The difference between the basal metabolic rate and the sleeping metabolic rate in Japanese.

Previous studies have demonstrated the difference between the basal metabolic rate (BMR) and the sleeping metabolic rate (SMR): however, the difference in the Japanese population has not yet been explored. This study examined the relationship between the BMR and SMR in ninety-four healthy Japanese subjects (37 males and 57 females, 39 +/- 12 y of age and 22.0 +/- 7.4% body fat) in a respiratory chamber. The SMR was significantly lower than the BMR (1416 +/- 245 vs. 1492 +/- 256 kcal/d): however, there was a highly significant correlation between the two (r = 0.867; p < 0.001). The ratio of SMR/BMR largely varied among individuals (0.95 +/-0.08, 8.4% of the coefficient of variation). The ratio was significantly lower in males than in females (0.93 +/- 0.10 vs. 0.97 +/- 0.06, p < 0.05). None of the anthropometric measures (age, weight, body mass index, body surface area or percent body fat) correlated with the ratio. These results showed that SMR was 95%, of BMR on average in a healthy Japanese group. However, when applied over a longer time period (24 h or more), the difference tends to become negligible for most analyses in a group. Although the difference between SMR and BMR will induce a 5% gap of physical activity level defined as the total energy expenditure divided by the BMR or SMR, this factor seems to have little practical importance in epidemiological research.

Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review.

Object The purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN). Methods Using the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70-90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study. Results The median time to retreatment in the Marseille study was 72 months (range 12-125 months) and in the literature it was 17 months (range 3-146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12-96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1-180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%-100%) and for new hypesthesia of 33% (range 11%-80%). Conclusions Results from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.

Estimation of glomerular filtration rate in hospitalised patients: are we overestimating renal function?

QUESTIONS UNDER STUDY AND PRINCIPLES: Estimating glomerular filtration rate (GFR) in hospitalised patients with chronic kidney disease (CKD) is important for drug prescription but it remains a difficult task. The purpose of this study was to investigate the reliability of selected algorithms based on serum creatinine, cystatin C and beta-trace protein to estimate GFR and the potential added advantage of measuring muscle mass by bioimpedance. In a prospective unselected group of patients hospitalised in a general internal medicine ward with CKD, GFR was evaluated using inulin clearance as the gold standard and the algorithms of Cockcroft, MDRD, Larsson (cystatin C), White (beta-trace) and MacDonald (creatinine and muscle mass by bioimpedance). 69 patients were included in the study. Median age (interquartile range) was 80 years (73-83); weight 74.7 kg (67.0-85.6), appendicular lean mass 19.1 kg (14.9-22.3), serum creatinine 126 μmol/l (100-149), cystatin C 1.45 mg/l (1.19-1.90), beta-trace protein 1.17 mg/l (0.99-1.53) and GFR measured by inulin 30.9 ml/min (22.0-43.3). The errors in the estimation of GFR and the area under the ROC curves (95% confidence interval) relative to inulin were respectively: Cockcroft 14.3 ml/min (5.55-23.2) and 0.68 (0.55-0.81), MDRD 16.3 ml/min (6.4-27.5) and 0.76 (0.64-0.87), Larsson 12.8 ml/min (4.50-25.3) and 0.82 (0.72-0.92), White 17.6 ml/min (11.5-31.5) and 0.75 (0.63-0.87), MacDonald 32.2 ml/min (13.9-45.4) and 0.65 (0.52-0.78). Currently used algorithms overestimate GFR in hospitalised patients with CKD. As a consequence eGFR targeted prescriptions of renal-cleared drugs, might expose patients to overdosing. The best results were obtained with the Larsson algorithm. The determination of muscle mass by bioimpedance did not provide significant contributions.

Assessment of adult formulas for glomerular filtration rate estimation in children.

BACKGROUND: Estimated glomerular filtration rate (eGFR) is an important diagnostic instrument in clinical practice. The National Kidney Foundation-Kidney Disease Quality Initiative (NKF-KDOQI) guidelines do not recommend using formulas developed for adults to estimate GFR in children; however, studies confirming these recommendations are scarce. The aim of our study was to evaluate the accuracy of the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, the Modification of Diet in Renal Disease (MDRD) formula, and the Cockcroft-Gault formula in children with various stages of chronic kidney disease (CKD). METHODS: A total of 550 inulin clearance (iGFR) measurements for 391 children were analyzed. The cohort was divided into three groups: group 1, with iGFR >90 ml/min/1.73 m(2); group 2, with iGFR between 60 and 90 ml/min/1.73 m(2); group 3, with iGFR of <60 ml/min/1.73 m(2). RESULTS: All formulas overestimate iGFR with a significant bias (p < 0.001), present poor accuracies, and have poor Spearman correlations. For an accuracy of 10 %, only 11, 6, and 27 % of the eGFRs are accurate when using the MDRD, CKD-EPI, and Cockcroft-Gault formulas, respectively. For an accuracy of 30 %, these formulas do not reach the NKF-KDOQI guidelines for validation, with only 25, 20, and 70 % of the eGFRs, respectively, being accurate. CONCLUSIONS: Based on our results, the performances of all of these formulas are unreliable for eGFR in children across all CKD stages and cannot therefore be applied in the pediatric population group.

