Photodynamic therapy for the treatment of complex anal fistula.

BACKGROUND: Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula. METHODS: Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded. RESULTS: There were no complications. The average length of patient follow-up was 14.9 months (range 12-20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively. CONCLUSIONS: PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.

Experimental study showed that adding fortifier and extra-hydrolysed proteins to preterm infant mothers' milk increased osmolality.

AIM: Measuring milk osmolality after adjustable fortification is clinically relevant, as values exceeding recommended safety thresholds might result in gastrointestinal consequences. The aim of this study was to evaluate the effect of four fortification levels and storage time on the osmolality of human milk. METHODS: This was an experimental study using 71 spare samples of fresh breastmilk collected from 31 mothers of preterm infants. Osmolality was measured before and after adding commercial human milk fortifier containing dextrinomaltose and hydrolysed proteins at four different concentrations. Measurements were performed at various points during the 23 hours after fortification. RESULTS: The mean basal osmolality of the 71 human milk samples was 296 ± 14 milliosmoles (mOsm)/kg, and these remained stable over a period of 23 hours. Just after fortification, the four fortified formulas showed higher osmolalities than the nonfortified human milk, ranging between 384 ± 14 and 486 ± 15 mOsm/kg, respectively (p < 0.01). This osmolality increased significantly from 20 minutes to 23 hours after fortification (p < 0.05). CONCLUSION: Adding fortifier and extra-hydrolysed proteins to human preterm milk increased osmolality, and these osmolality levels also increased with time. We recommend evaluating the risk of hyperosmolality when a higher fortification level is needed, to avoid gastrointestinal problems.

Effect on anal pressure of percutaneous posterior tibial nerve stimulation for faecal incontinence.

AIM: Previous studies on percutaneous posterior tibial nerve stimulation (PTNS) for faecal incontinence do not report anal pressure changes. In the present study the effect of percutaneous PTNS on anal manometry was determined. METHOD: This was a prospective observational study of patients with faecal incontinence. They underwent one 30-min session of PTNS weekly for 12 consecutive weeks. Patients who showed improvement were given six more sessions at 2-weekly intervals. Anal manometry was performed before and after treatment. Clinical data including the Wexner score, psychological testing, quality of life using the Fecal Incontinence Quality of Life Score and the contents of a continence diary were recorded before and after the procedure. RESULTS: Twenty-four patients were included in the study of whom 17 (70.83%) demonstrated some degree of clinical or manometric improvement at 3 months. Before treatment 18 patients had urgency of <1 min. At 3 and 6 months this had risen to 5 min in 62.5% and 70.83% (P < 0.001). The anal resting pressure increased from 21.7 to 37.6 mmHg (P = 0.021), the maximum squeeze pressure from 58.2 to 72.2 mmHg (P = 0.045) and the Wexner score fell from 15 to 10 (P = 0.018) at 6 months. Predictive factors for a response included fewer than three incontinent episodes per week (P = 0.027). Negative predictive factors included episiotomy and an initial Wexner score of > 12 (P = 0.035). CONCLUSION: Percutaneous PTNS was effective in over 70% of patients in the present study with improvements in urgency, anal pressures and Wexner score.

Paired subcutaneous and visceral adipose tissue aquaporin-7 expression in human obesity and type 2 diabetes: differences and similarities between depots.

