Ultrasound evaluation on carpal tunnel syndrome before and after bariatric surgery

Objective:To evaluate the prevalence of carpal tunnel syndrome in candidates for bariatric surgery comparing with the non-obese population and verify the effects on it of bariatric treatment. Methods:We studiedthree groups of individuals: 1) patients waiting for bariatric surgery (preoperative); 2) individuals who had already undergone the procedure (postoperative); and 3) control group. We collected demographic and clinical data of carpal tunnel syndrome. The Ultrasound examination was carried out to diagnose the syndrome by measuring the median nerve area. Results:We included 329 individuals (114 in the preoperative group, 90 in the postoperative group and 125 controls). There was a higher prevalence of paresthesias (p=0.0003), clinical tests (p=0.0083) on the preoperative group when compared with controls (p<0.00001). There were lowe levels of paresthesias (p=0.0002) and median nerve area (p=0.04) in postoperative patients but with no significant difference in general. A significant difference was found between the preoperative and postoperative groups (p=0.05) in those who performed non-manual work.Conclusion: There was a higher prevalence of carpal tunnel syndrome in the preoperative group compared with the control one, but no significant difference was observed between the pre and postoperative groups in general. There was difference between pre and postoperative groups for non-manual workers.

Risk factors for mortality in blunt abdominal trauma with surgical approach

ABSTRACTObjective:identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma.Methods:retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed.Results:of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002).Conclusion:the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

Pré-eclâmpsia precoce e tardia: uma classificação mais adequada para o prognóstico materno e perinatal?

OBJETIVO: avaliar as diferenças entre o resultado materno e perinatal de gestações complicadas pela pré-eclâmpsia, segundo classificação em sua forma grave/leve e de início precoce/tardio. MÉTODOS: estudo retrospectivo envolvendo 211 gestações complicadas pela pré-eclâmpsia, avaliadas em centro universitário de referência, no período de 2000 a 2010. O diagnóstico e a gravidade da doença foram baseados nos valores da pressão arterial, proteinúria e nos achados clínicos e laboratoriais. A idade da gestante, cor da pele, paridade, pressão arterial, valores de proteinúria semiquantitativa, presença de incisura bilateral em artérias uterinas à doplervelocimetria e as condições de nascimento foram comparados entre os casos de forma leve/grave, assim como entre aqueles de surgimento precoce/tardio. A doença foi considerada precoce quando diagnosticada antes da 34ª semana. RESULTADOS: a maioria das gestantes apresentava a forma grave da pré-eclâmpsia (82,8%) e 50,7%, de início precoce. Os valores da pressão arterial (133,6±14,8 versus 115,4 mmHg, p=0,0004, e 132,2±16,5 versus 125,7 mmHg, p=0,0004) e proteinúria semiquantitativa (p=0,0003 e p=0,0005) foram mais elevados nas formas grave e precoce em relação às formas leve e tardia. O peso ao nascimento (1.435,4±521,6 versus 2.710±605,0 g, 1.923,7±807,9 versus 2.415,0±925,0 g, p<0,0001 para ambos) e o índice de Apgar (p=0,01 para ambos) foram menores nas formas grave e precoce da pré-eclâmpsia, em relação às formas leve e tardia. Por outro lado, a presença de incisura bilateral em artérias uterinas se associou às formas de início precoce (69,2 versus 47,9%, p=0,02), enquanto a restrição de crescimento fetal foi mais frequente nas formas graves da pré-eclâmpsia (30 versus 4,4%, p=0,008). CONCLUSÃO: a classificação da pré-eclâmpsia baseada em parâmetros clínicos maternos refletiu melhor as condições de nutrição fetal, enquanto o seu surgimento precoce se associou melhor à vasculopatia placentária detectada à doplervelocimetria.

