Tratamiento de heridas complejas mediante fibrina rica en plaquetas y leucocitos (L-PRF), experiencia inicial de un centro / Treatment of complex wounds using platelet rich fibrin and leukocytes (L-PRF), initial experience of a center

Resumen Introducción El uso de concentrados plaquetarios para el tratamiento de heridas complejas y regeneración tisular está siendo ampliamente utilizado a nivel mundial. Durante el último tiempo, la segunda generación de concentrados plaquetarios, particularmente el L-PRF, ha permitido tratar de manera efectiva a pacientes con esta patología. Debido a su bajo costo y versatilidad, ha sido posible aplicar esta técnica en variadas situaciones clínicas con buenos resultados. El objetivo de este trabajo es presentar nuestra experiencia utilizando L-PRF para la curación de heridas complejas (CHC) como una alternativa al uso de injertos de distinto grado de complejidad. Materiales y Método: Se realizó un análisis prospectivo de una serie de casos de pacientes que fueron sometidos a tratamiento quirúrgico de heridas complejas mediante el uso de L-PRF en el Hospital Santiago Oriente - Luis Tisné Brousse, entre los meses de enero de 2017 y diciembre de 2018. Mediante examen clínico y parámetros de inclusión, de éxito y de fracaso definidos previamente, se evaluó un total de 11 pacientes con heridas complejas a los cuales se les realizó un tratamiento local con injerto de L-PRF. Resultados: _La etiología de las heridas fue variada. 8 (72%) de los casos lograron una epitelización del 100% y 3 (28%) fracasaron. Se identificaron factores predisponentes para el fracaso de la técnica, y también fue posible establecer una relación de predicción de éxito en donde se relaciona una probabilidad alta de epitelización cuando la granulación de la herida ocurre durante los primeros 10 días sobre el injerto de L-PRF. Conclusión: El tratamiento de heridas complejas mediante L-PRF es una alternativa factible, de bajo costo y requerimientos (comparada con el uso de injertos, colgajos y sustitutos dérmicos), es segura en la resolución de heridas complejas, permitiendo disminuir la morbilidad, los costos asociados al tratamiento y estadía hospitalaria.

Introduction: The use of platelet concentrates for the treatment of complex wounds and tissue regenera-tion is being widely used worldwide. During the last time, the second generation of platelet concentrates, particularly L-PRF, has made it possible to effectively treat patients with this pathology. Due to its low cost and versatility, it has been possible to apply this technique in various clinical situations with good results. The objective of this work is to present our experience using L-PRF for the healing of complex wounds (HCC) as an alternative to the use of grafts of different degrees of complexity. Materials and Method: A prospective analysis was carried out with a series of cases who underwent surgical treatment of complex wounds using L-PRF at Santiago Oriente - Luis Tisné Brousse Hospital, between the months of January 2017 and December 2018. Through clinical examination and previously defined inclusion, success, and failure parameters, a total of 11 patients with complex wounds were evaluated who underwent local treatment with an L-PRF graft. Results: The etiology of the wounds was varied. 8 (72%) of the cases achieved 100% epithelialization and 3 (28%) failed. Predisposing factors for the failure of the technique were identified, and it was also possible to establish a predictive relationship of success where a high probability of epithelialization is related when the granulation of the wound occurs during the first 10 days on the L-PRF graft. Conclusion: The treatment of complex wounds using L-PRF is a feasible alternative, with low cost and requirements (compared to the use of grafts, flaps and dermal substitutes) and safe in the resolution of complex wounds, allowing to reduce morbidity, the costs associated with treatment and hospital stay.

Colgajos Locales en Reconstrucción Facial. Alternativas de Tratamiento

RESUMEN: Los defectos faciales de piel son frecuentemente secuelas producto de carcinomas basoceulares, carcinomas espinocelulares, melanomas, grandes tumores benignos o traumatismos de tejidos blandos. Las unidades y subunidades estéticas de la cara, la textura y color de la piel, junto a otros parámetros deben ser considerados durante la planificación de la reconstrucción mediante colgajos locales. El objetivo de este artículo de revisión bibliográfica fue describir y definir las técnicas más relevantes en los de colgajos locales aplicados en la reconstrucción facial y sus algoritmos actuales, en relación con la unidad o subunidad facial involucrada; sus consideraciones estéticas y cirugía complementaria. Las unidades y subunidades estéticas de la cara se dividen en regiones de la frente, párpados, mejillas, nariz, labios y mentón. Los colgajos de rotación, en isla, de avance y transposición son la base para la mayoría de los colgajos faciales; los más conocidos según la zona donante son: el colgajo frontal, colgajo de rotación y avance de mejilla; colgajo cérvico-facial, y colgajos nasolabiales, entre otros. La elección del colgajo depende de la zona y la unidad estética facial involucrada, siendo importante elegir y usar las líneas, los surcos y márgenes de estas unidades cuando sea posible con el fin de mejorar los resultados estéticos y reducir la posibilidad de secuelas. La cirugía complementaria y los procedimientos estéticos pueden lograr un buen camuflaje de algunas complicaciones estéticas o secuelas.

