Terms used by physicians when deciding to withhold treatment for older patients not having received palliative care in an acute geriatric care unit.

PURPOSE: There are no guidelines or consensus statements on the terms to be used when discussing withholding of treatment for patients in acute geriatric care units and who have not received palliative care. The objective of the present study was to analyze the terms used in medical records to refer to the withholding of treatment for patients who died in an acute geriatric care unit and did not receive palliative care. METHODS: We conducted an ambispective multicentre cohort study based on the DAMAGE study. Data on 53 patients who died in the acute geriatric care unit and who had not received palliative care were extracted from medical records. The verbatims referring to the withholding of treatment were analyzed in terms of keywords and then key concepts, as defined by several reviewers in a consensus-based approach. RESULTS: The mean age of the patients was 86.4 years, 34.1% were male. Terms referring to the withholding of treatment were found for 25 of the 53 patients (47.2%). Most of the decisions on the withholding of treatment were recorded in the week following admission to the acute geriatric care unit. Our analysis of the terms identified 11 key concepts: treatment limitation, no resuscitation, withholding diagnostic procedures, justification of care, ethical considerations, disease progression, uncertainty, the patient's wishes, the family's wishes, patient's comfort, and collegiality. The terms used to describe key concepts varied markedly from one physician to another. CONCLUSION: Decisions about the withholding of treatment are frequently noted in the medical records of patients who die in the acute geriatric care unit without having received palliative care. The broad variety of key concepts and differences in the choice of words highlight the need for standardized terms.

Effects of dietary microbial feed supplement on production efficacy in lactating dairy cows.

This study evaluated the effects of a microbial feed supplement (MFS; Galaxis, Ascus Biosciences Inc.) comprising 2 native rumen microbes on performance parameters in mid-lactation dairy cows. Forty-six lactating primiparous and multiparous Holstein cows [629 ± 62 kg of body weight, mean ± standard deviation (SD); parity 1.64 ± 0.49; 119 ± 38 days in milk; 45.11 ± 3.81 and 52.73 ± 4.77 kg/d of milk yield for primiparous and multiparous, respectively] were enrolled in a study containing 3 experimental periods (P). During all periods, enrolled cows were fed the same base total mixed ration (TMR) ad libitum once daily. During P1 (7 d), baseline data were obtained for covariate analysis. At the beginning of P2 (60 d), cows were assigned to 1 of 2 dietary treatment groups in a randomized complete block design to balance for milk yield (MY), parity, and days in milk: (1) a control diet (CON; base TMR; n = 23), or (2) a control diet supplemented with 5 g/d of MFS (MFS; n = 23). Sample size was determined based on previous, unpublished results involving this MFS; a 3-kg difference between groups with a SD of 3.5 kg could be detected with sufficient power (0.81) using a total sample size of 46 cows. Treatment was top-dressed and hand-mixed into the top one-third of the TMR. During P3 (7 d), no treatment was administered, and all cows were fed the base TMR. When analyzing all cows in the data set, MFS had little to no effect on performance. However, modeling revealed that the fixed effect of covariate milk production level had a significant effect on the response of MY and ECM, and further investigation of the data revealed that treatment effectiveness in P2 correlated with milk production during P1. Cows were retrospectively categorized into 2 milk production groups (MPG) balanced for parity: MPG1 (i.e., <53 kg/d of ECM during P1; n = 34) or MPG2 (i.e., ≥53 kg/d of ECM during P1; n = 12). Energy-corrected milk was increased by 4.4% in MFS-administered MPG1 cows compared with CON cows during P2. Although there were no significant effects of MFS on production variables for MPG2 cows, MY tended to be decreased by 3.9% in MFS-administered cows compared with CON cows. Further investigation is needed to understand production level response differences and the effect of supplemented native rumen microbes on animal health and productivity.

Short communication: Compositional characteristics and aromatic profile of caciotta cheese obtained from Friesian cows fed with a dietary supplementation of dried grape pomace.

The aim of the present work was to explore the chemical-sensorial characteristics and aromatic profile of caciotta cheese obtained from Friesian cows fed a diet enriched with grape pomace obtained from red grape (Vitis vinifera L.). Dietary enrichment with grape pomace influenced the production of caciotta cheeses in interesting ways from a compositional point of view, as cheese samples were rich in polyphenols, giving a high antioxidant potential. From a biochemical standpoint, we noted a slight decrease of proteolysis during ripening, whereas, according to the analysis of volatile compounds, lipolysis was the most relevant phenomenon in samples. The presence of bioactive compounds also modified the fatty acid profile of milk and cheese, leading to an increase in concentration of linoleic, vaccenic, and rumenic acids. No significant variations were found in the sensory profile. These results showed the potential of dietary grape pomace intake to influence the chemical-nutritional and nutraceutical properties of cow milk and cheeses, whose introduction to the market could be attractive to consumers, providing interesting implications for the dairy industry. Finally, our results identified of a valid use of an agro-industrial by-product, grape pomace, whose disposal generally presents economic and environmental problems.