L'angioplastie coronaire chez le patient âgé [Coronary angioplasty in elderly patients]

Percutaneous transluminal coronary angioplasty (PTCA) is a widely accepted treatment of symptomatic coronary heart disease providing prompt and prolonged clinical, improvement in most patients. We have examined the value of this therapy in a group of 91 patients in their eighth decade treated by 133 consecutive angioplasties. Most patients had refractory or instable angor in spite of optimal pharmacotherapy. Multivessel disease was present in 67% and maintained left-ventricular function in 92% of the patients. The angiographic success rate of PTCA was 84%; technical failures occurred in 12% and adverse events in 14%. Two patients died. The rate of symptomatic restenosis was 24%. Survival and patients free of myocardial events were at 89% and 60%, respectively, estimated by Kaplan-Meier analysis. PTCA is an efficient and acceptable treatment for the elderly patient with severe and drug-resistant angina. Two years after PTCA the majority of patients was asymptomatic.

A gamma camera count rate saturation correction method for whole-body planar imaging.

Whole-body (WB) planar imaging has long been one of the staple methods of dosimetry, and its quantification has been formalized by the MIRD Committee in pamphlet no 16. One of the issues not specifically addressed in the formalism occurs when the count rates reaching the detector are sufficiently high to result in camera count saturation. Camera dead-time effects have been extensively studied, but all of the developed correction methods assume static acquisitions. However, during WB planar (sweep) imaging, a variable amount of imaged activity exists in the detector's field of view as a function of time and therefore the camera saturation is time dependent. A new time-dependent algorithm was developed to correct for dead-time effects during WB planar acquisitions that accounts for relative motion between detector heads and imaged object. Static camera dead-time parameters were acquired by imaging decaying activity in a phantom and obtaining a saturation curve. Using these parameters, an iterative algorithm akin to Newton's method was developed, which takes into account the variable count rate seen by the detector as a function of time. The algorithm was tested on simulated data as well as on a whole-body scan of high activity Samarium-153 in an ellipsoid phantom. A complete set of parameters from unsaturated phantom data necessary for count rate to activity conversion was also obtained, including build-up and attenuation coefficients, in order to convert corrected count rate values to activity. The algorithm proved successful in accounting for motion- and time-dependent saturation effects in both the simulated and measured data and converged to any desired degree of precision. The clearance half-life calculated from the ellipsoid phantom data was calculated to be 45.1 h after dead-time correction and 51.4 h with no correction; the physical decay half-life of Samarium-153 is 46.3 h. Accurate WB planar dosimetry of high activities relies on successfully compensating for camera saturation which takes into account the variable activity in the field of view, i.e. time-dependent dead-time effects. The algorithm presented here accomplishes this task.

The composition of mineral waters sourced from Europe and North America in respect to bone health: composition of mineral water optimal for bone.

The consumption of mineral waters is increasing in industrialised countries. High intakes of Ca and other alkalising cations as well as a low acid intake are beneficial to bone. We examined which components of mineral waters are conditioning their Ca content and their alkalinising power, in order to define the optimal profile. European mineral waters were randomly selected on the Internet: 100 waters with less than 200 mg Ca/l (9.98 mEq/l) and fifty with more than 200 mg/l, all with complete data for SO4, P, Cl, Na, K, Mg and Ca, and most also for HCO3. For comparison, forty North American mineral waters were randomly chosen. The potential renal acid load (PRAL) was calculated for each mineral water. North American waters did not reveal significant results because of their low mineralisation. We performed correlations between all eight components in order to explore the properties of the mineral waters. In the European waters, twenty-six out of twenty-eight correlations showed a P value of <or= 0.01. In waters with PRAL >0 (acidifying waters), PRAL was positively correlated with SO4, Ca, K and Mg (P < 0.001). In those with PRAL < 0 (alkalinising waters), PRAL was negatively correlated with HCO3, Na, Mg, Ca, K, Cl and SO4 (P < 0.001). SO4 and HCO3 were not found together in high quantities in the same water for geochemical reasons. A high Ca content is associated with either a high SO4 or a high HCO3 content. SO4 theoretically increases Ca excretion, while HCO3 and low PRAL values are associated with positive effects on bone. Therefore, the best waters for bone health are rich in both HCO3 and Ca, and by consequence low in SO4.