ABSTRACT: Skin face defects are frequently sequels of basal cell carcinomas, squamous cell carcinomas, melanomas, and large benign tumors or soft tissue trauma. Aesthetics units and subunits of the face, texture, color, and other parameters must be considered in the local flaps reconstructive planning. This review article aims to describe and define the most relevant techniques of facial local flaps in facial reconstruction and their current algorithms, regarding the unit or subunit, involve, their aesthetics considerations and complementary surgery. The aesthetics units and subunits of the face are divided into forehead, eyelids, cheek, nasal, lips, and chin. There are several well-known concepts and flaps used in these proceedings as rotation, island, advancement, and transposition flaps, and they are the basis for facial local flaps; The most relevant are: forehead flap, cheek advancement, and rotate flap; rhomboid, cervicofacial and bilobed flap, nasolabial flaps. The flap election depends on the zone and unit involve; it is important to choose the lines, sulcus, and borders of these units when is possible to enhance these aesthetics outcomes. These concerning improve the aesthetics outcomes and reduce the aesthetics sequels. Complementary surgery and aesthetics proceedings may accomplish a good camouflage of some aesthetics complications or sequels.

Success and failure of cardiovascular disease prevention in Czech Republic over the past 30 years. Czech part of the EUROASPIRE I-IV surveys.

Cardiovascular (CV) mortality was reduced more than 50 % in the Czech population at the turn of the century, due to an improvement of major CV risk factors in the general population, interventional procedures implemented into the treatment of acute coronary events, and new drugs (ACE inhibitors, statins etc.) for CV prevention (Czech MONICA and post-MONICA studies, 1985-2008). An insufficient level of preventive efforts is described in the Czech patients after acute coronary syndrome (Czech part of the EUROASPIRE studies, 1995-2013). Drug underdosing and wrong patients' compliance to life style and drug therapy recommendations represent two main reasons of this unsatisfactory situation. The residual vascular risk of patients with stable coronary heart disease (CHD) is still high due to a poor control of conventional risk factors on the one hand, and due to increasing weight and glucose metabolism abnormalities on the other hand. Patients with insulin resistance and glucose disorders have more frequently non LDL C dyslipidemia (atherogenic dyslipidemia), hypertriglyceridemic waist and high atherogenic index of plasma (AIP>0.24), i.e. markers of residual CV risk. Among others increased dose of statins and combined lipid modifying therapy should be implemented in patients with CHD, diabetes or metabolic syndrome.

A comparison of secondary prevention practice in poststroke and coronary heart disease patients.

OBJECTIVES: It is evident that patients with atherosclerotic vascular disease (AVD) benefit from appropriate secondary prevention. In clinical reality, the secondary prevention in AVD patients other than those with coronary heart disease (CHD) is often overlooked. Therefore, we compared the adherence to secondary prevention principles between poststroke and CHD patients. STUDY DESIGN: Descriptive (cross-sectional) study with prospective mortality follow-up. METHODS: We examined 1729 chronic patients with AVD (mean age 65.9 (±SD 9.6) years), 964 with CHD, and 765 poststroke (pooled data of Czech samples of EUROASPIRE III, IV, and the ESH stroke survey). The interview was performed 6-36 months after the coronary event/revascularization or the first ischemic stroke, while the mortality follow-up 5 years after this interview. RESULTS: Poststroke patients had a significantly higher risk of persistent smoking, blood pressure ≥140/90 mmHg and LDL ≥2.5 mmol/L than CHD patients [odds ratios adjusted for age, gender and survey were 1.63 (95% CI: 1.13-2.33), 1.38 (95% CI: 1.13-1.69) and 2.26 (95% CI: 1.84-2.78), respectively]. In contrast, poststroke patients showed a lower risk of inappropriate glucose control and hypertriglyceridemia [0.66 (95%CI: 0.54-0.82) and 0.74 (95%CI: 0.61-0.91), respectively]. The prescription rates of antiplatelets/anticoagulants, antihypertensives and statins were also significantly lower in poststroke than in CHD patients (89.4 vs 93.7, 85.9 vs 97.5, and 57.7 vs 89.8, respectively). Mortality analysis was performed in a subsample of 815 subjects interviewed in 2006/07. The 5-year all-cause mortality rates were 25.8% and 13.3% in poststroke and coronary patients, respectively (P = 0.0023); the hazard ratio for stroke adjusted for major risk factors was 1.85 (95% CI: 1.31-2.63). CONCLUSIONS: Compared to CHD patients, poststroke patients are strongly handicapped in terms of poor adherence to secondary prevention target, prescription of basic pharmacotherapies and mortality risk.

