Telomere length dynamics over 10-years and related outcomes in patients with COPD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been proposed as a disease of accelerated aging. Several cross-sectional studies have related a shorter telomere length (TL), a marker of biological aging, with COPD outcomes. Whether accelerated telomere shortening over time relates to worse outcomes in COPD patients, is not known. METHODS: Relative telomere length (T/S) was determined by qPCR in DNA samples from peripheral blood in 263 patients at baseline and up to 10 years post enrolment. Yearly clinical and lung function data of 134 patients with at least two-time measures of T/S over this time were included in the analysis. RESULTS: At baseline, T/S inversely correlated with age (r = - 0.236; p < 0.001), but there was no relationship between T/S and clinical and lung function variables (p > 0.05). Over 10 years of observation, there was a median shortening of TL of 183 bp/year for COPD patients. After adjusting for age, gender, active smoking and mean T/S, patients that shortened their telomeres the most over time, had worse gas exchange, more lung hyperinflation and extrapulmonary affection during the follow-up, (PaO2 p < 0.0001; KCO p = 0.042; IC/TLC p < 0.0001; 6MWD p = 0.004 and BODE index p = 0.009). Patients in the lowest tertile of T/S through the follow-up period had an increased risk of death [HR = 5.48, (1.23-24.42) p = 0.026]. CONCLUSIONS: This prospective study shows an association between accelerated telomere shortening and progressive worsening of pulmonary gas exchange, lung hyperinflation and extrapulmonary affection in COPD patients. Moreover, persistently shorter telomeres over this observation time increase the risk for all-cause mortality.

A content analysis of hand hygiene materials targeting elementary-age children.

Millions of dollars have been spent on the design and dissemination of educational materials to improve handwashing to prevent infectious diseases. School-age children have been the focus of many of these efforts; yet little is known about the content of these materials. This study uses content analysis to examine the theoretical and motivational trends as well as the communication approach used in a sample of hand hygiene intervention materials targeting elementary-age children. Two trained coders analyzed 144 communication materials. Study results indicate that educational materials infrequently exhibit information consistent with theories of communication for behavior change, commonly use fear-based messaging, and rarely recommend using technology in the design of the interventions. Implications for future research and the design of more strategic, child-focused hand hygiene interventions are discussed.

Key points to optimizing management and research on cancer-associated thrombosis.

Despite the fact that thromboembolism is relatively common in oncology patients and that the interrelationship between thrombotic risk and specific mechanisms of tumorigenesis has long been known, many cardinal elements of prevention and treatment remain unresolved. Among the existing knowledge gaps, the need to validate the Ay scale and compare it to the Khorana index, develop, and standardize the use of predictive biomarkers for thrombotic risk, conduct clinical trials in thromboprophylaxis adapted to thrombotic risk, evaluate the efficacy and safety of direct anticoagulants, select patients who can benefit from anticoagulants for antitumor treatment, validate the EPIPHANY study decision tree to choose patients with low-risk pulmonary embolism, and accumulate more practical experience in special situations (rethrombosis, prolonged therapy beyond 6 months, etc.) are especially remarkable. These gray areas surrounding cancer-related thromboembolism explain why it continues to be a relatively common cause of serious events, at times interfering significantly with the development of new tumor-fighting strategies.

Predicting serious complications in patients with cancer and pulmonary embolism using decision tree modelling: the EPIPHANY Index.

