Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy.

BACKGROUND: Pancreatic fistula (PF), which is a major complication of pancreaticoduodenectomy (PD), can be treated conservatively or by reoperation. The aim of this study was to evaluate conservative management of PF, which was attempted whenever possible as a first-intention treatment in a large series of PD. STUDY DESIGN: From 1990 to 2000, 242 patients underwent PD with pancreaticogastrostomy. PF was observed in 31 (13%) and was defined by an amylase-rich surgical drainage fluid (above fivefold serum amylase) after postoperative day 5, or by presence on CT scan of a fluid collection located close to the anastomosis or containing amylase-rich fluid, or by operative findings in case of reoperation. Conservative management included total parenteral nutrition, nasogastric suction, imaging-guided percutaneous drainage of collection when necessary, and somatostatin or its analogues. RESULTS: PF was symptomatic in 20 patients (65%). Amylase level on surgical drainage fluid was elevated in 23 patients (74%). Four patients (13%), including two with hemorrhage and two with intraabdominal collection not accessible by percutaneous approach, were not considered for conservative management and underwent early reoperation. Conservative management was successful in the 27 patients (100%) in whom it was attempted, including the 10 who required percutaneous drainage. The only death (3%) occurred after massive hemorrhage complicating misdiagnosed PF. Mean hospital stay was 36 +/- 12 days (range 18 to 71) after successful conservative management. CONCLUSIONS: Conservative management of PF complicating PD is feasible and successful in above 85% of patients.

Benthic macroinvertebrates assemblages and macrohabitat connectivity in Mediterranean-climate streams of northern California

Abstract. Drought leads to a loss of longitudinal and lateral hydrologic connectivity, which causes direct or indirect changes in stream ecosystem properties. Changes in macrohabitat availability from a rifflepool sequence to isolated pools are among the most conspicuous consequences of connectivity loss. Macroinvertebrate assemblages were compared among 3 distinct stream macrohabitats (riffles [R], pools connected to riffles [Pc], disconnected pools [Pd]) of 19 Mediterranean-climate sites in northern California to examine the influence of loss of habitat resulting from drought disturbance. At the time of sampling, 10 sites were perennial and included R and Pc macrohabitats, whereas 9 sites were intermittent and included only Pd macrohabitats. Taxa richness was more variable in Pd, and taxa richness was significantly lower in Pd than in Pc but not R. These results suggested a decline in richness between Pc and Pd that might be associated with loss of connectivity. Lower Ephemeroptera, Plecoptera, and Trichoptera (EPT) richness relative to Odonata, Coleoptera, and Heteroptera (OCH) richness was observed for Pd than R and Pc macrohabitats. Family composition was more similar between R and Pc than between R or Pc and Pd macrohabitats. This similarity may be associated with greater connectivity between R and Pc macrohabitats. Correspondence analysis indicated that macroinvertebrate composition changed along a gradient from R to Pc and Pd that was related to a perennialintermittent gradient across sites. High variability among macroinvertebrate assemblages in Pd could have been related to variability in the duration of intermittency. In cluster analysis, macroinvertebrate assemblages were grouped by macrohabitat first and then by site, suggesting that the macrohabitat filter had a greater influence on macroinvertebrate assemblages than did local site characteristics. Few taxa were found exclusively in Pc, and this macrohabitat shared numerous taxa with R and Pd, indicating that Pc may act as a bridge between R and Pd during drought. Drought is regarded as a ramp disturbance, but our results suggest that the response of macroinvertebrate assemblages to the loss of hydrological connectivity among macrohabitats is gradual, at least in Mediterranean-climate streams where drying is gradual. However, the changes may be more dramatic in arid and semiarid streams or in Mediterranean-climate streams if drying is rapid.