Desphospho-uncarboxylated matrix Gla protein is associated with increased aortic stiffness in a general population.

Matrix Gla protein (MGP), a natural inhibitor of calcification, strongly correlates with the extent of coronary calcification. Vitamin K is the essential cofactor for the activation of MGP. The nonphosphorylated-uncarboxylated isoform of MGP (dp-ucMGP) reflects the status of this vitamin. We investigated whether there is an association between dp-ucMGP and stiffness of elastic and muscular-type large arteries in a random sample from the general population. In a cross-sectional design, we analyzed 1087 subjects from the Czech post-MONICA study. Aortic and femoro-popliteal pulse wave velocities (PWVs) were measured using a Sphygmocor device. Dp-ucMGP concentrations were assessed in freshly frozen samples by enzyme-linked immunosorbent assay methods using the InaKtif MGP iSYS pre-commercial kit developed by IDS and VitaK. Aortic PWV significantly (P<0.0001) increased across the dp-ucMGP quartiles. After adjustment for all potential confounders, aortic PWV independently correlated with dp-ucMGP (with beta coefficient (s.d.) 11.61 (5.38) and P-value=0.031). In a categorized manner, subjects in the top quartile of dp-ucMGP (⩾ 671 pmol l(-1)) had a higher risk of elevated aortic PWV, with corresponding adjusted odds ratio (95% confidence interval) 1.73 (1.17-2.5). In contrast, no relation between dp-ucMGP and femoro-popliteal PWV was found. In conclusion, increased dp-ucMGP, which is a circulating biomarker of vitamin K status and vascular calcification, is independently associated with aortic stiffness, but not with stiffness of distal muscular-type arteries.

Tobacco smoking strongly modifies the association of prothrombin G20210A with undetermined stroke: consecutive survivors and population-based controls.

OBJECTIVE: Due to contradictory results of previous studies evaluating the association between ischemic stroke (IS) and thrombophilic polymorphisms, their routine screening in IS patients, particularly those older than 60 years, is not recommended. We evaluated the differences in the distribution of rs6025 and rs1799963 polymorphisms according to IS subtypes and their interaction with smoking. METHODS: We conducted a case-control study of 423 hospital-based consecutive survivors of their first-ever IS and 614 population-based controls. Survivors (18-81 years) with IS documented by brain imagining were examined at a median of 16 months after the index event. The stroke subtype was categorized using the Causative Classification of Stroke System. Controls (50-75 years) were free of a history of stroke/TIA, coronary heart disease, and venous thromboembolism. RESULTS: Age- and gender-adjusted prevalence of individuals carrying at least one copy of the rs1799963A minor allele was 5.3% among stroke survivors (by subtypes: 3.1% in large artery atherosclerosis, 2.0% in cardio-aortic embolism, 2.4% in small artery occlusion, and 10.3% in undetermined stroke) vs. 2.4% among controls. In multinomial multivariate adjusted analysis, rs1799963 was exclusively associated with undetermined stroke (OR: 3.67; 95% CI: 1.52-8.85; p = 0.004). There was strong evidence of rs1799963 × smoking synergistic interaction (OR: 5.14; 95% CI: 1.65-16.01; p = 0.005). There was no association of rs6025 with IS in general, or with any subtype. CONCLUSIONS: In our consecutive IS survivors, carriage of the rs1799963A allele is associated with undetermined stroke. This effect appears to be confined to smokers.

Characterization of pulmonary function in Duchenne Muscular Dystrophy.