Intestinal obstruction by giant Meckel's diverticulum. Case report.

Most cases of Meckel's diverticulum (MD) are asymptomatic and discovered by chance. Management of MD is controversial. The authors describe an exceptional case of intestinal obstruction caused by a giant MD in a patient who had previously undergone appendectomy. A review of the contradictory literature on this subject leads to the conclusion that careful consideration of clinical and morphological data (patient's age, ASA score, the surgical procedure to be performed, morphology and position of the MD, any fibrotic bands) is required before deciding whether or not to resect an asymptomatic MD.

Potential role of culture mediums for successful isolation and neuronal differentiation of amniotic fluid stem cells.

In recent years, the use of stem cells has generated increasing interest in regenerative medicine and cancer therapies. The most potent stem cells derive from the inner cell mass during embryonic development and their use yields serious ethical and methodological problems. Recently, a number of reports suggests that another suitable source of multipotent stem cells may be the amniotic fluid. Amniotic fluid mesenchymal stem cells (AFMSCs) are capable of extensive self-renewal, able to differentiate in specialized cells representative of all three germ layers, do not show ethical restriction, and display minimal risks of teratomas and a very low immunogenity. For all these reasons, amniotic fluid appears as a promising alternative source for stem cell therapy. Their recent discovery implies a lack of knowledge of their specific features as well as the existence of a protocol universally recognized as the most suitable for their isolation, growth and long-term conservation. In this study, we isolated stem cells from six amniotic fluids; these cells were cultured with three different culture mediums (Mesenchymal Stem Cell Medium (MSCGM), PC-1 and RPMI-1640), characterized by cytofluorimetric analysis, and then either frozen or induced to neuronal differentiation. Even if the immunophenotype seemed not to be influenced by culture medium (all six samples cultured in the above-mentioned mediums expressed surface antigens commonly found on stem cells), cells showed different abilities to differentiate into neuron-like cells and to re-start the culture after short/long-term storage. Cells isolated and cultured in MSCGM showed the highest proliferation rate, and formed neuron-like cells when sub-plated with neuronal differentiation medium. Cells from PC-1, on the contrary, displayed an increased ability to re-start culture after short/long term storage. Finally, cells from RPMI-1640, even if expressing stem cells markers, were not able to differentiate in neuron-like cells. Further studies are still needed in order to assess the effective role of culture medium for a successful isolation, growth, differentiation and storage of AFMSCs, but our data underline the importance of finding a universally accepted protocol for the use of these cells.

Assessment of cyclin D1 overexpression as a prognostic factor in soft tissue sarcomas: role of laparoscopy and core needle biopsy.

BACKGROUND: This study was designed to test cyclin D1 as a prognostic marker in patients with soft tissue sarcomas (STS), and to evaluate the usefulness of laparoscopy for determining cyclin D1 overexpression. METHODS: The records of 62 patients with STS were collected: 28 with retroperitoneal STS (RSTS) and 34 with extremity STS (ESTS). A total of 51 patients underwent surgical resection, whereas 11 did not undergo surgery because of advanced tumor stage. Preoperative-intraoperative laparoscopic staging was performed for patients judged to be resectable at preoperative imaging. RESULTS: Cyclin D1 was overexpressed in 30 (58.8%) of 51 resected patients and in 10 (90.9%) of 11 nonresected patients. Laparoscopy avoided unnecessary laparotomy in 9 (32.1%) of 28 RSTS patients. CONCLUSIONS: High tumor grade, positive surgical margins, local recurrence, distant metastases, and cyclin D1 overexpression were related to poor survival. Multivariate analysis demonstrated cyclin D1 to be the only independent factor. Laparoscopy was shown to be useful for avoiding useless laparotomies.

[Pseudomyxoma peritonei associated with mucinous cystadenoma of the appendix]. / Pseudomixoma peritoneale associato a cistoadenoma mucinoso dell'appendice.