Efeitos da everminação de matrizes e de bezerros lactentes em sistema de produção de bovinos de corte na região de Cerrado

Estudou-se o efeito da everminação de vacas no pré-parto e de bezerros antes do desmame, no número de ovos de nematódeos nas fezes (OPG) e nos parâmetros produtivos em dois rebanhos de gado de corte na região do Brasil Central. Quatro lotes de vacas prenhes receberam os seguintes tratamentos: T1- vacas e bezerros controle, T2- somente bezerros tratados, T3- somente vacas tratadas antes do parto com ivermectina e T4- vacas e bezerros tratados. Os bezerros dos lotes T2 e T4 foram distribuídos nos seguintes grupos: A- tratados aos 3 a 5 meses de idade com ivermectina de ação prolongada, B- tratados com ivermectina e C- controle. Nas vacas a everminação não diminuiu o OPG durante a lactação, como também não teve efeito significativo na taxa de concepção, no ganho de peso e no peso dos bezerros aos 3 a 5 meses de idade. Os bezerros do Grupo A ganharam até o desmame, 84 a 108 dias após o tratamento, em média 4,2kg (P= 0,0003) e 7,1kg (P<0,0001) mais que aqueles dos Grupos B e C, respectivamente. A diferença média, no ganho de peso, de 2,9kg entre os bezerros dos Grupos B e C não foi significativa. Antes do tratamento não houve diferença significativa (P= 0,8665), mas ao desmame, o OPG médio dos bezerros do Grupo A era menor que os do Grupo B (P= 0,0004) e do Grupo C (P< 0,0001). Não houve diferença no OPG entre os bezerros dos Grupos B e C.

Experimental swainsonine poisoning in goats ingesting Ipomoea sericophylla and Ipomoea riedelii (Convolvulaceae)

Ipomoea sericophylla and Ipomoea riedelii cause a glycoprotein storage disease in goats. This paper reports the experimental poisoning in goats by dried I. sericophylla and I. riedelii containing 0.05% and 0.01% swainsonine, respectively. Three groups with four animals each were used. Group 1 received daily doses of 2g/kg body weight (bw) of dried I. sericophylla (150mg of swainsonine/kg). Goats from this group had clinical signs 36-38 days after the start of ingestion. Group 2 received dried I. riedelii daily doses of 2g/kg of I. riedelii (30mg of swainsonine/kg) for 70 days. No clinical signs were observed, therefore the swainsonine dose was increased to 60mg/kg for another 70 days. Goats from Group 2 had clinical signs 26-65 days after increase in swainsonine dose to 60mg/kg. Group 3 was used as control. In these experiments the minimum toxic dose was 60mg/kg which represents 0.0004% of the dry matter in goats ingesting 1.5% bw of the dry matter. For goats ingesting 2%-2.5% bw of dry matter this dose would be 0.00024%-0.0003% of the dry matter. After the end of the experiment two goats were euthanized and another six were observed for recovery of clinical signs. Four goats that continued to consume swainsonine containing plant for 39-89 days after the first clinical signs had non reversible signs, while two goats that ingested the plant for only 15 and 20 days after the first clinical signs recovered completely. These and previous results indicate that irreversible lesions due to neuronal loss occur in goats that continue to ingest the plants for about 30 days after the first clinical signs. Clinical signs and histological lesions were similar to those reported previously for goats poisoned by swainsonine containing plants. No significant alterations were found in packed cell volume, red and white blood cell counts, hemoglobin and mean corpuscular hemoglobin concentrations, mean corpuscular volume, and serum levels of glucose, total protein, and albumin, and the serum activities of gamma glutamyl transferase and aspartate aminotransferase. Swainsonine concentration of 0.05% in I. sericophylla and 0.01% in I. riedelii are different from samples of these plants used in previous experiments, which contained 0.14% and 0.5% swainsonine, respectively, demonstrating a wide variation in the toxicity of different samples.