Decline in pulmonary function in Duchenne Muscular Dystrophy (DMD) contributes to significant morbidity and reduced longevity. Spirometry is a widely used and fairly easily performed technique to assess lung function, and in particular lung volume; however, the acceptability criteria from the American Thoracic Society (ATS) may be overly restrictive and inappropriate for patients with neuromuscular disease. We examined prospective spirometry data (Forced Vital Capacity [FVC] and peak expiratory flow [PEF]) from 60 DMD patients enrolled in a natural history cohort study (median age 10.3 years, range 5-24 years). Expiratory flow-volume curves were examined by a pulmonologist and the data were evaluated for acceptability using ATS criteria modified based on the capabilities of patients with neuromuscular disease. Data were then analyzed for change with age, ambulation status, and glucocorticoid use. At least one acceptable study was obtained in 44 subjects (73%), and 81 of the 131 studies (62%) were acceptable. The FVC and PEF showed similar relative changes in absolute values with increasing age, i.e., an increase through 10 years, relative stabilization from 10-18 years, and then a decrease at an older age. The percent predicted, FVC and PEF showed a near linear decline of approximately 5% points/year from ages 5 to 24. Surprisingly, no difference was observed in FVC or PEF by ambulation or steroid treatment. Acceptable spirometry can be performed on DMD patients over a broad range of ages. Using modified ATS criteria, curated spirometry data, excluding technically unacceptable data, may provide a more reliable means of determining change in lung function over time.

[Distribution of lipoprotein associated phospholipase A2 in Czech population and its interaction with conventional cardiovascular risk]. / Distribuce s lipoproteiny asociované fosfolipázy A2 v ceské populaci a její interakce s konvencním kardiovaskulárním rizikem.

INTRODUCTION: Lipoprotein associated phospholipase A2 (Lp PLA2) represent new cardiovascular risk factor and potential treatment target. We aimed to analyze the epidemiological situation of this factor in Czech population. METHODS AND RESULTS: The study population consisted from 1 962 subjects, a random samples of general population (postMONICA study), and from patients with manifest coronary or cerebrovascular disease (Czech samples of EUROASPIRE III survey). Lp PLA2 activity was estimated using commercial kits by diaDexus Inc. in frozen samples. Increased activity (by definition, i.e. > 195 nmol/ min/ ml) was observed in 21.1 % of sample, no apparent difference between subject with and without manifest vascular disease was found. Males showed higher Lp PLA2 activity, than females (179.6 vs 146, resp., p < 0.0001), while no substantial increase with age was observed. Taking Lp PLA2 activity > 195 as dependent variable, following independent variables entered the multiple logistic regression: male gender [with odds ratio 4.26 (3.26- 5.58)], low HDL cholesterol (i.e. < 1.0 mmol/ l in males or < 1.2 mmol/ l in females) [3.49 (2.62- 4.64)], LDLcholesterol > 2.5 mmol/ l [6.95 (4.79- 10.07)] and lipid  lowering treatment [0.59 (0.44- 0.79)]. In subject without manifest vascular disease, 6.3 % of them showed co incidence of markedly increased Lp PLA2 activity with high conventional risk (SCORE > 10 %). Expanding this group by intermediate risk subjects (ie. with Lp PLA2 activity 152- 194 and/ or SCORE 5- 9.9 %) leads to increase of this prevalence to 28.9 % of primary prevention subjects. CONCLUSION: Increased Lp PLA2 activity is in Czech population highly prevalent and with exception of lipid parameters, generally independent from conventional cardiovascular risk. However, up to 29 % of subject in primary prevention amalgamate increased Lp PLA2 activity with high conventional cardiovascular risk.

The association between low 25-hydroxyvitamin D and increased aortic stiffness.

There is accumulating evidence that vitamin D exerts important pathophysiological effects on cardiovascular system. Low vitamin D was associated with increased cardiovascular risk in several reports. We studied the association between vitamin D and arterial stiffness in a random sample of 560 subjects selected from general population. Arterial stiffness was measured as aortic pulse-wave velocity (PWV) using Sphygmocor device. Serum 25-hydroxyvitamin D (25(OH)D) was measured using commercial kits. We found a clear negative trend in aortic PWV among 25(OH)D quartiles. Subjects in the bottom 25(OH)D quartile (<20 ng ml(-1)) showed the highest aortic PWV (9.04 m s(-1)), compared with 2nd-4th quartile (8.07 m s(-1), 7.93 m s(-1) and 7.70 m s(-1), respectively; P for trend <0.0001). The association between 25(OH)D and aortic PWV remained significant after adjustment for age, gender and other potential confounders; subjects in the first 25(OH)D quartile had adjusted odds ratio 2.04 (1.26-3.30) for having aortic PWV ≥9 m s(-1) (top quartile) in multiple regression. In conclusion, we found a clear significant and independent negative association between 25(OH)D and aortic PWV. Subjects with lowest vitamin D status showed the highest arterial stiffness.