CONTEXT: AQP7 is considered to be the sole adipose glycerol channel, and its regulation is crucial for glycemia control. OBJECTIVES: In this work, we aimed to further characterize AQP7 in human adipose tissue in obesity and type 2 diabetes (T2D): 1) to assess AQP7 expression levels in paired abdominal adipose tissue depots (sc and visceral); 2) to relate it with gene expression of genes involved in lipid metabolism; and 3) to confirm that AQP7 is mainly expressed in the adipocytes. DESIGN: We conducted a transversal study of gene expression in paired samples of sc adipose tissue (SAT) and visceral adipose tissue (VAT). PATIENTS: Caucasian lean and obese subjects (n = 62, matched for age and gender) and T2D subjects (n = 11, matched for age, gender, and BMI with their control group) participated in the study. MAIN OUTCOME MEASURE: We measured AQP7 expression levels in paired SAT and VAT. RESULTS: We have proved the presence of AQP7 mRNA and protein in the adipocyte rather than the stromovascular fraction of adipose tissue (P = 0.001) and in mature adipocytes when differentiated in vitro. Increased AQP7 mRNA expression levels in VAT from T2D obese subjects (P < 0.05) were found. AQP7 transcript levels ratio of SAT vs. VAT changed with the presence of obesity and T2D. Interestingly, there were positive associations between AQP7 and both lipogenic and lipolytic genes in a similar manner in both adipose depots. CONCLUSIONS: Taken together, these data suggest a subtle regulation between adipose depots of the sole adipose aquaporin, AQP7, which is unbalanced in obesity and T2D.

Macrophages are novel sites of expression and regulation of retinol binding protein-4 (RBP4).

Obesity is linked to a low-level chronic inflammatory state that may contribute to the development of associated metabolic complications. Retinol-binding protein 4 (RBP4) is an adipokine associated with parameters of obesity including insulin resistance indices, body mass index, waist circumference, lipid profile, and recently, with circulating inflammatory factors. Due to the infiltration of adipose tissue in obesity by macrophages derived from circulating monocytes and, on the other hand, the existence of a close genetic relationship between adipocytes and macrophages, we decided to examine if RBP4 is expressed in monocytes and/or primary human macrophages. While we did not detect expression of RBP4 in undifferentiated monocytes, RBP4 expression became evident during the differentiation of monocytes into macrophages and was highest in differentiated macrophages. Once we demonstrated the expression of RBP4 in macrophages, we checked if RBP4 expression could be regulated by inflammatory stimuli such as tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), or the endotoxin lipopolysaccharide (LPS). We observed that while RBP4 expression was strongly inhibited by TNF-alpha and LPS, it was not affected by IL-6. Our results highlight the complexity behind the regulation of this adipokine and demonstrate that RBP4 expression in macrophages could be modulated by inflammatory stimuli.

Comparison of the microbicidal efficacy on germ carriers of several tertiary amine compounds with ortho-phthalaldehyde and Perasafe.

Several tertiary amine formulations have been marketed as high-level disinfectants (HLDs). This study compared some of these formulations with two accepted HLDs [ortho-phthalaldehyde (OPA) and Perasafe] by determining the bactericidal effect on 52 micro-organisms using a metallic germ carrier, determining the sporicidal effect using a commercial germ carrier (3M spores), and performing a corrosion test on surgical blades with human blood. OPA and Perasafe were significantly more effective than all the tertiary amines tested, and acted within a contact time of 10 min compared with 20 min for the other products. For Gram-negative micro-organisms, Instrunet FA showed no significant differences at 20 min compared with OPA and Perasafe at 10 min. The amines tested did not differ significantly in global bactericidal efficacy. Unlike the tertiary amines, OPA and Perasafe were effective against mycobacteria (15-min contact period), but were not sporicidal. All agents (except one tertiary amine) passed the corrosion test. In conclusion, OPA and Perasafe can be considered as HLDs. However, 15-20 min of contact is required and both products have disadvantages.

The influence of laboratory adaptation on test strains, such as Pseudomonas aeruginosa, in the evaluation of the antimicrobial efficacy of ortho-phthalaldehyde.

The microbiocidal efficacy of 0.55% ortho-pthalaldehyde (OPA) was evaluated in a rough carrier test, using more than 200 strains of bacteria and yeasts from patients and reference ATCC strains. This test was then compared with the European carrier test (prEN14561) using Pseudomonas aeruginosa. We also sought to determine whether recently isolated P. aeruginosa had the same susceptibility to OPA, after laboratory adaptation. It was shown that P. aeruginosa was less susceptible to OPA (being reduced by a factor of 10(3.8)) than the other strains (reduced by a factor of 10(4)). The surface test used, produced a lesser reduction of P. aeruginosa than the European test. For recently isolated strains (N = 66), the rough model demonstrated that the number of survivors increased both quantitatively and qualitatively from day one to day seven. It was concluded that disinfectant efficacy should be confirmed with recently isolated organisms.