Gestão da informação na Embrapa Amazônia Oriental: uso relativo versus uso efetivo da literatura técnico-científica agropecuária periódica - 1990-1999

Análise bibliométrica de uso da coleção de periódicos, evidenciando o papel fundamental que as bibliotecas da Embrapa desempenham na estrutura organizacional e na estratégia competitiva da empresa. Bibliotecas formam a interface entre a geração e a disseminação do processo de pesquisa, desenvolvimento e inovações ( PD&I).Resultados apontaram que 77,05% dos títulos de periódicos utilizados efetivamente encontram-se no Catálogo de Periódicos da Embrapa (CCPE), dos quais 81,83% pertencem ao Catálogo de Periódicos da Unidade, demonstrando a eficácia do acervo da biblioteca para as atividades de PD&I na Unidade, no período estudado. Dos títulos estrangeiros adquiridos por compra, 20% atingiram um indicador de freqüência de uso no período > 10, merecendo priorização de manuteção de assinaturas e processos de preservação.

VPS35 mutations in Parkinson disease.

The identification of genetic causes for Mendelian disorders has been based on the collection of multi-incident families, linkage analysis, and sequencing of genes in candidate intervals. This study describes the application of next-generation sequencing technologies to a Swiss kindred presenting with autosomal-dominant, late-onset Parkinson disease (PD). The family has tremor-predominant dopa-responsive parkinsonism with a mean onset of 50.6 ± 7.3 years. Exome analysis suggests that an aspartic-acid-to-asparagine mutation within vacuolar protein sorting 35 (VPS35 c.1858G>A; p.Asp620Asn) is the genetic determinant of disease. VPS35 is a central component of the retromer cargo-recognition complex, is critical for endosome-trans-golgi trafficking and membrane-protein recycling, and is evolutionarily highly conserved. VPS35 c.1858G>A was found in all affected members of the Swiss kindred and in three more families and one patient with sporadic PD, but it was not observed in 3,309 controls. Further sequencing of familial affected probands revealed only one other missense variant, VPS35 c.946C>T; (p.Pro316Ser), in a pedigree with one unaffected and two affected carriers, and thus the pathogenicity of this mutation remains uncertain. Retromer-mediated sorting and transport is best characterized for acid hydrolase receptors. However, the complex has many types of cargo and is involved in a diverse array of biologic pathways from developmental Wnt signaling to lysosome biogenesis. Our study implicates disruption of VPS35 and retromer-mediated trans-membrane protein sorting, rescue, and recycling in the neurodegenerative process leading to PD.

Malignant lymphoma cells induce tolerance of T cells

Inhibitory receptors are involvedin the induction of T cell dysfunctionand exhaustion in chronic viral infectionsand in tumors. In the presentstudy, we analyzed the expressionpattern of 3 different inhibitory receptors(PD-1, Lag-3, 2B4) in a murine Bcell lymphoma model. Furthermore,we functionally characterized CD8+T cells expressing inhibitory receptorsfor cytokine production and proliferation.Expansion and secretion ofpro-inflammatory cytokines of CD8+T cells from lymphoma-bearing E-myc mice were significantly reducedcompared to the healthy controls.Similarly, expansion and effectorfunction of CD8+ TCR transgenic(p14) Tcells specific for the gp-33 antigenof lymphocytic choriomeningitisvirus (LCMV) was reduced inlymphoma-bearing E-myc mice afteractivation with LCMV. The functionalimpairment of CTL in the presenceof lymphoma was reversible aftertransfer to naive C57BL/6 recipients.In vitro co-culture experimentsrevealed that the proliferation ofanti-CD3-activated CD8+ T cellsfrom WT mice was significantly inhibitedby CD19+ lymphoma cellsfrom E-myc mice, whereas no inhibitionwas observed after co-culturewith normal B cells. Supernatants ofin vitro cultured lymphoma B cellsand blood sera from lymphoma-bearingE-myc mice significantly reducedT cell proliferation in vitro, ascompared to supernatants from normalB cells cultures or sera of healthyanimals. These experiments indicatethat the lymphoma B cells inactivateCTL by a soluble factor. Expressionanalysis of different important immunologicalcytokines revealed that themacrophage migration inhibitory factor(MIF) is selectively overexpressedin malignant B cells. This finding wasconfirmed by analyzing MIF proteinin culture supernatants and in celllysates. Therefore, lymphoma B cellsmay reduce T cell function and suppresslymphoma surveillance by secretionof MIF.

