Executive summary and conclusions from the European Hydration Institute Expert Conference on human hydration, health, and performance.

On April 7-8, 2014, the European Hydration Institute hosted a small group of experts at Castle Combe Manor House, United Kingdom, to discuss a range of issues related to human hydration, health, and performance. The meeting included 18 recognized experts who brought a wealth of experience and knowledge to the topics under review. Eight selected topics were addressed, with the key issues being briefly presented before an in-depth discussion. Presented here is the executive summary and conclusions from this meeting.

Body protein metabolism and plasma amino acids in cirrhosis of the liver. The effect of varying the branched chain amino acid content of intravenous amino acid solutions.

Body protein metabolism and plasma amino acids were measured in 37 patients with stable cirrhosis of the liver to assess the effect of disease severity (Child's classification). Thirty two patients underwent a second series of measurements while nutrition was administered intravenously as one of five different infusions. Four infusions were formulations of amino acids with dextrose of varying branched chain amino acid content (100%, 53%, 35% and 16% branched chain to total amino acids). The fifth infusion was dextrose alone. No differences were detected in body protein synthesis and breakdown between patients on the basis of disease severity although some small differences were noted in the plasma amino acids. Infusion of dextrose alone and the 16% BCAA solution led to negative protein balance and a lowering of the plasma branched chain amino acid concentrations. Improved protein balance was observed with 35% BCAA, this solution also lowered the levels of methionine and aromatic amino acids. In those patients given 53% BCAA protein balance was achieved and the plasma branched chain amino acids elevated. Protein balance also occurred with 100% BCAA, in association with marked increases in underlying protein synthesis and breakdown and with this infusion there were marked elevations in the plasma branched chain amino acids and depression of the other plasma amino acids. The increase in protein breakdown with this last formulation was unexpected and may be harmful. On the basis of these findings it is suggested that the composition of the 53% and 35% solutions may be optimal to protein metabolism and manipulation of plasma amino acids in this group of patients.

Triacylglycerol synthesis in the oleaginous yeast Candida curvata D.

Low rates of triacylglycerol (TAG) biosynthesis were observed in cell-free extracts of Candida curvata, but rates were increased up to 10-fold by adding either alpha- or beta-cyclodextrins. Spheroplasts, whole or gently disrupted, had higher rates of incorporation of both [U-14C]glycerol 3-phosphate or [1-14C]oleate into triacylglycerol and the intermediates of its biosynthesis: lysophosphatic acid, phosphatidic acid and diacylglycerol. Fatty acyl-CoA synthetase was highest with palmitate, oleate and linoleate but was some 6- to 8-fold lower with stearate. Stearate and stearoyl-CoA were poorly incorporated into lipids. Subcellular fractionation of the spheroplasts into mitochondrial, microsomal, lipid bodies and supernatant fractions diminished the rates of 14C incorporation of oleate into triacylglycerol. By comparing the relative specific activities for each activity in each fraction, the fatty acyl-CoA synthetase activity appeared mainly in the lipid bodies, and that for phosphatidic acid formation was mainly in the mitochondrion; other activities were too weak and too dispersed for accurate assessment of their location. Recombining all the subcellular fractions restored triacylglycerol synthesizing activity. Omitting any single fraction from the mixture did not result in restoration of triacylglycerol synthesizing activity. Starvation of the yeast, which leads to utilization of the endogenous lipid reserves, stimulated fatty acyl-CoA synthetase activity, but diminished phosphatidic acid and triacylglycerol biosynthesis indicating probable induction of beta-oxidation in the peroxisomes and repression of lipid biosynthesis.

Rehydration of air-dried smears. An alternative method for cytologic analysis of exfoliative cells.

OBJECTIVE: To compare the cytologic characteristics of gastric mucosal cell smears prepared by air drying and rehydration prior to alcohol fixing with cells wet fixed in alcohol. STUDY DESIGN: Gastric mucosal cells were obtained from 55 consecutive patients undergoing gastroscopy. Paired smears were made, one immediately fixed in 95% ethanol for 20 minutes (wet fixed [WF]) and the other air dried for at least 20 minutes prior to rehydration with normal saline for 30 seconds and fixation in 95% ethanol for 20 minutes (air dried/rehydrated/fixed [ARF]). Both slides were stained by the Papanicolaou method. Coded slides were examined blind and graded 1 (superior), 2 (satisfactory) or 3 (poor) with respect to staining of chromatin, nuclear membrane, nucleoli, cytoplasm/cell border and group morphology. Histology confirmed a benign disease process or normal mucosa. RESULTS: Comparing grade 1 versus grades 2 and 3, ARF slides were significantly better than WF slides for all cytologic features (P < .05). Comparing grade 1 and 2 versus grade 3, there was no significant difference between ARF and WF slides (P > .05) (chi 2 analysis). CONCLUSION: The cytologic features of ARF smears of gastric cells were equal or superior to those of WF smears. This method of preparing smears is simpler and avoids some of the problems of ethanol fixation of wet smears.