Exame citológico em medicina veterinária: estudo retrospectivo de 11.468 casos (1994-2008)

Foi realizado um estudo retrospectivo dos resultados dos exames citológicos provenientes dos arquivos do Serviço de Citopatologia do Laboratório de Patologia Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, São Paulo, entre janeiro de 1994 e dezembro de 2008. Do total de 139.986 animais atendidos no Hospital Veterinário da instituição, 11.468 (8,2%) foram encaminhados para exame citológico. Desses diagnósticos, 57,28% corresponderam a lesões neoplásicas, 19,28% a lesões inflamatórias e 14,79% a processos não neoplásicos (imunológicos, degenerativos, hiperplásicos ou displásicos). Não foi possível concluir o diagnóstico por meio do exame citológico em 7,28% dos casos e não haviam informações diagnósticas registradas em 1,37% dos casos. Dentre os animais que mais receberam indicação para exame citológico destacaram-se os caninos (92,06%), seguidos pelos felinos (4,08%), bovinos (1,77%) e equinos (1,30%). Lesoes neoplásicas foram as mais comumente observadas e foram mais prevalentes nos cães (59,18%), afetando principalmente animais com idade média de 119,60 meses e principalmente fêmeas (61,61%). O incremento anual observado ao longo dos 15 anos de aplicação da citologia demonstra que o exame citológico é um método de suma importância para confirmar, sugerir ou afastar o diagnóstico de diversas afecções, inclusive neoplasia, em todas as espécies animais.

Metabolic evaluation of Crioulo horses participating in competitions of 750 km

The Crioulo breed of horses performs in one of the most physically demanding equestrian competitions, the Marcha de Resistência, which is a contest in which the horses run 750 km in 15 days. The study's aim was to characterize the metabolic responses during this period. We evaluated eleven Crioulo horses in the competition, specifically, two males and nine females. Blood samples were collected 24 hours before the contest and on the 4th, 9th, 11th, 14th and 15th days of competition. We evaluated CK, AST, LDH, glucose, lactate, urea, creatinine, sodium, potassium, chloride, magnesium, total calcium, ionized calcium, total protein, hematocrit and the white blood cell count. At the end of the competition, the mean values of serum AST were 1151±358 IU/ L the mean LDH values were 7418±1695 IU/L and CK was 13,867±3998UI /L. There was a significant increase in urea, creatinine and lactate (p<0.0001). A decrease in the mean values of chloride, sodium, potassium, and total and ionized calcium was observed (p≤0.0002). An evaluation of the total leukocytes and segmented neutrophils (p≤0.0002) revealed their increased values, and decreased values were observed for hematocrit, plasma protein and total lymphocytes (p≤0.0003). The values of glucose, on average, remained constant. Based on these data, we conclude that the Marcha de Resistência competition necessitated a high muscular demand and the depletion of energy and electrolytes, suggesting an inflammatory process in the animals evaluated.

Efeito da cerosidade foliar na reação de variedades de cebola (Allium cepa L.) a herbicidas de pós-emergência

Em ensaios experimentais, realizados no Departamento de Genética da Escola Superior de Agricultura "Luiz de Queiroz" da Universidade de São Paulo, Piracicaba - SP, verificou-se o efeito da ce rosidade foliar na reação de variedades de cebola a herbicidas de pós-emergência. Utilizaram-se variedades do grupo não ceroso, como Granex e Texas Grano, e variedades do grupo ceroso, como Baia Periforme, Barreiro SMP-IV, Red Creole e Roxa Chata SMP-IV, no 1.º ensaio; e variedades do grupo não ceroso, como Excel Bermudas 986 e Texas Grano, e variedades do grupo ceroso, como Baia Periforme, Pira Couto, Pira Dura, Pira Ouro A/R, Red Creole e Roxa Chata SMP-IV, no 2.º ensaio. Os herbicidas de pós-emergência e as doses utilizadas foram: bentazon, 0,48 kg i.a./ha e prometryne 1,60 kg i.a./ha, no 1.0 ensaio; e ácido sulfúrico (4%), bentazon 0,48 kg i.a./ha, prometryne 1,60 kg i.a./ha e diuron 1,60 kg i.a./ha, no 2: ensaio. Os resultados obtidos mostram que a cerosidade foliar é um dos mecanismos de resistência de cebola à ação de herbicidas de pós-emergência.