BACKGROUND: Our objective was to develop a prognostic stratification tool that enables patients with cancer and pulmonary embolism (PE), whether incidental or symptomatic, to be classified according to the risk of serious complications within 15 days. METHODS: The sample comprised cases from a national registry of pulmonary thromboembolism in patients with cancer (1075 patients from 14 Spanish centres). Diagnosis was incidental in 53.5% of the events in this registry. The Exhaustive CHAID analysis was applied with 10-fold cross-validation to predict development of serious complications following PE diagnosis. RESULTS: About 208 patients (19.3%, 95% confidence interval (CI), 17.1-21.8%) developed a serious complication after PE diagnosis. The 15-day mortality rate was 10.1%, (95% CI, 8.4-12.1%). The decision tree detected six explanatory covariates: Hestia-like clinical decision rule (any risk criterion present vs none), Eastern Cooperative Group performance scale (ECOG-PS; <2 vs ⩾2), O2 saturation (<90 vs ⩾90%), presence of PE-specific symptoms, tumour response (progression, unknown, or not evaluated vs others), and primary tumour resection. Three risk classes were created (low, intermediate, and high risk). The risk of serious complications within 15 days increases according to the group: 1.6, 9.4, 30.6%; P<0.0001. Fifteen-day mortality rates also rise progressively in low-, intermediate-, and high-risk patients: 0.3, 6.1, and 17.1%; P<0.0001. The cross-validated risk estimate is 0.191 (s.e.=0.012). The optimism-corrected area under the receiver operating characteristic curve is 0.779 (95% CI, 0.717-0.840). CONCLUSIONS: We have developed and internally validated a prognostic index to predict serious complications with the potential to impact decision-making in patients with cancer and PE.

On the necessity of new decision-making methods for cancer-associated, symptomatic, pulmonary embolism.

BACKGROUND: Acute symptomatic pulmonary embolism (PE) varies in its clinical manifestations in patients with cancer and entails specific issues. The objective is to assess the performance of five scores (PESI, sPESI, GPS, POMPE, and RIETE) and a clinical decision rule to predict 30-day mortality. METHODS: This is an ambispective, observational, multicenter study that collected episodes of PE in patients with cancer from 13 Spanish centers. The main criterion for comparing scales was the c-indices and 95% confidence intervals (CIs) of the models for predicting 30-day mortality. RESULTS: 585 patients with acute symptomatic PE were recruited. The 30-day mortality rate was 21.3 (95% CI; 18.2-24.8%). The specific scales (POMPE-C and RIETE) were equally effective in discriminating prognosis (c-index of 0.775 and 0.757, respectively). None of these best performing scales was superior to the ECOG-PS with a c-index of 0.724. The remaining scores (PESI, sPESI, and GPS) performed worse, with c-indexes of 0.719, 0.705, and 0.722, respectively. The dichotomic "clinical decision rule" for ambulatory therapy was at least equally reliable in defining a low risk group: in the absence of all exclusion criteria, 30-day mortality was 2%, compared to 5% and 4% in the POMPE-C and RIETE low-risk categories, respectively. CONCLUSION: The accuracy of the five scales examined was not high enough to rely on to predict 30-day mortality and none of them contribute significantly to qualitative clinical judgment.

Total artificial heart in the pediatric patient with biventricular heart failure.

Mechanical circulatory support emerged for the pediatric population in the late 1980s as a bridge to cardiac transplantation. The Total Artificial Heart (TAH-t) (SynCardia Systems Inc., Tuscon, AZ) has been approved for compassionate use by the Food and Drug Administration for patients with end-stage biventricular heart failure as a bridge to heart transplantation since 1985 and has had FDA approval since 2004. However, of the 1,061 patients placed on the TAH-t, only 21 (2%) were under the age 18. SynCardia Systems, Inc. recommends a minimum patient body surface area (BSA) of 1.7 m(2), thus, limiting pediatric application of this device. This unique case report shares this pediatric institution's first experience with the TAH-t. A 14-year-old male was admitted with dilated cardiomyopathy and severe biventricular heart failure. The patient rapidly decompensated, requiring extracorporeal life support. An echocardiogram revealed severe biventricular dysfunction and diffuse clot formation in the left ventricle and outflow tract. The decision was made to transition to biventricular assist device. The biventricular failure and clot formation helped guide the team to the TAH-t, in spite of a BSA (1.5 m(2)) below the recommendation of 1.7 m(2). A computed tomography (CT) scan of the thorax, in conjunction with a novel three-dimensional (3D) modeling system and team, assisted in determining appropriate fit. Chest CT and 3D modeling following implantation were utilized to determine all major vascular structures were unobstructed and the bronchi were open. The virtual 3D model confirmed appropriate device fit with no evidence of compression to the left pulmonary veins. The postoperative course was complicated by a left lung opacification. The left lung anomalies proved to be atelectasis and improved with aggressive recruitment maneuvers. The patient was supported for 11 days prior to transplantation. Chest CT and 3D modeling were crucial in assessing whether the device would fit, as well as postoperative complications in this smaller pediatric patient.