Is PaCO2 management optimal under controlled mechanical ventilation (CMV) during neuro-resuscitation?

INTRODUCTION. Both hypocapnia and hypercapnia can be deleterious to brain injured patients. Strict PaCO2 control is difficult to achieve because of patient's instability and unpredictable effects of ventilator settings changes. OBJECTIVE. The aim of this study was to evaluate our ability to comply with a protocol of controlled mechanical ventilation (CMV) aiming at a PaCO2 between 35 and 40 mmHg in patients requiring neuro-resuscitation. METHODS. Retrospective analysis of consecutive patients (2005-2011) requiring intracranial pressure (ICP) monitoring for traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), intracranial haemorrhage (ICH) or ischemic stroke (IS). Demographic data, GCS, SAPS II, hospital mortality, PaCO2 and ICP values were recorded. During CMV in the first 48 h after admission, we analyzed the time spent within the PaCO2 target in relation to the presence or absence of intracranial hypertension (ICP[20 mmHg, by periods of 30 min) (Table 1). We also compared the fraction of time (determined by linear interpolation) spent with normal, low or high PaCO2 in hospital survivors and non-survivors (Wilcoxon, Bonferroni correction, p\0.05) (Table 2). PaCO2 samples collected during and after apnoea tests were excluded. Results given as median [IQR]. RESULTS. 436 patients were included (TBI: 51.2 %, SAH: 20.6 %, ICH: 23.2 %, IS: 5.0 %), age: 54 [39-64], SAPS II score: 52 [41-62], GCS: 5 [3-8]. 8744 PaCO2 samples were collected during 150611 h of CMV. CONCLUSIONS. Despite a high number of PaCO2 samples collected (in average one sample every 107 min), our results show that patients undergoing CMV for neuro- resuscitation spent less than half of the time within the pre-defined PaCO2 range. During documented intracranial hypertension, hypercapnia was observed in 17.4 % of the time. Since non-survivors spent more time with hypocapnia, further analysis is required to determine whether hypocapnia was detrimental per se, or merely reflects increased severity of brain insult.

Isochorismate synthase (PchA), the first and rate-limiting enzyme in salicylate biosynthesis of Pseudomonas aeruginosa.

In Pseudomonas aeruginosa the extracellular metabolite and siderophore pyochelin is synthesized from two major precursors, chorismate and l-cysteine via salicylate as an intermediate. The regulatory role of isochorismate synthase, the first enzyme in the pyochelin biosynthetic pathway, was studied. This enzyme is encoded by pchA, the last gene in the pchDCBA operon. The PchA protein was purified to apparent electrophoretic homogeneity from a PchA-overexpressing P. aeruginosa strain. The native enzyme was a 52-kDa monomer in solution, and its activity strictly depended on Mg(2+). At pH 7.0, the optimum, a K(m) = 4.5 microm and a k(cat) = 43.1 min(-1) were determined for chorismate. No feedback inhibitors or other allosteric effectors were found. The intracellular PchA concentration critically determined the rate of salicylate formation both in vitro and in vivo. In cultures grown in iron-limiting media to high cell densities, overexpression of the pchA gene resulted in overproduction of salicylate as well as in enhanced pyochelin formation. From this work and earlier studies, it is proposed that one important factor influencing the flux through the pyochelin biosynthetic pathway is the PchA concentration, which is determined at a transcriptional level, with pyochelin acting as a positive signal and iron as a negative signal.

Effects of caffeine on energy metabolism, heart rate, and methylxanthine metabolism in lean and obese women.