The place of apomorphine prior to obstetric analgesia.

The use of apomorphine is investigated as an alternative to the use of a stomach tube to empty the stomachs of patients in labour prior to the induction of general anaesthesia. Apomorphine was found to be much pleasanter for the patients, to be just as effective as a stomach tube and to have no deleterious effects on the infant.

A fresh look at magnesium trisilicate.

Confusion exists about the correct way to use magnesium trisilicate as an antacid prior to inducing general anaesthesia in the pregnant woman. The effectiveness of two-hourly doses of antacid is discussed with special reference to the rate at which the stomach empties. Consequently, it is important to know whether the patient is in labour and if so the type of analgesic used. Some of the chemical characteristics of Mist. Mag. Trisil. B.P.C. are discussed. It is shown that it is capable of raising the pH of the stomach contents above 3.0 within two minutes in comparatively small doses. Clinically it is shown to be almost completely effective in a large series of patients. Inadequate mixing of the alkali with the stomach contents when it is given as an immediate pre-induction dose leads to a hazard of acid regurgitation when anaesthesia is induced in these patients.

Ten-year audit of arterial surgery from a district hospital.

An audit of 10 years of arterial surgery was undertaken to compare the first 5 years with the second 5 years. The aim was to see if the surgery during the second 5 years was being undertaken to an acceptable standard, and if there had been improvements in haemorrhagic complications and outcome for femoro-crural bypass grafts, which had previously been identified as problem areas during the first 5 years. Between the two 5-year periods, combined general surgical and arterial admissions and operations reduced by 21.8% and 26.2%, respectively, owing to marked reductions in gastrointestinal and biliary patients. At the same time, arterial admissions and operations increased by 55.7% and 46.6%, respectively. Improvements were found in outcome for aortic and iliac aneurysms and lower limb bypasses, in particular crural grafts. Aorto-iliac and aortofemoral bypasses were undertaken less frequently with a higher mortality and more complications, but in the second 5 years these patients were more urgent and more likely to have a threatened limb. There was a reduction in re-operation for postoperative bleeding in the second 5 years (4.6% vs 2.2%). It was concluded that the surgery was being undertaken to an acceptable standard, but that the quantity of vascular surgery during the second 5 years was such that continued single-surgeon practice in the present setting was unacceptable.

Treatment of infective and potentially infective complications of vascular bypass grafting using gentamicin with collagen sponge.

The use of gentamicin with collagen sponge (GCS) in treating patients with infective and potentially infective complications of vascular bypass grafting was reviewed. GCS was used in 25 patients. These were: 11 in situ applications to a proven graft infection, 2 to a superficial wound infection over an underlying graft, 4 at removal of an infected prosthesis, 4 for a persistent lymphatic leak, 3 for an anastomotic aneurysm and one for an anastomotic dehiscence. The GCS was used with rifampicin-soaked collagen impregnated Dacron in 3 of these patients. Of the 11 in situ treatments of a graft infection with GCS, 7 infections were successfully aborted, 3 grafts were removed resulting in 2 patients losing a leg and one patient died before the outcome was known. None of the other patients treated with GCS subsequently had infective sequelae. GCS is a simple, safe and often effective treatment when dealing with these difficult complications of arterial surgery, the use of which requires greater recognition.

Complications following re-exploration of the groin for recurrent varicose veins.

BACKGROUND: Groin surgery for recurrent varicose veins can be technically difficult due to scarring from previous surgery. Access to the sapheno-femoral junction (SFJ) can be facilitated by approaching the veins indirectly (subfascially) by first exposing the common femoral artery. The aim of this paper was to document experience with both direct and indirect approaches to the SFJ for recurrent varicose veins. METHOD: A retrospective analysis of all patients having groin surgery for recurrent varicose veins. RESULTS: Of 128 legs having surgery, the approach to the SFJ was direct in 46%, indirect in 53% and unknown in one leg. Complications occurred after 40% of all procedures but were significantly more common following indirect surgery (57% versus 20%, P < 0.001), of which the most frequent were of a lymphatic nature (26% versus 5%, P < 0.001) or wound infection (16% versus 7%, P = 0.05). CONCLUSION: Wound complications are common following groin surgery for recurrent varicose veins especially after an indirect approach to the SFJ.

Audit of introduction of hand-held Doppler and duplex ultrasound in the management of varicose veins.