Fibroma cemento osificante: análisis clínico, radiológico e histológico de 2 casos en una misma familia / Cemento-ossifying fibroma: clinical, radiological and histological analysis of 2 cases in one family

El Fibroma Cemento Osificante (FCO) es una lesión pseudo tumoral benigna de origen odontogénico, que se ubica preferentemente a nivel de molares y premolares mandibulares. Nuestro objetivo es presentar casos de FCO dentro de una misma familia, describiendo las características clínicas, radiográficas, histológicas, tratamiento y seguimiento de cada uno de ellos. Dos pacientes hermanos con FCO mandibulares atendidos en el Hospital de Carabineros fueron incluidos en este estudio. La evolución completa de cada caso es expuesta, resaltando el componente familiar de esta patología poco prevalente. Todos los pacientes fueron tratados con remoción completa de la lesión y relleno del defecto óseo con injerto autólogo de cresta iliaca o con injerto óseo particulado sintético (ChronOS®). Un paciente presento recidiva de la lesión y posteriormente un nuevo FCO en el lado contra lateral. En este tipo de lesiones, es muy importante valerse de todas las herramientas diagnosticas que estén a nuestro alcance, ya que la baja ocurrencia de estas lesiones, junto con la gran similitud tanto clínica, radiográfica e histológica que presenta con otras entidades patológicas de los maxilares, hacen que un estudio superficial, puedan llevar a un diagnostico y tratamiento erróneo, afectando la calidad de vida del paciente. El tratamiento de estas lesiones es conservador, y las recidivas son raras.

The Cemento-ossifying fibroma (COF) is a benign fibro-osseous neoplasm of odontogenic origin, that is preferentially localized in the molar and premolar mandibular area. Our goal is to present cases of COF that occurred within the same family, describing clinical, radiological and histological characteristics, in addition to treatment and monitoring of each case. Two patients who are brothers, treated at the Hospital de Carabineros, who had mandibular COF, were included in this study. The complete evolution of each case is presented, highlighting the family component of this uncommon disease. All patients were treated with complete removal of the lesion and filling the bone defect with autologous iliac crest graft or synthetic particulated bone graft (ChronOS®). One patient had recurrence of the injury and then presented a new COF on the contralateral side. In this type of injury it is very important to use all the diagnostic tools within our reach. The rarity of these lesions, and the great similarity of both clinical, radiological and histological features with other pathological conditions of the jaws, and a poorly conducted study can lead to wrong diagnosis and treatment affecting the quality of life of patients. The treatment of these lesions is conservative, and relapses are rare.

Tratamiento de fracturas en mandíbulas atróficas: presentación de dos casos clínicos / Management of Atrophic Mandible Fractures: Report of Two Clinical Cases

El siguiente trabajo tiene por objetivo presentar la experiencia del equipo de Cirugía Maxilofacial del Hospital San José, para el manejo de las fracturas en mandíbulas atróficas, reportando el tratamiento médico-quirúrgico y evolución post operatoria de casos clínicos. Se presentan dos casos clínicos de pacientes de sexo femenino, con enfermedades sistémicas de base, edéntulas, con diagnóstico de fractura en mandíbula atrófica consecutivos a caídas de nivel. De los casos tratados, el equipo logró resultados satisfactorios, mediante un tratamiento integral para los pacientes con este tipo de fracturas, basado en protocolos actuales encontrados en la literatura. El tratamiento de elección para este tipo de fracturas corresponde a la reducción anatómica quirúrgica y fijación mediante placas y tornilos de osteosíntesis. Fundamentado por sus favorables resultados y a la rápida rehabilitación funcional del paciente. El manejo multidisciplinario es fundamental para tratar este tipo de pacientes, por la posible concomitancia de enfermedades de base que pudiesen poseer estos pacientes.

The objective of the present case report is to present the experience of the maxillofacial surgery team of the Hospital San Jose in the management of atrophic mandible fracture, through the medical-surgical treatment and post-operatory evolution of two clinical cases. We studied two women with systemic conditions, edentulous with a diagnosis of atrophic mandible fracture subsequent to fall injury. In all treated cases the surgical team achieved satisfactory results through an integral treatment of patients with this type of fracture, based on actual literature reported protocols. The treatment of choice for this type of fractures is an anatomical open reduction, by internal fixation with osteosynthesis plates and screws on the basis of favorable results and functional rehabilitation of patients. The multidisciplinary management is fundamental for treatment of this type of patient due to the concomitant systemic conditions of these patients.

Cyclosporine A area-under-time-concentration-curve in rheumatologic patients after the first dose. Which of the sparse sampling strategies will predict the best?