Ectopic third molar in condylar region.

Inclusion of the third molar is relatively frequent in oral and maxillofacial surgery, but ectopic placement is quite rare. Only a few cases of third molar inclusion in the condyle region of the mandible have been reported. Presented here are two cases of ectopic location of a third molar in the condyle of the mandible. A description of the management of this pathology through open surgery and extraction of the molar is given, while preserving the anatomy of the condylar region.

Cuerpo extraño cervical: paciente afortunado / Cervical foreign body: a lucky patient

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[Prognostic significance of tumor size in the survival of patients with advanced gastric carcinoma]. / Significancia pronóstica del tamaño tumoral en la sobrevida de pacientes con carcinoma gástrico avanzado.

OBJECTIVES: To determine the prognostic significance of size tumor in the survival of patients with advanced gastric carcinoma. MATERIAL AND METHODS: This retrospective study evaluated 95 patients with advanced gastric adenocarcinoma with a diameter smaller than 7 centimeters (Group I) and 85 cases with lesions equal or greater than 7 centimeters (Group II) whom underwent radical gastrectomy with lymphadenectomy D0-D1 (n=148) or D2-D3-D4 (n=32) at Belen Hospital, Trujillo, Peru, between 1966 and 1998. RESULTS: The median age of the Group I and II was of 58.1 12.9 and 58.5 15.3 years, respectively. The patients of the group II had a lower level of seric hemoglobin (p=0.007) and more frequency of lesions Borrmann type II and IV (p= 0.003). Using the log-rank test, there was no statistically significant difference with relation to five-year survival between both groups using the multivariate analysis of Cox regression. There was not statistically significance difference between the size tumoral and the survival but there were independent factors statistically related with the survival: depth of invasion (p=0.017) and lymph nodes compromised (p=0.014). CONCLUSIONS: Clinically the size of the tumor was not a factor to take as parameter in the prediction of the actuarial survival in patients with advanced gastric cancer.

[Intestinal obstruction for malrotation in an adult patient. Report of a case]. / Obstrución intestinal por malrotación en el adulto: A propósito de un caso.

We present a case of a 78 year-old man with the pathological antecedent of chronic constipation that comes to our emergency room at the Victor Lazarte Echegaray Hospital. He presented abdominal pain and progressive abdominal distension, nausea and bilious vomits of two days of evolution. The clinical examination showed an evident abdominal distension, and some metallic intestinal noises. A frontal and lateral simple abdominal x- ray showed a considerable distension of the gastric camera and intestinal loops and free fluid all over the abdominal cavity, all of which was compatible with the diagnosis of intestinal obstruction. At the operating room we proceeded with a exploration and we founded an intestinal obstruction at the ascending colon (Ladd's Bands) of high location with bloody fluid in the abdominal cavity, multiple fecalomas in the descending colon, and intestinal ischemia in the distal small bowel, the color, tone and coiling of the intestine recovered after section of the Ladd's bands. The patient evolved favorably.

[Intestinal obstruction by Meckel's diverticulum: a case study]. / Obstrucción intestinal por divertículo de Meckel: A propósito de un caso.

The intestinal obstruction by Meckel s diverticulum is caused by an adherence, volvulus or invagination affecting this diverticulum. This is not a very frequent event and our purpose is to describe a case of intestinal obstruction by a bridle formed by Meckel s diverticulum. Clinically, the patient experienced pain in the periumbilical region, abdominal distension and bilious vomits. The exploratory laparotomy evidenced the existence of Meckel s diverticulum without signs of inflammation.

[Foreign body in abdomen: report of a case]. / Cuerpo extraño en abdomen: a propósito de un caso.