Estimating the apparent transverse relaxation time (R2(*)) from images with different contrasts (ESTATICS) reduces motion artifacts.

Relaxation rates provide important information about tissue microstructure. Multi-parameter mapping (MPM) estimates multiple relaxation parameters from multi-echo FLASH acquisitions with different basic contrasts, i.e., proton density (PD), T1 or magnetization transfer (MT) weighting. Motion can particularly affect maps of the apparent transverse relaxation rate R2(*), which are derived from the signal of PD-weighted images acquired at different echo times. To address the motion artifacts, we introduce ESTATICS, which robustly estimates R2(*) from images even when acquired with different basic contrasts. ESTATICS extends the fitted signal model to account for inherent contrast differences in the PDw, T1w and MTw images. The fit was implemented as a conventional ordinary least squares optimization and as a robust fit with a small or large confidence interval. These three different implementations of ESTATICS were tested on data affected by severe motion artifacts and data with no prominent motion artifacts as determined by visual assessment or fast optical motion tracking. ESTATICS improved the quality of the R2(*) maps and reduced the coefficient of variation for both types of data-with average reductions of 30% when severe motion artifacts were present. ESTATICS can be applied to any protocol comprised of multiple 2D/3D multi-echo FLASH acquisitions as used in the general research and clinical setting.

Nível e natureza do estoque orgânico de latossolos sob diferentes sistemas de uso e manejo

O papel fundamental da matéria orgânica (MO) justifica o crescente interesse pela identificação de sistemas de uso e manejo que melhorem o estoque orgânico em solos tropicais. O objetivo deste trabalho foi analisar variações quantitativas e qualitativas da MO e caracterizar compartimentos orgânicos em um Latossolo Vermelho-Escuro argiloso sob vegetação natural antropizada (CER), pastagem de longa duração (PAL), pastagem degradada (PAD), e pousio (PAC), comparados com culturas sob preparo convencional (CCL) e plantio direto (PD). Foi encontrada pouca variação dos estoques orgânicos na camada superficial, explicada pela antropização da vegetação em CER, pela não-exportação dos resíduos em PD e CCL e pela prática de pousio em PAC. Fracionamento granulométrico, considerando os compartimentos: resíduos vegetais (20-2.000 µm), organo-siltoso (2-20 µm) e organo-argiloso (0-2 µm), mostrou diferenças na qualidade da MO quando comparadas situações edafoambientais semelhantes. Mesmo com pequenas variações, o compartimento resíduos vegetais foi um indicador da evolução dos estoques orgânicos, permitindo a caracterização da degradação nas pastagens e do efeito do plantio direto, quando comparado ao sistema convencional. PD favoreceu a estocagem de C no compartimento organo-argiloso. Solos estudados diferem de outros solos argilosos tropicais pela mais elevada relação C/N encontrada nas frações 0-20 µm.

Análise de crescimento de duas cultivares de feijoeiro sob irrigação, em plantio direto e preparo convencional

O objetivo deste trabalho foi avaliar, através da análise de crescimento, os efeitos do plantio direto (PD) e do preparo convencional (PC) sobre o desenvolvimento de duas cultivares de feijoeiro (Phaseolus vulgaris L.), em dois espaçamentos diferentes, irrigadas via pivô central. O experimento foi conduzido no ano de 1994, em Senador Canedo, GO, a 16º 41' de latitude Sul, 49º 16' de longitude Oeste e 741 m de altitude. O delineamento experimental foi inteiramente casualizado em parcelas subsubdivididas, com oito tratamentos. Para avaliação da área foliar e da produção de matéria seca total (MST), foram feitas dez coletas periódicas a cada sete dias, com três plantas ao acaso e duas repetições. A análise de crescimento evidenciou que no sistema PD o feijoeiro aumentou a MST, o índice de área foliar, a taxa de crescimento da cultura, a taxa de crescimento relativo, a taxa assimilatória líquida e a duração da área foliar, ocorrendo diminuição da razão de área foliar. A cultivar Aporé destacou-se em relação à Safira, sem efeito para espaçamento. A análise de crescimento apresentou-se adequada para avaliar o desenvolvimento do feijoeiro.