OBJECTIVE: The aim of the present study was to validate the limited sampling strategies (LSS:s) for prediction of AUC of cyclosporine A (CsA) after the first dose in rheumatologic patients. METHODS: 22 patients suffering from rheumathoid arthritis, systemic lupus erythematodus, ankylosing spondylitis dermato(poly)myositis or seronegative spondylarthritis were treated with Neoral® (female/male: 11/3, mean ± SD: age 49 ± 14 y, body weight 75 ± 12 kg, height 166 ± 7 cm, dose 71 ± 25 mg, dose per kg 1.0 ± 0.3 mg/kg), or Consupren® (7/1, 78 ± 36, 175 ± 8, 82 ± 22, 1.1 ± 0.3). Two patients whose C12h were missing were excluded from the AUC0-12 calculation. Whole blood levels of CsA were analyzed with HPLC. Blood samples were collected at 0, 0.5, 1, 1.5, 2, 3, 4, 6, 8, and 12 hours after taking the first dose. Altogether 115 LSS:s obtained from the literature were validated. A linear trapezoidal rule was used as a reference method. Mean percentage prediction error (%PE) < ± 15% and maximal one value of absolute %PE > 30% were considered to be acceptable. The root mean squared error (RMSE) was evaluated for equations that passed the criteria. RESULTS: The best performance with all values of the absolute %PE < 30% was found in three LSS:s for AUC0-12 and two for AUC0-8: AUC0-12 = 123.792 + 1.165 × C1h + 3.021 × C3h + 7.33 × C8h; 97.6 + 1.27 × C1h + 3.14 × C3h + 4.06 × C6h; or 124.3 + 1.34 × C1h - 0.16 × C2h + 3.27 × C3h + 3.96 × C6h; AUC0-8 = -19.8 + 1.99 × C2h + 2.38 × C4h + 3.15 × C6h or -22.4 + 2.51 × C2h + 5.49 × C6h. Validation criteria were further fulfilled in AUC0-12 = 24 + 3.66 × C0h + 2.11 × C1.5h + 4.54 × C4h or 0.2 + 2 × C2h + 10.2 × C6h; AUC0-8 = 55.37 + 2.89 × C0h + 1.08 × C1 + 0.9 × C2h + 2.23 × C3h; and AUC0-4 = -41 + 1.17 × C1h + 1.85 × C2h. Only one equation proposed for AUC0-6 did not pass the validation criteria. CONCLUSIONS: Equations validated for prediction of AUC0-12, AUC0-8 and AUC0-4 might be used for LSS:s of CsA independently of the length of treatment, indication, dosage or galenic formulation.

Improved outcomes with a standardized feeding protocol for very low birth weight infants.

OBJECTIVE: The objective of this study was to evaluate the impact of a standardized enteral feeding protocol for very low birth weight (VLBW) infants on nutritional, clinical and growth outcomes. STUDY DESIGN: Retrospective analysis of VLBW cohorts 9 months before and after initiation of a standardized feeding protocol consisting of 6-8 days of trophic feedings, followed by an increase of 20 ml/kg/day. The primary outcome was days to reach full enteral feeds defined as 160 ml/kg/day. Secondary outcomes included rates of necrotizing enterocolitis and culture-proven sepsis, days of parenteral nutrition and growth end points. RESULT: Data were analyzed on 147 VLBW infants who received enteral feedings, 83 before ('Before') and 64 subsequent to ('After') feeding protocol initiation. Extremely low birth weight (ELBW) infants in the After group attained enteral volumes of 120 ml/kg/day (43.9 days Before vs 32.8 days After, P=0.02) and 160 ml/kg/day (48.5 days Before vs 35.8 days After, P=0.02) significantly faster and received significantly fewer days of parenteral nutrition (46.2 days Before vs 31.3 days After, P=0.01). Necrotizing enterocolitis decreased in the After group among VLBW (15/83, 18% Before vs 2/64, 3% After, P=0.005) and ELBW infants (11/31, 35% Before vs 2/26, 8% After, P=0.01). Late-onset sepsis decreased significantly in the After group (26/83, 31% Before vs 6/64, 9% After, P=0.001). Excluding those with weight <3rd percentile at birth, the proportion with weight <3rd percentile at discharge decreased significantly after protocol initiation (35% Before vs 17% After, P=0.03). CONCLUSION: These data suggest that implementation of a standardized feeding protocol for VLBW infants results in earlier successful enteral feeding without increased rates of major morbidities.

An inverse association between serum leptin concentration and reported alcohol intake in patients with manifest vascular disease.