The authors report a case of a male 86 years old patient with peritoneal pseudomyxoma associated to cystoadenoma of the appendix. Preoperative CT scan showed the presence of a mass in the appendiceal site containing a gelatinous fluid collection and calcifications. Notwithstanding, diagnosis of pseudomyxoma was preoperatively considered less probable due to the rarity of the affection and the advanced age. At laparatomy was revealed the presence of the large mass observed at CT scan, involving the caecum and occupying the retroperitoneal space along the ascending colon. Mucinous ascites was present without invasive mucinous implants in the peritoneum. Operation consisted in a right hemicolectomy with total removal of the retroperitoneal mass and evacuation of the mucinous ascites. Histology confirmed the clinical diagnosis of pseudomyxoma peritonei associated to cystoadenoma of the appendix. The case is of paradigmatic interest as being quite correspondent to the classical Ronnett's definition of pseudomyxoma: a clinicopathological entity characterized by mucinous ascites and non-invasive mucinous implants with a characteristic distribution and containing histologically benign mucinous epithelium derived from an appendiceal mucinous adenoma and having a benign course. According to such definition, the authors stress the importance of an appropriate classification of the observed cases of pseudomyxoma, under whose term is often collected a heterogeneous group of pathological lesions, in order to better evaluate the prognosis and treatment.

The effects of a diode laser (810 nm) on pigmented guinea-pig skin.

Various types of lasers, such as the Q-switched ruby laser and the Alexandrite laser, cause selective damage to cutaneous pigmented cells and are currently used in the therapy of pigmented lesions. The aim of this study was to evaluate the effects of a diode laser at a wavelength of 810 nm on pigmented guinea-pig skin. The diode laser was supplied by OcuLight Iris Medical Instruments, Inc. and was used to deliver 0.15, 0.2, 0.3, 0.4, 0.5, 1 and 1.5 J/cm2 laser beams in micropulses of 100 micros. The study was carried out on albino and black-spotted guinea pigs (GP). After irradiation, punch biopsies were taken and analysed by light and electron microscopy. Albino animals developed just a few signs of cutaneous injury. This mostly consisted of spongiotic disarray, after the highest doses were administered (>1 J/cm2). In the black skin of spotted GPs alterations appeared at 0.15 J/cm2 and included melanosome damage and, at doses higher than 0.3 J/cm2, also melanocyte damage. These observations demonstrate that the diode laser at 810 nm selectively affects pigmented structures and that the cellular targets of diode laser radiation are the melanosomes. The diode laser specificity for melanin may provide a biological basis for the treatment of pigmented superficial cutaneous lesions.

Changing concepts in long-term central venous access: catheter selection and cost savings.

BACKGROUND AND OBJECTIVES: Long-term central venous access is becoming an increasingly important component of health care today. Long-term central venous access is important therapeutically for a multitude of reasons, including the administration of chemotherapy, antibiotics, and total parenteral nutrition. Central venous access can be established in a variety of ways varying from catheters inserted at the bedside to surgically placed ports. Furthermore, in an effort to control costs, many traditionally inpatient therapies have moved to an outpatient setting. This raises many questions regarding catheter selection. Which catheter will result in the best outcome at the least cost? It has become apparent in our hospital that traditionally placed surgical catheters (ie, Hickmans and central venous ports) may no longer be the only options. The objective of this study was to explore the various modalities for establishing central venous access comparing indications, costs, and complications to guide the clinician in choosing the appropriate catheter with the best outcome at the least cost. METHODS: We evaluated our institution's central venous catheter use during a 3-year period from 1995 through 1997. Data was obtained retrospectively through chart review. In addition to demographic data, specific information regarding catheter type, placement technique, indications, complications, and catheter history were recorded. Cost data were obtained from several departments including surgery, radiology, nursing, anesthesia, pharmacy, and the hospital purchasing department. RESULTS: During a 30-month period, 684 attempted central venous catheter insertions were identified, including 126 surgically placed central venous catheters, 264 peripherally inserted central catheters by the nursing service, and 294 radiologically inserted peripheral ports. Overall complications were rare but tended to be more severe in the surgical group. Relative cost differences between the groups were significant. Charges for peripherally inserted central catheters were $401 per procedure, compared with $3870 for radiologically placed peripheral ports and $3532 to $4296 for surgically placed catheters. CONCLUSIONS: Traditional surgically placed central catheters are increasingly being replaced by peripherally inserted central venous access devices. Significant cost savings and fewer severe complications can be realized by preferential use of peripherally inserted central catheters when clinically indicated. Cost savings may not be as significant when comparing radiologically placed versus surgically placed catheters. However, significant cost savings and fewer severe complications are associated with peripheral central venous access versus the surgical or radiologic approach.

Bone regeneration in the edentulous ridge expansion technique: histologic and ultrastructural study of 20 clinical cases.