Desempenho da semeadora-adubadora MAGNUM 2850 em plantio direto no basalto paranaense

O sistema de plantio direto atingiu, no Estado do Paraná, cerca de dois milhões de hectares, nos últimos anos, e um dos seus principais entraves é a falta de semeadoras-adubadoras apropriadas para operação em solos argilosos e de origem basáltica. Portanto, estudou-se a MAGNUM 2850 PD quanto à demanda energética e desempenho operacional, com a finalidade de oferecer subsídios ao seu aperfeiçoamento, de acordo com a realidade paranaense. Observou-se que o esforço de tração variou em função da umidade e características mecânicas do solo, atingiu valores elevados, e exigiu, em situações extremas, potência de até 79,5 kW do trator. Os componentes de ataque ao solo mostraram um bom desempenho no corte da vegetação e na uniformidade da profundidade de trabalho, porém apresentaram grande área mobilizada no sulco. Obteve-se boa qualidade de semeadura, avaliada pela porcentagem e velocidade de emergência das sementes no campo. Foram identificados erros de dosagem do fertilizante e deposição das sementes, e principalmente na velocidade de deslocamento de 8,0 km/h; porém, foi boa a uniformidade transversal das sementes e plantas no campo.

Hippocampal atrophy predicts conversion to dementia after STN-DBS in Parkinson's disease.

BACKGROUND: Hippocampal atrophy (HA) is a known predictor of dementia in Alzheimer's disease. HA has been found in advanced Parkinson's disease (PD), but no predicting value has been demonstrated yet. The identification of such a predictor in candidates for subthalamic deep brain stimulation (STN-DBS) would be of value. Our objective was to compare preoperative hippocampal volumes (HV) between PD patients who subsequently converted to dementia (PDD) after STN-DBS and those who did not (PDnD). METHODS: From a cohort of 70 consecutive STN-DBS treated PD patients, 14 converted to dementia over 25.6+/-20.2 months (PDD). They were compared to 14 matched controls (PDnD) who did not convert to dementia after 43.9+/-11.7 months. On the preoperative 3D MPRAGE MRI images, HV and total brain volumes (TBV) were measured by a blinded investigator using manual and automatic segmentation respectively. RESULTS: PDD had smaller preoperative HV than PDnD (1.95+/-0.29 ml; 2.28+/-0.33 ml; p<0.01). This difference reinforced after normalization for TBV (3.28+/-0.48, 3.93+/-0.60; p<0.01). Every 0.1 ml decrease of HV increased the likelihood to develop dementia by 24.6%. A large overlap was found between PD and PDnD HVs, precluding the identification of a cut-off score. CONCLUSIONS: As in Alzheimer's disease, HA may be a predictor of the conversion to dementia in PD. This preoperative predictor suggests that the development of dementia after STN-DBS is related to the disease progression, rather then the procedure. Further studies are needed to define a cut-off score for HA, in order to affine its predictive value for an individual patient.

Common variants near MC4R are associated with fat mass, weight and risk of obesity.

To identify common variants influencing body mass index (BMI), we analyzed genome-wide association data from 16,876 individuals of European descent. After previously reported variants in FTO, the strongest association signal (rs17782313, P = 2.9 x 10(-6)) mapped 188 kb downstream of MC4R (melanocortin-4 receptor), mutations of which are the leading cause of monogenic severe childhood-onset obesity. We confirmed the BMI association in 60,352 adults (per-allele effect = 0.05 Z-score units; P = 2.8 x 10(-15)) and 5,988 children aged 7-11 (0.13 Z-score units; P = 1.5 x 10(-8)). In case-control analyses (n = 10,583), the odds for severe childhood obesity reached 1.30 (P = 8.0 x 10(-11)). Furthermore, we observed overtransmission of the risk allele to obese offspring in 660 families (P (pedigree disequilibrium test average; PDT-avg) = 2.4 x 10(-4)). The SNP location and patterns of phenotypic associations are consistent with effects mediated through altered MC4R function. Our findings establish that common variants near MC4R influence fat mass, weight and obesity risk at the population level and reinforce the need for large-scale data integration to identify variants influencing continuous biomedical traits.

Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?

Background The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC).Methods Between 2001 and 2007, all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed. Cases were collected from a prospective database. Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach. Patients' general condition and organ dysfunction were assessed by two validated scoring systems (SAPS II and SOFA, respectively). Morbidity, mortality, and long-term outcome were systematically reviewed and analyzed in both groups.Results Forty-two patients [median age = 65.5 years (range = 32-94)] were included; 45% underwent EC (ten laparoscopic, nine open) and 55% PD (n = 23). Both patient groups had similar preoperative characteristics. Percutaneous drainage and EC were successful in 91 and 100% of patients, respectively. Organ dysfunctions were similarly improved by the third postoperative/postdrainage days. Despite undergoing PD, two patients required EC due to gangrenous cholecystitis. The conversion rate after laparoscopy was 20%. Overall morbidity was 8.7% after PD and 47% after EC (P = 0.011). Major morbidity was 0% after PD and 21% after EC (P = 0.034). The mortality rate was not different (13% after PD and 16% after EC, P = 1.0) and the deaths were all related to the patients' preexisting disease. Hospital and ICU stays were not different. Recurrent symptoms (17%) occurred only after ACC in the PD group.Conclusions In high-risk patients, PD and EC are both efficient in the resolution of acute cholecystitis sepsis. However, EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible. Percutaneous drainage represents a valuable intervention, but secondary cholecystectomy is mandatory in cases of acute calculous cholecystitis.

Análisis de contenido de constructos personales en la depresión

Desde el marco de la Psicología de los Constructos Personales (PCP) de Kelly, es posible estudiar de forma sistemática la construcción subjetiva que las personas hacen de sí mismas y de sus problemas. Feixas et al. destacan la pertinencia del estudio de los sistemas de construcción en la evaluación del trastorno depresivo puesto que miden aspectos que no son suficientemente valorados por las medidas cognitivas estándar sobre los síntomas y las distorsiones cognitivas. La mayoría de los trabajos sobre la depresión basados en la PCP se han centrado en las características estructurales, en cambio los aspectos del contenido han recibido menor interés. El propósito de este estudio es realizar un análisis de contenido de los constructos personales en la depresión. Actualmente no existe ningún estudio que haya explorado de forma sistemática las dimensiones de contenido más significativas para esta población. En concordancia con la PCP y otros enfoques cognitivos, hipotetizamos que el contenido de los sistemas de construcción de la muestra depresiva es distinto al de la población normal. En concreto, creemos que la población clínica presenta mayor frecuencia de constructos de tipo moral y emocional en comparación con la muestra no clínica. Para poder poner a prueba estas hipótesis se analizaron los constructos de 106 sujetos, con edades comprendidas entre los 19 y los 57 años, divididos en dos grupos, un grupo clínico (n=53) de personas diagnosticadas con alguna modalidad depresiva unipolar y otro grupo no clínico (n=53). Categorizamos el contenido de los constructos elicitados con la técnica de rejilla por medio del Sistema de Categorías de Constructos Personales (SCCP) desarrollado por Feixas et al. El SCCP es un sistema de clasificación compuesto por un total de seis áreas temáticas (moral, emocional, relacional, personal, intelectual y valores e intereses) que se desglosan en 45 categorías para codificar el contenido de los constructos personales. Los principales resultados muestran que existen diferencias significativas entre las distribuciones de frecuencias del contenido de ambas poblaciones. Las personas con depresión (PD) utilizan significativamente más constructos de tipo emocional, y menos de tipo intelectual. Además, en comparación a la muestra normal, los depresivos muestran mayor número de constructos en las categorías «reflexiva-superficial», «tolerante-autoritaria» y, de forma más destacada, en la dimensión «fuerte-débil». Los resultados indican que el patrón prototípico del contenido de los sistemas de constructos de las PD difiere en el énfasis temático predominante. En efecto, de la variedad de acontecimientos de la experiencia, los aspectos conativos resultan especialmente notorios para las personas con depresión. Por otro lado, la carencia de constructos intelectuales y personales refuerza la idea de que las personas con depresión emplean gran parte de su actividad mental en el procesamiento de los aspectos emocionales de la experiencia. Aunque la naturaleza exploratoria de este estudio no permite establecer líneas causales, parece evidente que la focalización de la actividad psicológica de las PD en la dimensión afectiva de la experiencia puede estar desempeñando un papel importante en el mantenimiento de la problemática depresiva. Por último, a partir de las limitaciones de este estudio se proponen algunos diseños para la investigación futura acerca de la relación entre el contenido y la estructura de los sistemas de construcción de las personas con depresión.