Comparison of the disinfectant efficacy of Perasafe and 2% glutaraldehyde in in vitro tests.

Two percent glutaraldehyde has been the reference disinfectant for high-level disinfection, but its frequent association with adverse effects has stimulated a search for newer disinfectants. We compared the efficacy of 2% glutaraldehyde with that of a new disinfectant formulation, Perasafe (0.2% peracetic acid) in six in vitro tests: germicidal effect in a suspension of micro-organisms; using a microbe-contaminated metallic endodoncy file; an endoscope model; a modified capacity test; a sporicidal test, and corrosiveness on metallic instruments. Both products were effective germicides in 10-20 min, completely destroying microbial inocula except for Mycobacterium and spores. Internal irrigation of endoscopes with 100 mL of either was totally effective. Both substances resisted inactivation after repeated inoculation and did not corrode clean instruments; however, when organic matter was added the 0.2% peracetic acid formulation cleaned without corrosion, while 2% glutaraldehyde fixed the matter to the scalpel, causing corrosion within 2 h. In summary, Perasafe is a good substitute for 2% glutaraldehyde for high-level disinfection.

Usefulness of an alcohol solution of N-duopropenide for the surgical antisepsis of the hands compared with handwashing with iodine-povidone and chlorhexidine: clinical essay.

BACKGROUND: The usual surgical antisepsis involves scrubbing the skin with antiseptic solutions. This procedure can damage the skin, with the subsequent risk of infection for the patient. There are several efficient and quick-acting antiseptic alcohol solutions that require no scrubbing. MATERIAL AND METHODS: We compare four alcohol solutions with the classic surgical handwashing products (chlorhexidine and iodine-povidone), in both in vitro (pigskin germ carriers) and in vivo studies. The latter (clinical essays) were done with healthy volunteers (crossed design) as well as with 154 surgical team members (Plastic Surgery or Traumatology), whose hand microbial flora were measured before and after scrubbing up and after surgery. RESULTS AND DISCUSSION: Because of its efficiency in the germ carrier, we chose a solution of N-duopropenide in 60 degrees alcohol with emollients for further comparison with the standard surgical scrub: 4% chlorhexidine and 7.5% iodine-povidone. The quantitative, semiquantitative, and qualitative results obtained with N-duopropenide without scrubbing were better in the healthy volunteers and surgical teams. This product reduced hand microorganisms by more than 2 log, and maintained the reduction for the entire study period. Four percent chlorhexidine initially reduced colonization more than 2 log but lost part of its effect over time during the surgical intervention. Last, 7.5% iodine-povidone reduced the germs by 1 log but at the end of surgery there were even more germs than before washing. CONCLUSION: Because of its efficacy, persistent effect, and skin protection, we advise that scrubbing with classic antiseptic solutions be replaced with gentle washing with an alcohol solution such as N-duopropenide in alcohol.

Analytic epidemiology of clinical urinary tract infection in spinal cord injury.

The authors studied all patients (121) who were admitted to the National Paraplegic Center of Toledo, during a 6-month period, with spinal cord injuries (SCI). We obtained a clinical urinary tract infection predictive equation dependent on different risk factors (age, hospitalization time, level of SCI, sex, etc.). It is important to note that the main clinical-UTI risk factors were: (1) age, (2) hospitalization period, and (3) SCI category. We also achieved a mathematical model that we can use when the patient is admitted to this Center (in this case we do not include hospitalization time). This model enables us to predict clinical UTI depending on patient characteristics.

Efficacy of a broad-spectrum antibiotic (mupirocin) in an in vitro model of infected skin.