The case of a 51 year-old female patient, who underwent a cholecystectomy four years ago is presented. She approached the surgical department at the Hospital Belén of Trujillo, Peru, suffering of abdominal pain for the past four months and with the presence of a mass located in the epigastrium occupying part of the right hypochondrium. A thoracic x-ray showed an encysted left pleural effusion, and an abdominal echography was compatible with a pancreatic pseudo-cyst. An exploratory laparectomy was performed and a 15x9 cm mass was found in the sub-hepatic area. This mass had a semisolid consistency with a rounded shape and multiple adherences to the upper omentum and the liver. In the macroscopic exam, after the dissection of the cyst, a 25x42 cm gauze was found inside the mass which was full of biliary fluid. Due to the unspecific clinical and image diagnosis it was decided to carry out a review of this topic, which is suspected of being under-recorded in this country.

Cutaneous warts: diagnosis and treatment.

Cutaneous warts are a common malady that affects all ages, but are most prevalent in children and young adults. Warts result from infection with human papillomavirus and can lead to a condition that may be painful, disfiguring, and recurrent, despite treatment. A multitude of therapeutic modalities exist, though no single agent is invariably effective. Successful treatment must take into consideration the patient's level of motivation, expense, and physician experience.

[Second primary tumors in patients with pharyngo-laryngeal carcinoma]. / Segundos tumores primarios en pacientes con carcinoma faringolaríngeo.

The risk of second primary tumors of the respiratory and upper digestive tract developing in patients treated for head and neck cancer is well known. In these cases, the entire mucous membrane surface of the tract is affected and predisposed to metachronous or synchronous neoplasms. The mucosa of these patients is extremely susceptible to external carcinogenic stimuli. We report the results obtained in 83 patients with cancer of the oral cavity, pharynx, or larynx who experienced at least one second primary tumor. The most common site of the second primary was the lung (43.2%). We reviewed tobacco and alcohol use, treatments, and survival.

[Thyroid nodules: factors suggestive of malignancy]. / Nódulos tiroideos: factores sugerentes de malignidad.

The evaluation and management of thyroid nodules is a common problem in medicine. In a review of 250 cases of thyroid disease seen at the 12 de Octubre Hospital (Madrid, Spain), 191 cases of solitary nodules and multinodular goiter were analyzed. The clinical findings, complementary studies, and postoperative histology were analyzed to determine the parameters most closely related to malignant thyroid processes. The overall rate of malignancy was 22.5%. Major clinical factors associated with malignancy were fixation to deep structures, cervical lymph node enlargement, and paralysis of the vocal cords. None of the complementary tests was absolutely reliable in excluding malignancy, but fine needle aspiration biopsy, in spite of its limitations, was the best diagnostic tool. Surgery is indicated if the benignity of a nodule cannot be confirmed.

Comparison among DNA polymerases 1, 2 and 3 from maize embryo axes. A DNA primase activity copurifies with DNA polymerase 2.

Three DNA polymerase activities, named 1, 2 and 3 were purified from maize embryo axes and were compared in terms of ion requirements, optimal pH, temperature and KCl for activity, response to specific inhibitors and use of templates. All three enzymes require a divalent cation for activity, but main differences were observed in sensitivity to inhibitors and template usage: while DNA polymerases 1 and 2 were inhibited by N-ethyl maleimide and aphidicolin, inhibitors of replicative-type enzymes, DNA polymerase 3 was only marginally or not affected at all. In contrast, DNA polymerase 3 was highly inhibited by very low concentrations of ddTTP, an inhibitor of repair-type enzymes, and a 100-fold higher concentration of the drug was needed to inhibit DNA polymerases 1 and 2. Additionally, DNA polymerases 1 and 2 used equally or more efficiently the synthetic template polydA-oligodT, as compared to activated DNA, while polymerase 3 used it very poorly. Whereas DNA polymerases 1 and 2 shared properties of replicative-type enzymes, DNA polymerase 3 could be a repair-type enzyme. Moreover, a DNA primase activity copurified with the 8000-fold purified DNA polymerase 2, strengthening the suggestion that polymerase 2 is a replicative enzyme, of the alpha-type. This DNA primase activity was also partially characterized. The results are discussed in terms of relevant data about other plant DNA polymerases and primases reported in the literature.