Parkinson's disease.

In advanced Parkinson's disease (PD), the emergence of symptoms refractory to conventional therapy poses therapeutic challenges. The success of deep brain stimulation (DBS) and advances in the understanding of the pathophysiology of PD have raised interest in noninvasive brain stimulation as an alternative therapeutic tool. The rationale for its use draws from the concept that reversing abnormalities in brain activity and physiology thought to cause the clinical deficits may restore normal functioning. Currently the best evidence in support of this concept comes from DBS, which improves motor deficits, and modulates brain activity and motor cortex physiology, although whether a causal interaction exists remains largely undetermined. Most trials of noninvasive brain stimulation in PD have applied repetitive transcranial magnetic stimulation (rTMS), targeting the motor cortex. Current studies suggest a possible therapeutic potential for rTMS and transcranial direct current stimulation (tDCS), but clinical effects so far have been small and negligible with regard to functional independence and quality of life. Approaches to potentiate the efficacy of rTMS include increasing stimulation intensity and novel stimulation parameters that derive their rationale from studies on brain physiology. These novel parameters are intended to simulate normal firing patterns or to act on the hypothesized role of oscillatory activity in the motor cortex and basal ganglia with regard to motor control and its contribution to the pathogenesis of motor disorders. Noninvasive brain stimulation studies will enhance our understanding of PD pathophysiology and might provide further evidence for potential therapeutic applications.

Gene transfer of programmed death ligand-1.Ig prolongs cardiac allograft survival.

BACKGROUND: The CD28 homologue programmed death-1 (PD-1) and its ligands, PD-L1 and PD-L2 (which are homologous to B7), constitute an inhibitory pathway of T cell costimulation. The PD-1 pathway is of interest for immune-mediated diseases given that PD-1-deficient mice develop autoimmune diseases. We have evaluated the effect of local overexpression of a PD-L1.Ig fusion protein on cardiac allograft survival. METHODS: Adenovirus-mediated PD-L1.Ig gene transfer was performed in F344 rat donor hearts placed in the abdominal position in Lewis recipients. Inflammatory cell infiltrates in the grafts were assessed by immunohistochemistry. RESULTS: Allografts transduced with the PD-L1.Ig gene survived for longer periods of time compared with those receiving noncoding adenovirus or virus dilution buffer alone: median survival time (MST), 17 (range: 16-20) days vs. 11 (8-14) and 9 (8-13) days, respectively (P < 0.001). PD-L1.Ig gene transfer combined with a subtherapeutic regimen of cyclosporin A (CsA) was superior to CsA alone: MST, 25 (15-42) vs. 15 (13-19) days (P < 0.05). PD-L1.Ig gene transfer was associated with decreased numbers of CD4 cells and monocytes/macrophages infiltrating the graft (P < 0.05). CONCLUSIONS: Localized PD-L1.Ig expression in donor hearts attenuates acute allograft rejection in a rat model. The effect is additive to that of a subtherapeutic regimen of CsA. These results suggest that targeting of PD-1 by gene therapy may inhibit acute cardiac allograft rejection in vivo.