BACKGROUND/OBJECTIVES: It has been reported that alcohol stimulates appetite. We aimed to establish the association between leptin, as a major food intake regulating factor, and alcohol intake in patients with chronic manifest coronary artery or cerebrovascular disease. SUBJECTS/METHODS: A cross-sectional study of 820 subjects after acute coronary syndrome, coronary revascularization or after first ischemic stroke (the Czech part of EUROASPIRE III surveys). Leptin concentrations were evaluated among predefined categories of reported weekly alcohol intake: abstainers, light drinkers (up to 2 drinks weekly, 1-44 g of pure alcohol), mild regular drinkers (3-14 drinks weekly, 45-308 g) and moderate or heavy drinkers (more than 15 drinks, ≥ 309 g of alcohol). RESULTS: Leptin showed a clear negative trend among the alcohol intake categories. Mild regular drinkers showed significantly lower leptin levels (9.3(8.2) ng/ml) compared with abstainers (18.7(18.7) ng/ml, P<0.0001) and light occasional drinkers (14.2(17.8) ng/ml, P=0.00064). The negative association between leptin and alcohol intake as a dependent variable remained significant even after adjustment for potential confounders in multiple linear regression analysis (P=0.00032). CONCLUSIONS: Drinking of small amounts of alcohol was, in our setting, associated with decreased serum leptin concentration, with a possible benefit in terms of cardiovascular risk.

The interaction of endothelial nitric oxide synthase polymorphism and current smoking in terms of increased arterial stiffness.

Nitric oxide belongs to the most important factors influencing structural and functional properties of vessel wall. Both genetic and environmental factors may influence its metabolism. The aim of this study was to explore whether two common polymorphisms of endothelial nitric synthase (eNOS) may, jointly with smoking, influence the stiffness of large arteries, quantified as pulse wave velocity (PWV). One hundred ninety four subjects free of manifest atherosclerotic disease or chronic pharmacotherapy were selected from population-based postMONICA study. PWV´s were measured using Sphygmocor® device between carotic and femoral arteries (aortic PWV) and between femoral and tibialis-posterior arteries (peripheral PWV). Two common polymorphisms, T786C and G894T, were assessed. Among current smokers, homo- or heterozygous carriers of T786C mutation showed significantly higher peripheral PWV than normal genotype carriers (14.0 vs 10.7 m/s, p<0.002); the same was true for the carriers of G894T mutation (13.9 vs 11.0 m/s, p<0.015). No differences were found in non-smokers, and neither of the eNOS polymorphisms influenced aortic PWV in our setting. In conclusion, genetically determined disorder of nitric oxide metabolism was associated with increased stiffness of peripheral, muscular-type arteries in generally healthy, untreated subjects, but only in the interaction with current smoking.

Detection of disseminated tumour cells in mediastinoscopic lymph node biopsies and endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected lung cancer.

PURPOSE: Ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes (EBUS-TBNA) is apparently more accurate for cancer diagnosis than standard transbronchial needle aspiration (TBNA), but it is less sensitive than mediastinoscopy. The detection of disseminated tumour cells in transbronchial needle aspiration and mediastinoscopic biopsies could improve staging and might be helpful concerning indications for neoadjuvant regimen. The goal of this study was to develop a quantitative method for the detection of disseminated tumour cells (DTCs) in lymph node samples from patients with suspected lung cancer. PATIENTS AND METHODS: We compared in a prospective trail EBUS-TBNA (n=58 patients, 86 samples) and mediastinoscopy (n=22 patients, 37 samples) in two largely independent cohorts of lung cancer patients. Eleven patients, 14 samples were analysed using both methods. Patients without evidence of malignant disease were available as controls for EBUS-TBNA (n=20 patients, 28 samples) and mediastinoscopy (n=6 patients, 8 samples). Real-time quantitative mRNA analysis was performed for the cytokeratin 19 (CK19) and MAGE-A genes (MAGE-A 1-6, MAGE-A12) as markers, using a LightCycler 480 instrument. RESULTS: CK19 mRNA expression in EBUS-TBNA samples was detected in 84/86 (98%) and in 28/28 control samples (100%). After mediastinoscopy 16/37 (43%) samples of lung cancer patients were CK19 mRNA positive while controls showed no CK19 mRNA expression (0/8). MAGE-A expression was detectable in 42/86 (49%) EBUS-TBNA samples and in 13/37 (35%) mediastinoscopy samples. MAGE-A expression was detected in EBUS-TBNA controls in 3/28 (11%) and 1/8 (12%) mediastinoscopy controls. High MAGE-A expression correlated with increased tumour stage. CONCLUSION: Since CK19 expression was detected in all EBUS-TBNA samples from the control patients, but not in mediastinoscopy samples, we conclude that CK19 is not suitable as a marker for disseminated tumour cells in samples attained by EBUS-TBNA. One possible explanation is a contamination with epithelial cells from the bronchial tubes. MAGE-A genes are promising markers for disseminated tumour cells in lymph nodes in patients with suspected lung cancer which merit further investigation.