The edentulous ridge expansion (ERE) technique is a partial-thickness flap procedure for implant surgery that was developed in 1986. The ERE technique permits the use of osseointegrated implants at sites whose minimal orofacial dimensions are insufficient for traditional implant surgery. The present work is a histologic and ultrastructural study of hard tissue repair modalities at edentulous sites that were treated with the ERE technique in 20 humans. Biopsies were obtained from the tissue regenerating within the surgically created bone gap between the mobile buccal and nonmobile lingual or palatal bone-periosteum plates ("bone flaps") on days 40, 90, 120, 150, and 480 (day 0 = day of implant insertion). The results suggest that osteoblasts differentiate from preexisting mesenchymal cells located on the original fissure walls, with consequent deposition of new bone in the surgically created intrabony defect.

Stimulation of ATP synthesis via oxidative phosphorylation in wheat mitochondria irradiated with helium-neon laser.

In order to ascertain whether oxidative phosphorylation in plant mitochondria is sensitive to light, coupled durum wheat (Triticum durum Desf.) mitochondria were irradiated with a low power continuous wave Helium-Neon laser (fluence: 2 Joules/cm2), with measurements made of certain processes related to ATP production. As a result of irradiation, an increase in the rate of ATP synthesis was found, as continuously monitored via luciferine/luciferase, moreover the mitochondrial ATP and ADP endogenous contents were found to increase and decrease, respectively with a 1:1 stoichiometry, as revealed by HPLC measurements. Consistently, an increase in mitochondrial rate of delta psi generation was found as measured by using the fluorescent probe safranine. Thus, this paper gives a first evidence of a novel property of plant mitochondria: the direct light sensitivity of ATP synthesis via oxidative phosphorylation.

Distinct regulatory roles of lymphocyte costimulatory pathways on T helper type-2 mediated autoimmune disease.

We assessed the role of CD40-CD40L, cytotoxic T lymphocyte (CTL)A4/CD28-B7s, and CD2-CD48/CD58 lymphocyte costimulatory pathways in the development of mercury chloride (HgCl2)-induced autoimmune disease in mice, which is believed to be mediated by T helper (Th) subset Th2. Inhibition of CD40-CD40-L and CTLA4/CD28-B7s interactions by anti-CD40-L antibody and soluble CTLA4-immunoglobulin (Ig) fusion protein, respectively, abrogated the autoimmune disease without affecting interleukin 4 (IL-4) production, showing the importance of physical contact between T and B lymphocytes in the Th2-mediated process. In contrast, two anti-CD2 antibodies that have been shown to induce immunosuppression of Th1-mediated events exacerbated the autoantibody response and augmented IgG1, IgE, and IL-4 production, transforming a mild mesangial glomerulopathy into a severe systemic immune complex disease. These observations demonstrate that manipulation of lymphocyte accessory counterreceptor interactions may affect the course of Th2-associated autoimmune disease and suggest that signals resulting from CD2 engagement play an essential role in the regulation of the Th1-Th2 effector equilibrium.

Early fracture callus in the diaphysis of human long bones. Histologic and ultrastructural study.

The medullary callus and the periosteal callus of fractured long bones were studied in 26 adults undergoing open reduction and internal fixation of closed diaphyseal fractures that occurred 1 to 21 days before surgery. In the 1st week after fracture, a progressive increase was observed in the number of polymorphic mesenchymal cells in the medullary callus and of fibroblast-like cells in the periosteum, where the first calcification foci were seen 7 days after injury. In the 2nd week after fracture, the medullary callus presented numerous mesenchymal cells, fibroblasts, and newly formed capillaries, whereas the inner periosteal layer showed many osteoblast-like cells. New bone trabeculae were first seen in the periosteal callus 12 days after injury. In the 3rd week after fracture, new trabecular bone appeared in the medullary callus. Cartilage also became apparent in the medullary and periosteal callus but remained limited in amount. Calcification within cartilage was first observed in the periosteum 18 days after fracture. The process of fracture healing in long bones in humans is similar, though not identical, to that described for long bones in laboratory animals.

Histology and ultrastructure of arteries, veins, and peripheral nerves during limb lengthening.