The microbicidal effect of mupirocin (Bactroban) was studied using an in vitro model of burn eschar in contact with this antimicrobial cream, to indicate its inhibiting action after 1, 2, 4, and 24 h. The microorganisms used were 20 isolates of Ps. aeruginosa, 20 isolates of MRSA, 10 isolates of Staph. epidermidis, 12 isolates of Enterobacteriaceae and eight isolates of Candida albicans. There was a marked effect on Gram-negative bacilli (< 0.1 per cent surviving) by 4 h, whereas on Gram-positive organisms its effect was slower, principally on MRSA with 2.2 per cent survivors by 24 h. The action on Candida was very slow initially, but after 24 h, the mupirocin's effect was marked (< 0.1 per cent survivors). The studies showed that mupirocin (a topical broad-spectrum antimicrobial agent) can be used in vitro against Gram-positive and Gram-negative bacteria and yeasts, which contaminate skin and mucosa. Further clinical experience is required before mupirocin can be used to treat colonized or infected wounds in burned patients.

Predictive equation for acquisition of hepatitis B in hospital workers in a general hospital.

A cross-sectional study was performed to obtain risk factors for hepatitis B disease, HBsAg carriers and immunised personnel, among 2470 workers in a general hospital in Madrid, Spain. The data obtained were analyzed with multiple logistic regression to obtain beta coefficients for variables. The results of the analysis show that being a nurse or being regularly exposed to blood are the most important risk factors for hepatitis B acquisition. The length of time working at the same job activity was also a risk factor. The resulting beta coefficients allow the construction for a hepatitis non-immunised, HBsAg carrier and immunised HBV status, which can select subjects for a hepatitis B vaccination program.

[Hepatitis B vaccination in children and adolescents]. / Vacunación contra la hepatitis B en niños y adolescentes.

OBJECTIVE: This study's main aim was to investigate the immunogenicity of genetic recombinant vaccine in children and adolescents in Madrid, with the intention of determining the length of protection according to the titer of antibodies. A second aim was that of finding the optimum vaccine dosage, in order to suggest possible courses of action leading to an adequate strategy of vaccination. DESIGN: Crossover study. SETTING: Three educational centres in Madrid. PATIENTS AND OTHERS PARTICIPANTS: 1,184 pupils between 5 and 17 years old. INTERVENTIONS: Each individual was given three doses of Engerix B recombinant vaccine in the deltoid area at 0, 1 and 6 months. The vaccine dosage was 10 micrograms for children under 12 and 20 micrograms for those aged 12 and over. MAIN MEASUREMENTS AND RESULTS: The pre-vaccination markers were determined. A month after completing the vaccination, the titer of antibodies was quantified using the Abbott laboratories' microenzyme-immunoanalysis technique. The overall seroprotection rate was 98.9%. The MGT of the titer of antibodies was 9,283.2 mUI/ml. The seroprotection rates were similar among children under 12. The rates were also similar among those who were 12 or over, with titers of antibodies showing significantly higher in the children aged 12 or over. CONCLUSIONS: Given the good results obtained, we consider that the children will be protected for about 10 years. We suggest that all children and/or adolescents should be vaccinated as a means of controlling Hepatitis B. The recommended dosage for children under 8 is 10 micrograms and for those aged 8 and over, 20 micrograms.

[The descriptive and analytical epidemiology of traumatic spinal cord lesions occurring in Spain during 1984 and 1985]. / Epidemiología descriptiva y analítica de la lesión medular espinal traumática ocurrida en España durante 1984 y 1985.

Descriptive and analytic epidemiology of traumatic spinal cord injury (Traumatic-SCI) in Spain, with a sample of 33% of all incidental cases between 1984 and 1985, underlining the traffic accidents as the origin of those lesions. OR was obtained next of different variables of T-SCI, after controlling possible confusing factors through logistic regression and taking as "control group" Non Traumatic-SCI. OR in Traumatic-SCI decreases with age and in females. These Traumatic-SCI produce especially "cervical" lesions (OR = 3) and "complete" (OR = 4) with higher dependence on second persons. In the rest of variables there are no significative differences.