[Colorectal cancer: its clinical picture and survival]. / Cáncer colorectal: cuadro clínico y sobrevida.

Retrospectively collected information on 77 patients who had undergone resection for colorectal cancer at Belén Hospital, Trujillo, Perú, from 1966 to 1993, was analyzed to establish their clinical features and the importance of both clinical and pathological factors affecting outcome. Common presenting features in right colon cancer were abdominal pain, pallor, and palpable mass; in left colon cancer were symptoms of obstruction, and in rectal carcinoma predominated bleeding. The diagnostic accuracy of barium enema (n = 25) and proctosigmoidoscopy (n = 18) was 72 and 100% respectively. In 54.5% (n = 42) curative resection and in 45.5% (n = 35) palliative resection was performed The surgical procedures performed were right hemicolectomy (n = 29), transverse colectomy (n = 6), left hemicolectomy (n = 11), sigmoid resection (n = 14), low anterior resection (n = 5), and abdominoperineal resection of the rectum (n = 12). The total perioperative mortality rate was 18%. The 5 year survival rate in this series was 28% (53% for curative resection and 0% for palliative resection). An univariate analysis of survival time using long-rank test revealed that presence of bowel obstruction or perforation, macroscopic appearance, tumor size, depth of invasion, lymph node status, number of lymph node metastasis, distant metastasis, and clinical stage had and individual prognostic significance. Age, sex, length of disease, serum hemoglobin level, blood transfusions, location of tumor, histologic type, and tumor grade did not affect the prognosis. Improvement in the survival probably depends on development of better adjuvant therapy in association with surgery.

[Differential diagnosis of neurinomas of the jugular foramen and glomus jugulare: a clinical case]. / Diagnóstico diferencial entre neurinomas de agujero rasgado posterior y glomus yugular: Caso clínco.

Neurinomas or schwannomas of the jugular foramen are rare tumors whose differentiation from tumors of the jugular body may be difficult because they share common symptoms. Since schwannomas at this site are less aggressive than tumors of the jugular body and certain elements of their treatment differ, it is important to make a correct diagnosis promptly. A well-documented case of schwannoma of the jugular foramen is reported and its differential diagnosis is discussed in the light of the literature.

[Resectable stomach cancer: analysis of 134 consecutive cases]. / Cáncer de estómago resecable: análisis de 134 casos consecutivos.

An analysis was made on 134 patients with gastric cancer underwent conventional gastrectomy consecutively at Belen Hospital, Trujillo, Peru from 1966 to 1990. The main objective was to determine the influence on prognosis of independent treatment variables and treatment-dependent variables. Gastric cancer patients (78M:56F) had a median age of 58 years (range, 23 to 82 years). The resectability rate was 48%. The operative mortality rate was of 14.2%. The 5-year actuarial survival rate of this series was 16% (33% for curative gastrectomy and 1% for palliative gastrectomy, p < 0.001). Using univariate analysis, the evolution of gastric cancer was related to palpable mass, macroscopic appearance, tumor size, depth of invasion, tumor stage, lymph node involvement, distant metastases, number of lymph node metastases and operative curability, parameters that affected the rate of survival. However the most important prognostic factor was curability, and almost all patients who survived more than five years were among those submitted to curative gastric resection. The clinical course was not related to age, gender, length of history, location of tumor, histologic type and operative procedure. We concluded that the feasibility of a curative resection would be increased and the prognosis probably improved if the carcinoma could be detected at an early stage.

[Orbital cellulitis and permanent amaurosis: clinical case]. / Celulitis orbitaria y amaurosis permanente: caso clínico.

Orbital cellulitis is a rare, potentially serious but complication of acute sinusitis. It is more frequent and benign in children, but in adults usually requieres surgical drainage of the affected sinus. We report a case of aggressive evolution with permanent blindness in an adult without general or local risk factors, in spite of adequate treatment. The literature is reviewed.