The magnitude of coffee-induced thermogenesis and the influence of coffee ingestion on substrate oxidation were investigated in 10 lean and 10 obese women, over two 24-h periods in a respiratory chamber. On one occasion the subjects consumed caffeinated coffee and on the other occasion, decaffeinated coffee. The magnitude of thermogenesis was smaller in obese (4.9 +/- 2.0%) than in lean subjects (7.6 +/- 1.3%). The thermogeneic response to caffeine was prolonged during the night in lean women only. The coffee-induced stimulation of energy expenditure was mediated by a concomitant increase in lipid and carbohydrate oxidation. During the next day, in postabsorptive basal conditions, the thermogenic effect of coffee had vanished, but a significant increase in lipid oxidation was observed in both groups. The magnitude of this effect was, however, blunted in obese women (lipid oxidation increased by 29 and 10% in lean and obese women, respectively). Caffeine increased urinary epinephrine excretion. Whereas urinary caffeine excretion was similar in both groups, obese women excreted more theobromine, theophylline, and paraxanthine than lean women. Despite the high levels of urinary methylxanthine excretion, thermogenesis and lipid oxidation were less stimulated in obese than in lean subjects.

Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial.

BACKGROUND: Surgical site infection after stoma reversal is common. The optimal skin closure technique after stoma reversal has been widely debated in the literature. OBJECTIVE: We hypothesized that pursestring near-complete closure of the stoma site would lead to fewer surgical site infections compared with conventional primary closure. DESIGN: This study was a parallel prospective multicenter randomized controlled trial. SETTINGS: This study was conducted at 2 university medical centers. PATIENTS: Patients (N = 122) presenting for elective colostomy or ileostomy reversal were selected. INTERVENTIONS: Pursestring versus conventional primary closure of stoma sites were compared. MAIN OUTCOME MEASURES: Stoma site surgical site infection within 30 days of surgery, overall surgical site infection, delayed healing (open wound for >30 days), time to wound epithelialization, and patient satisfaction were the primary outcomes measured. RESULTS: The pursestring group had a significantly lower stoma site infection rate (2% vs 15%, p = 0.01). There was no difference in delayed healing or patient satisfaction between groups. Time to epithelialization was measured in only 51 patients but was significantly longer in the pursestring group (34.6 ± 20 days vs 24.1 ± 17 days, p = 0.02). LIMITATIONS: This study was limited by the variability in procedures and surgeons, the limited follow-up after 30 days, and the inability to perform blinding. CONCLUSION: Pursestring closure after stoma reversal has a lower risk of stoma site surgical site infection than conventional primary closure, although wounds may take longer to heal with the use of this approach. REGISTRATION NUMBER: NCT01713452 (www.clinicaltrials.gov).

Risk factors of latent tuberculosis infection among asylum-seekers recently arrived in Switzerland : A pilot study in Vaud county

Background: Asylum seekers may have a higher rate of latenttuberculosis infection (LTBI) than resident populations in Westerncountries. LTBI can be detected by an Interferon Gamma ReleaseAssay (IGRA). Screening asylum seekers at highest risk for LTBI orfuture tuberculosis by IGRA could be considered. The aims of this pilotstudy were to assess the prevalence and the risk factors of LTBI amonga group of asylum seekers recently arrived in Switzerland.Methods: A prospective cross-sectional study was performed amongadult asylum seekers, staying in two migrant centers of the Vaud county,Switzerland, after a first screening for active tuberculosis at the border.The participants were offered IGRA screening using T-SPOT.TB andwere questioned about risk factors associated with LTBI. Migrants with apositive test had a chest radiograph and a medical examination. Thosewith active tuberculosis were excluded and were treated. The migrantswith LTBI received a preventive treatment, if indicated. The risk factorswere analyzed by univariate and multivariate logistical regression.Results: Among 788 migrants recently arrived, 639 were adults, 393agreed to be screened (61.50%) and 98 of them had a positive T-SPOT.TB (24.93%) of which 5 (5.1%) had an active tuberculosis (previouslynot detected at the border), and 2 had already been treated for activetuberculosis. In univariate analysis, the major risk factors associatedwith LTBI were country of origin and travel conditions. Compared withmigrants from Balkanic countries, migrants from Africa had an OR forLTBI of 3.68, migrants from Asia an OR of 4.3 and migrants fromFormer Soviet Union an OR of 4.5. Migrants who crossed severalborders before arriving in Switzerland had an OR of LTBI of 2.49compared with migrants who came directly from the home country.Age, cough and prior exposure to tuberculosis had a non-significantinfluence on the rate of test positivity. In multivariate analysis, thecombination of country of origin, travel conditions, age, cough andexposure to tuberculosis resulted in a score with optimal predictivevalue (Roc = 81%).Conclusions: Asylum seekers recently arrived in Vaud county had ahigh prevalence of LTBI and active tuberculosis. The major risk factorswere country of origin and travel conditions. Selecting for screening byIGRA the asylum seekers with the highest risk factors seems possible.