Laboratory evaluation of antiphospholipid antibodies in patients with venous thromboembolism.

The objective of our study was to evaluate the significance of extended antiphospholipid profile in patients with venous thromboembolism without any systemic autoimmune disease. In 140 patients (age 18-69 years; 47.1% men) with venous thromboembolism and 136 control participants we tested anticardiolipin antibodies, anti-beta 2 glycoprotein I (anti-beta2-GPI) and also non-criteria antiphospholipid antibodies: antiphosphatidic acid, antiphosphatidylethanolamine, antiphosphatidylglycerol, antiphosphatidylinositol, antiphosphatidylserine. Commercial and in-house enzyme-linked immunosorbent assays were used. The antibodies with significantly higher prevalence in patients (compared to controls) were: immunoglobulin (Ig) M-anticardiolipin antibodies (12.9%; P = 0.035), IgG-anti-beta2-GPI (16.4%; P = 0.0032), IgM-antiphosphatidylethanolamine (14.3%; P = 0.014). In most cases, these three antibodies did not overlap. In conclusion, of non-criteria antiphospholipid antibodies, only antiphosphatidylethanolamine were significantly more prevalent in patients with venous thromboembolism, with only minor overlapping with the criteria antiphospholipid antibodies. Our results suggest the possible utility of searching for antiphosphatidylethanolamine in the clinical suspicion of antiphospholipid syndrome and the absence of criteria antiphospholipid antibodies.

Asymmetric dimethylarginine and the effect of folate substitution in children with familial hypercholesterolemia and diabetes mellitus type 1.

A recently discussed cardiovascular risk factor, asymmetric dimethylarginine (ADMA), is known to act as an endogenous inhibitor of endothelial nitric oxide synthase. The aim of this study was to establish 1) the relationship between ADMA and ultrasonographically or biochemically determined endothelial dysfunction in children, and 2) the effect of folate supplementation on these parameters. The study cohort included 32 children with familial hypercholesterolemia (FH), 30 with diabetes mellitus type 1 (DM1) and 30 age-matched healthy children as the control group. Furthermore, twenty-eight randomly selected FH and DM1 children were re-examined after 3-months supplementation with folic acid. Baseline levels of ADMA and oxidized low density lipoproteins (oxLDL) were significantly higher in FH group than in DM1 and healthy children. Children in DM1 group had significantly lower concentration of homocysteine, but ADMA levels were normal. Folic acid supplementation significantly lowered homocysteine and hsCRP levels in both FH and DM1 group; however, ADMA and oxLDL concentrations remained unaltered. In conclusion, ADMA and oxLDL appear to be associated with endothelial dysfunction in children with FH. Administration of folic acid did not influence these markers in both FH and DM1 children.

Synergistic effect of angiotensin II type 1 receptor and endothelial nitric oxide synthase gene polymorphisms on arterial stiffness.

Angiotensin II and nitric oxide belong to important factors in the functional and structural changes of vessel wall, leading to its increased stiffness. We investigated, whether common mutations of angiotensin II type 1 receptor (AGTR(1)) and endothelial nitric oxide synthase (eNOS) are associated with increased arterial stiffness. Two polymorphisms, A(1166)C of AGTR(1) and T(786)C of Enos, were estimated in a random, general population-based sample of 250 subjects. Arterial stiffness was measured using Sphygmocor as aortic (carotid-femoral) and peripheral (femoral-tibial) pulse wave velocities (PWV). Carriers of 3-4 mutant alleles from both polymorphisms, that is, homozygous for both mutations or homozygous for one and heterozygous for the second one, showed significantly higher peripheral PWV (17.92+/-2.40) than those with none or only 1-2 mutant alleles (12.37+/-0.51; P<0.003). Carriers of 3-4 mutant alleles had three times higher risk of having increased peripheral PWV (>or= 13.63 m s(-1), that is, in the top quartile) and this association remained significant after adjustment for potential confounders. No association was found between estimated genotypes and aortic PWV. In conclusion, combination of A(1166)C of AGTR(1) and T(786)C of eNOS mutations increased stiffness of muscular-type arteries.