Resposta de cultivares de algodoeiro a subdoses de glyphosate

Avaliou-se a resposta de nove cultivares de algodoeiro, de importância econômica no Estado do Mato Grosso, quanto à intoxicação causada por subdoses de glyphosate. Os cultivares de algodoeiro utilizados foram Fabrika, Makina, ITA-90, FM 986, FM 966, Delta Opal, BRS Facual, Antares e Coodetec 407. As plantas foram cultivadas em tubetes preenchidos com substrato de solo e mantidas em casa telada, tendo recebido a aplicação do glyphosate aos 20 dias após a emergência, época em que apresentavam quatro folhas verdadeiras. As subdoses de glyphosate, simulando deriva, foram de 270 e 540 g ha-1. Também foi utilizada testemunha, sem aplicação do herbicida, para efeito de comparação. Foram realizadas avaliações semanais até 42 dias após a aplicação dos tratamentos (DAA), período em que também foi tomada a altura das plantas. Os sintomas visuais de intoxicação iniciaram-se aos 3 DAA, caracterizados pelo amarelecimento das pontas das folhas mais novas, seguido de murchamento do ápice das plantas. Na dose de 270 g ha-1 esses sintomas foram de baixa intensidade, mas a 540 g ha-1 causaram, na maioria dos casos, toxidez "preocupante" a "muito alta". Os cultivares BRS Facual e FM 986 mostraram-se os mais suscetíveis. A altura das plantas foi mais afetada quando se aplicou a menor dose de glyphosate. Houve recuperação de todos os cultivares tratados com 270 g ha-1 de glyphosate até os 42 DAA. Quando tratados com 540 g ha-1 de glyphosate, os cultivares Fabrika, Coodetec 407, BRS-Facual e ITA-90 foram mais sensíveis, apresentando redução de altura entre 84 e 90% aos 42 DAA. Os cultivares menos sensíveis na dose de 270 g ha-1 de glyphosate não foram os mesmos para a dose de 540 g ha-1.

The effects of positive end-expiratory pressure on respiratory system mechanics and hemodynamics in postoperative cardiac surgery patients

We prospectively evaluated the effects of positive end-expiratory pressure (PEEP) on the respiratory mechanical properties and hemodynamics of 10 postoperative adult cardiac patients undergoing mechanical ventilation while still anesthetized and paralyzed. The respiratory mechanics was evaluated by the inflation inspiratory occlusion method and hemodynamics by conventional methods. Each patient was randomized to a different level of PEEP (5, 10 and 15 cmH2O), while zero end-expiratory pressure (ZEEP) was established as control. PEEP of 15-min duration was applied at 20-min intervals. The frequency dependence of resistance and the viscoelastic properties and elastance of the respiratory system were evaluated together with hemodynamic and respiratory indexes. We observed a significant decrease in total airway resistance (13.12 ± 0.79 cmH2O l-1 s-1 at ZEEP, 11.94 ± 0.55 cmH2O l-1 s-1 (P<0.0197) at 5 cmH2O of PEEP, 11.42 ± 0.71 cmH2O l-1 s-1 (P<0.0255) at 10 cmH2O of PEEP, and 10.32 ± 0.57 cmH2O l-1 s-1 (P<0.0002) at 15 cmH2O of PEEP). The elastance (Ers; cmH2O/l) was not significantly modified by PEEP from zero (23.49 ± 1.21) to 5 cmH2O (21.89 ± 0.70). However, a significant decrease (P<0.0003) at 10 cmH2O PEEP (18.86 ± 1.13), as well as (P<0.0001) at 15 cmH2O (18.41 ± 0.82) was observed after PEEP application. Volume dependence of viscoelastic properties showed a slight but not significant tendency to increase with PEEP. The significant decreases in cardiac index (l min-1 m-2) due to PEEP increments (3.90 ± 0.22 at ZEEP, 3.43 ± 0.17 (P<0.0260) at 5 cmH2O of PEEP, 3.31 ± 0.22 (P<0.0260) at 10 cmH2O of PEEP, and 3.10 ± 0.22 (P<0.0113) at 15 cmH2O of PEEP) were compensated for by an increase in arterial oxygen content owing to shunt fraction reduction (%) from 22.26 ± 2.28 at ZEEP to 11.66 ± 1.24 at PEEP of 15 cmH2O (P<0.0007). We conclude that increments in PEEP resulted in a reduction of both airway resistance and respiratory elastance. These results could reflect improvement in respiratory mechanics. However, due to possible hemodynamic instability, PEEP should be carefully applied to postoperative cardiac patients.