Hand-held Doppler (HHD) examination and duplex ultrasound scanning of patients with varicose veins are more accurate than clinical assessment alone. To assess how the introduction of HHD and the availability of duplex ultrasound scanning affects patient management, a retrospective review was carried out comparing the year before the introduction with the subsequent 2 years. Information was extracted from a computer database containing details of all new venous outpatients, their initial management and investigations and subsequent operations. HHD and duplex ultrasound resulted in a marked increase in secondary investigations (16% versus 41%) and fewer patients being listed directly for surgery (47% versus 29%). Operations on the long saphenous vein decreased from 84% to 76% whereas short saphenous surgery increased from 6% to 21% during this time.

District hospital management and outcome of critical lower limb ischaemia: comparison with national figures.

OBJECTIVE: To compare local with national management and outcome of critical limb ischaemia (CLI). DESIGN: Use of nationally identified management groups for allocation of local patients. These were: revascularisation, primary major amputation, medical/minor surgical treatment and no treatment. MATERIAL: All admissions with CLI for the 5 year period January 1990 to December 1994. RESULTS: Local compared to national revascularisation of 43% vs. 63%, primary major amputation of 18% vs. 16%, medical/minor surgical of 20% vs. 8% and no treatment of 19% vs. 13%. During the fifth year 59% of limbs were revascularised. Fewer patients died in hospital locally (8% vs. 14%), particularly the group having no treatment (9% vs. 44%), but by 6 months only 58% of this group had survival. Local compared to national hospital limb salvage of 76% vs. 68% and patency of revascularisation of 86% vs. 75%. Of the revascularisations a low rate of percutaneous transluminal angioplasty (PTA) was noted locally (16% vs. 34%) and more grafts were being taken to above-nee popliteal artery (26% vs. 13%). Crural grafts were revised to a secondary amputation in 42%. CONCLUSION: Although differences were observed between local and national management of CLI, overall acceptable outcomes were being obtained locally despite there being an identifiable deficiency in the availability of radiological services with regard to urgent PTA and thrombolysis.

Five-year vascular audit from a district hospital.

Vascular patients under the care of one surgeon over a 5-year period have been reviewed, from computer-based discharge records, with regard to in-hospital measures of outcome to determine whether or not surgery was being performed to an acceptable standard. Out of 466 procedures, 30 per cent of patients had at least one complication, 14 per cent had further surgery and 9 per cent died. Outcome was examined within the following treatment groups: aorto/iliac aneurysm, aortofemoral bypass, femoroproximal popliteal bypass, femorodistal popliteal bypass, femorocrural bypass, embolectomy and percutaneous transluminal angioplasty. Patients having below-knee bypass surgery were found to have an unacceptably high rate of complications, reoperations and amputations. An overall rate of reoperation for postoperative bleeding of 5 per cent was also considered to be high. With these exceptions, it was concluded that the surgery was being performed to an acceptable standard, but that comparative audit of this type remained difficult while there was a deficiency of national statistics against which the work of individual surgeons could be judged.

Relationship between stomach contents and analgesia in labour.

The volume of stomach contents found in patients undergoing Caesarean section was studied. The largest volumes were found in patients who had received pethidine analgesia and the smallest volumes in patients who had received either extradural analgesia or no analgesia. Intermediate volumes were found in patients who had received pethidine in addition to extradural analgesia. Pethidine, rather than the emotional stress of labour, was thought to cause gastric retention. Patients having elective Caesarean sections had considerably less gastric retention than patients in labour.

Screening for abdominal aortic aneurysm in Northumberland.

A study was carried out to examine the feasibility of setting up a community-based screening programme for abdominal aortic aneurysm (AAA) in men aged 65-79 years served by a district general hospital. A pilot project was run in two general practices from which 800 men were invited to undergo ultrasonography of the abdominal aorta. Of these, 628 (78.5 per cent) attended; 42 (6.7 per cent) were found to have an aneurysm (aortic diameter greater than 29 mm), ten (1.6 per cent) had a large aneurysm (diameter above 49 mm) and seven (1.1 per cent) received aortic grafts. On the basis of these findings it was felt that to screen all men aged 65-79 years (n = 12,800) or aged 65-74 years (n = 10,300) would lead to more operations than local facilities could handle. A more practical option would be to target annually men aged 65 years, with rescreening at intervals of 5 years until age 75 years, but even this would eventually lead to an unmanageable number of operations.

Reversed rotation of the midgut in an adult. Case report.

Management of a patient with a congenital anomaly of the midgut can be difficult for a surgeon since these abnormalities are extremely rare particularly in adults. However a thorough knowledge of embryology and anatomy will allow the complexity of a rotational anomaly to be resolved. A case of reversed rotation of the midgut is presented and the literature on this subject reviewed.