.047). Our results confirm that disease status at transplant and chronic GVHD are the more important risk factors associated with leukemia relapse, and suggest that CY-TBI has only a partial role in eradicating leukemia in AML.

[A comparative study in rectal adenocarcinoma: preoperative or postoperative radiotherapy]. / Estudio comparativo en el adenocarcinoma de recto: radioterapia preoperatoria o postoperatoria.

PURPOSE: To compare the results of preoperative and postoperative radiotherapy in rectal adenocarcinoma, in terms of overall survival and disease-free survival. PATIENTS AND METHODS: From 1989 to 1993, 52 patients with clinically operable rectal cancer were retrospectively analyzed. Two groups were compared: Patients in Group I received postoperative radiotherapy and those in Group II preoperative radiotherapy. Patients with a Karfnosky index > 70%, no evidence of distant disease and no major systemic problems were included in this study. RESULTS: The overall 5-year actuarial survival was 75% in Group I and 83% in Group II. The 5-year disease-free survival was 52% in Group I compared to 86% in Group II, a statistically significant difference (p = 0.025). A reduction in all Dukes' stages was observed in the preoperative radiation group, allowing preservation of the anorectal function in an increased number of patients. CONCLUSIONS: We observed better results with preoperative radiotherapy and conclude that this treatment might be justified in rectal carcinoma.

ABH antigen secretion in Basques and the spatial variation pattern of the secretor locus in Spain.

Secretion of the ABH blood group antigen was analyzed in 305 saliva samples of students in the Basque Country University. The frequency of ABH non-secretor was 26.23%, a result very close to that obtained in autoctonous Basques (22-23%) and in other populations from the West (Galicia) and Centre (Castille) of Spain. With certain exceptions, the frequencies of non-secretor se allele present a fairly homogeneous variability pattern and no significant spatial orientation or tendencies of se gene distribution are observed in the Iberian Peninsula.

Evaluacion comparativa de dos formulas alimenticias en ninos con diarrea aguda. / Comparative evaluation of 2 feeding formulas in children with acute diarrhea

Se estudiaron 61 pacientes con diarrea aguda y deshidratacion del 5-10%, para valorar su comportamiento clinico al recibir una de las dos formulas alimenticias estudiadas, a saber: dieta transicional (DT) y formula especial (HN-25) inmediatamente despues de corregir el desequilibrio hidroelectronico (D.H.E.). Los resultados muestran una diferencia estadisticamente significativa (p < 0.05) en el grupo de enfermos con deshidratacion al 5% que recibieron la formula especial durante las primeras 24 horas de ayuno. Se observo que los parametros: edad, sexo, condicion socioeconomica y agente causal de la diarrea no modifican el comportamiento del cuadro enteral con ninguno de los alimentos recibidos. La necesidad de preparar una de la formulas (D.T.) en el hospital, constituye una desventaja para su uso en pacientes ambulatorios. La existencia de un preparado comercial con un contenido bajo en lactosa y grasas y elevado en electrolitos y vitaminicos, lo hace de mayor utilidad para los enfermos no hospitalizados y tambien para aqueles que han requerido internamiento en un hospital