The effects of lengthening of the metacarpal bone on peripheral nerves and blood vessels were studied in 8 calves. Specimens for light and electron microscopy were obtained from the palmar neurovascular bundle at 1 cm (8% of the initial length), 2.5 cm (20% of the initial length), and 4 cm (33% of the initial length) of metacarpal lengthening. In 2 calves, specimens were studied 2 months after the end of the lengthening procedure. At 8% of lengthening, myelinated fibers of the palmar nerve showed moderate degenerative changes in the myelin sheath. This became severe at 20% and 33% of lengthening, and affected the axoplasm as well. At 20% of lengthening, the palmar vein started to show fibrous metaplasia of the smooth muscle tissue of the tunica media. This became much thinner than normal. The palmar artery showed moderate alterations of the inner part of the tunica media and the intima. The palmar nerve and blood vessels recovered their normal structure almost completely 2 months after the end of the lengthening procedure. The morphologic alterations of peripheral nerves and vessels may constitute the pathophysiologic basis of the nervous and circulatory disturbance observed in clinical practice.

Magnetic resonance imaging to avoid laparotomy in pregnancy.

OBJECTIVE: To determine whether magnetic resonance imaging (MRI) in pregnancy would help define a benign pelvic mass, thereby avoiding laparotomy. METHODS: During a 2-3-year period, five pregnant women with adnexal masses suspected to be leiomyomas underwent MRI. RESULTS: Four patients had evidence of leiomyoma and one had a benign cystic teratoma. All avoided laparotomy because of the almost certain radiologic findings of a benign process. In two women, there was an important effect on the pregnancy; one had fetal growth retardation and the other an outlet obstruction precluding vaginal delivery. Four of the patients underwent cesarean delivery. CONCLUSIONS: Magnetic resonance imaging can be used in the differential diagnosis of an adnexal mass in pregnancy. This will enable some pregnant patients to avoid laparotomy and its concomitant risks.

Localization of ahe alpha 6 and beta 4 integrin subunits in normal human non-lymphoid tissues.

The alpha 6/beta 4 integrin, of undefined receptor activity, has been shown to be expressed in a variety of murine epithelial cells. To gain information on the role of this heterodimer in tissue architecture as well as in malignant transformation we have performed an extensive immunohistochemical analysis of normal human tissues using monoclonal antibodies to alpha 6 and beta 4 subunits. Because alpha 6 is known to associate also with the beta 1 subunit to form a non-promiscuous receptor for laminin, the expression of beta 1 chain was also evaluated. The results of this study have shown that the alpha 6 chain has a wide distribution in tissues, including small vessels and peripheral nerves. alpha 6 colocalizes with beta 4 and beta 1 in most epithelial cells at the basolateral or basal aspect abutting the basement membrane. In a minority of tissues lacking beta 4, the alpha 6 chain is coexpressed with beta 1. These findings demonstrate that the expression of alpha 6/beta 1 laminin receptor and alpha 6/beta 4 heterodimer is phylogenetically conserved, suggesting that they are likely to play an important role in cellular scaffolding through binding to laminin and to still uncharacterized ligand/s present in basement membranes.

A DNA polymerase from the archaeon Sulfolobus solfataricus shows sequence similarity to family B DNA polymerases.

The gene encoding the thermostable DNA polymerase from the archaeon Sulfolobus solfataricus (strain MT 4) was isolated by means of two degenerate oligonucleotide probes. They were designed on the basis of partial enzyme amino acid sequences. The gene was found to encode a 882 residues polypeptide chain with a deduced molecular mass of about 100 kDa. By comparison with other archaeal genes, putative regulatory sites were identified in the gene-flanking regions. By computer-assisted homology search, several sequence similarities among S. solfataricus and family B DNA polymerases were found. In addition, conserved sequence motifs, implicated in the 3'-5' exonuclease activity of E. coli DNA polymerase I and shared by various family A and B DNA polymerases, were also identified. This result suggests that the proofreading domains of all these enzymes are evolutionarily related.

On the mechanism of action of lonidamine: a study on human erythrocyte membrane.

The incubation of human erythrocytes with increasing levels of the antineoplastic drug Lonidamine clearly indicated a dose-dependent effect on the lipid composition of the plasma membranes. A selective transfer of phosphatidylcholine and cholesterol from membrane to incubation medium and the consequent enrichment in phosphatidylethanolamine of the membrane itself was observed. Moreover, the membranes were found to contain increasing levels of the drug which was incorporated at a constant membrane/medium partition ratio. The changes in composition appeared to be consistent with morphological alterations observed by scanning and freeze-fracture electron microscopy demonstrating changes in cell shape, the presence of numerous intracellular vesicles, and a membrane protein rearrangement. The analysis of intact red cells by nuclear magnetic resonance ruled out the possibility that the alterations described above could be due to an ATP depletion. This further confirmed that cell membranes were the primary target of the Lonidamine action, the previously described energy metabolism impairment being a consequence of a selective damage of cellular membranes, probably originating from the incorporation of the drug into the lipid bilayer.