Comparison of AutoSetä and polysomnography for the detection of apnea-hypopnea events

The use of the flow vs time relationship obtained with the nasal prongs of the AutoSetä (AS) system (diagnosis mode) has been proposed to detect apneas and hypopneas in patients with reasonable nasal patency. Our aim was to compare the accuracy of AS to that of a computerized polysomnographic (PSG) system. The study was conducted on 56 individuals (45 men) with clinical characteristics of obstructive sleep apnea (OSA). Their mean (± SD) age was 44.6 ± 12 years and their body mass index was 31.3 ± 7 kg/m2. Data were submitted to parametric analysis to determine the agreement between methods and the intraclass correlation coefficient was calculated. The Student t-test and Bland and Altman plots were also used. Twelve patients had an apnea-hypopnea index (AHI) <10 in bed and 20 had values >40. The mean (± SD) AHI PSG index of 37.6 (28.8) was significantly lower (P = 0.0003) than AHI AS (41.8 (25.3)), but there was a high intraclass correlation coefficient (0.93), with 0.016 variance. For a threshold of AHI of 20, AS showed 73.0% accuracy, 97% sensitivity and 60% specificity, with positive and negative predictive values of 78% and 93%, respectively. Sensitivity, specificity and negative predictive values increased in parallel to the increase in AHI threshold for detecting OSA. However, when the differences of AHI PSG-AS were plotted against their means, the limits of agreement between the methods (95% of the differences) were +13 and -22, showing the discrepancy between the AHI values obtained with PSG and AS. Finally, cubic regression analysis was used to better predict the result of AHI PSG as a function of the method proposed, i.e., AHI AS. We conclude that, despite these differences, AHI measured by AutoSetä can be useful for the assessment of patients with high pre-test clinical probability of OSA, for whom standard PSG is not possible as an initial step in diagnosis.

Ethnicity and glutathione S-transferase (GSTM1/GSTT1) polymorphisms in a Brazilian population

The distribution of polymorphisms related to glutathione S-transferases (GST) has been described in different populations, mainly for white individuals. We evaluated the distribution of GST mu (GSTM1) and theta (GSTT1) genotypes in 594 individuals, by multiplex PCR-based methods, using amplification of the exon 7 of CYP1A1 gene as an internal control. In São Paulo, 233 whites, 87 mulattos, and 137 blacks, all healthy blood-donor volunteers, were tested. In Bahia, where black and mulatto populations are more numerous, 137 subjects were evaluated. The frequency of the GSTM1 null genotype was significantly higher among whites (55.4%) than among mulattos (41.4%; P = 0.03) and blacks (32.8%; P < 0.0001) from São Paulo, or Bahian subjects in general (35.7%; P = 0.0003). There was no statistically different distribution among any non-white groups. The distribution of GSTT1 null genotype among groups did not differ significantly. The agreement between self-reported and interviewer classification of skin color in the Bahian group was low. The interviewer classification indicated a gradient of distribution of the GSTM1 null genotype from whites (55.6%) to light mulattos (40.4%), dark mulattos (32.0%) and blacks (28.6%). However, any information about race or ethnicity should be considered with caution regarding the bias introduced by different data collection techniques, specially in countries where racial admixture is intense, and ethnic definition boundaries are loose. Because homozygous deletions of GST gene might be associated with cancer risk, a better understanding of chemical metabolizing gene distribution can contribute to risk assessment of humans exposed to environmental carcinogens.