Diagnosis of local infection of a burn by semiquantitative culture of the eschar surface.

The purpose of this study was to determine whether semiquantitative surface cultures of the burn eschar are as reliable or useful as the classic invasive biopsy culture method. We used eschars from patients with burns in an in vitro system. Lyophilized pigskin was used to validate our methodology. Because of its simplicity and high degree of sensitivity and specificity as compared with quantitative biopsy culture, semiquantitative surface culture has a place in burn wound surveillance.

A new in vitro model to test the effectiveness of topical antimicrobial agents. Use of an artificial eschar.

An in vitro method using a burn eschar 'equivalent' is described to compare the efficacy of several antimicrobial creams. Fragments of lyophilized pigskin were used as 'germ carriers' and after 24 h of treatment the effectiveness of the antimicrobial creams was tested through the evaluation of bacterial recovery both from the surface and from within the 'germ carriers'. The results showed a striking full skin thickness effectiveness of 0.5 per cent chlorhexidine, 10 per cent providone iodine and 2 per cent cerium nitrate in comparison with the weak activity demonstrated by 1 per cent silver sulphadiazine cream.

Evaluation of the penetration strength, bactericidal efficacy and spectrum of action of several antimicrobial creams against isolated microorganisms in a burn centre.

The antibacterial activity of eight antiseptic creams: 1 per cent silver sulphadiazine; 0.2 per cent nitrofurazone; 0.1, 0.5 and 1 per cent chlorhexidine; 2.2 per cent cerium nitrate; 10 per cent povidone iodine; and 1 per cent silver sulphadiazine with 2.2 per cent cerium nitrate were evaluated in vitro. The evaluation included the minimum inhibitory concentration (MIC) against 100 microorganisms isolated from burn patients, the chronology of the bacterial activity against Ps. aeruginosa and Staph. aureus and the penetration strength of the creams through a novel in vitro model contaminated with 17 microorganisms of different species isolated from burn patients. The results revealed that 0.5 per cent or 1 per cent chlorhexidine, 2.2 per cent cerium nitrate, and 1 per cent silver sulphadiazine with 2.2 per cent cerium nitrate were the creams which were effective at the highest dilutions. 0.5 per cent chlorhexidine and 10 per cent povidone iodine had the greater bactericidal activity. Finally, 0.2 per cent nitrofurazone showed greater penetration strength within the eschar model in comparison with the weaker penetration of 0.5 per cent and 1 per cent chlorhexidine and the absence of penetration by the rest of the antibacterial creams.

Serum CK-BB as a tumor marker in patients with carcinoma confirmed histologically.

We determined serum CK-BB mass concentration using a specific RIA method, in 267 patients with carcinoma confirmed histologically distributed as follows: 46 prostatic adenocarcinoma, 52 lung neoplasies, 70 colon carcinoma, 52 breast carcinoma and 41 gastric carcinoma; and also in 135 patients with histologically proved non-neoplastic diseases distributed as follows: 28 prostatic hyperplasy, 31 lung tuberculosis, 29 inflammatory bowel disease, 27 fibrocystic mastopathy and 20 gastroduodenal ulcer. Reference values in healthy subjects (n = 360) were 5.46 +/- 2.68 (SD) ng/ml. We found that serum CK-BB mass concentration is not a specific tumor marker but it is a valuable indicator of responsing to therapy and metastatic widespread. However, in prostatic carcinoma--prevalence 0.25, predictive positive value (PPV) 0.51 and predictive negative value (PNV) 0.88--and breast carcinoma--prevalence 0.32, PPV 0.60 and PNV 0.87--serum CK-BB can be used as a tumor marker. Only 12 over 268 patients with different neoplastic disease (4.47%) showed detectable serum CK-BB catalytic concentrations.