Cytosine arabinoside-metabolizing enzyme genes are underexpressed in children with MLL gene-rearranged acute lymphoblastic leukemia

Infant acute lymphoblastic leukemia (IALL) is characterized by mixed lineage leukemia (MLL) gene rearrangements, unique gene expression profiles, poor prognosis, and drug resistance. One exception is cytosine arabinoside (Ara-C) to which IALL cells seem to be more sensitive. We quantified mRNA expression of Ara-C key enzymes in leukemic lymphoblasts from 64 Brazilian ALL children, 15 of them presenting MLL gene rearrangement, and correlated it with clinical and biological features. The diagnosis was based on morphological criteria and immunophenotyping using monoclonal antibodies. MLL gene rearrangements were detected by conventional cytogenetic analysis, RT-PCR and/or fluorescence in situ hybridization. The DCK and HENT1 expression levels were determined by real-time quantitative PCR using SYBR Green I. Relative quantification was made by the standard curve method. The results were analyzed by Mann-Whitney and Fisher exact tests. A P value of £0.05 was considered to be statistically significant. DCK and HENT1 expression levels were significantly lower in children with MLL gene-rearranged ALL compared to children with MLL germ line ALL (P = 0.0003 and 0.03, respectively). Our results differ from previous ones concerning HENT1 mRNA expression that observed a higher expression level in MLL gene-rearranged leukemias. In conclusion, the expression of the genes related to Ara-C metabolism was lower in MLL-positive children in the sample studied, suggesting the presence of population differences in the expression profile of these genes especially for HENT1.

Plasma von Willebrand factor as a predictor of survival in pulmonary arterial hypertension associated with congenital heart disease

Biomarkers have been identified for pulmonary arterial hypertension, but are less well defined for specific etiologies such as congenital heart disease-associated pulmonary arterial hypertension (CHDPAH). We measured plasma levels of eight microvascular dysfunction markers in CHDPAH, and tested for associations with survival. A cohort of 46 inoperable CHDPAH patients (age 15.0 to 60.2 years, median 33.5 years, female:male 29:17) was prospectively followed for 0.7 to 4.0 years (median 3.6 years). Plasma levels of von Willebrand factor antigen (VWF:Ag), tissue plasminogen activator (t-PA) and its inhibitor (PAI-1), P-selectin, reactive C-protein, tumor necrosis factor alpha, and interleukin-6 and -10 were measured at baseline, and at 30, 90, and 180 days in all subjects. Levels of six of the eight proteins were significantly increased in patients versus controls (13 to 106% increase, P < 0.003). Interleukin-10 level was 2.06 times normal (P = 0.0003; Th2 cytokine response). Increased levels of four proteins (t-PA, PAI-1, P-selectin, and interleukin-6) correlated with disease severity indices (P < 0.05). Seven patients died during follow-up. An average VWF:Ag (mean of four determinations) above the level corresponding to the 95th percentile of controls (139 U/dL) was independently associated with a high risk of death (hazard ratio = 6.56, 95%CI = 1.46 to 29.4, P = 0.014). Thus, in CHDPAH, microvascular dysfunction appears to involve Th2 inflammatory response. Of the biomarkers studied, plasma vWF:Ag was independently associated with survival.

Prognostic significance of snail expression in hilar cholangiocarcinoma

Many patients with hilar cholangiocarcinoma (HC) have a poor prognosis. Snail, a transcription factor and E-cadherin repressor, is a novel prognostic factor in many cancers. The aim of this study was to evaluate the relationship between snail and E-cadherin protein expression and the prognostic significance of snail expression in HC. We examined the protein expression of snail and E-cadherin in HC tissues from 47 patients (22 males and 25 females, mean age 61.2 years) using immunohistochemistry and RT-PCR. Proliferation rate was also evaluated in the same cases by the MIB1 index. High, low and negative snail protein expression was recorded in 18 (38%), 17 (36%), and 12 (26%) cases, respectively, and 40.4% (19/47) cases showed reduced E-cadherin protein expression in HC samples. No significant correlation was found between snail and E-cadherin protein expression levels (P = 0.056). No significant correlation was found between snail protein expression levels and gender, age, tumor grade, vascular or perineural invasion, nodal metastasis and invasion, or proliferative index. Cancer samples with positive snail protein expression were associated with poor survival compared with the negative expresser groups. Kaplan-Meier curves comparing different snail protein expression levels to survival showed highly significant separation (P < 0.0001, log-rank test). With multivariate analysis, only snail protein expression among all parameters was found to influence survival (P = 0.0003). We suggest that snail expression levels can predict poor survival regardless of pathological features and tumor proliferation. Immunohistochemical detection of snail protein expression levels in routine sections may provide the first biological prognostic marker.