Severe Protein-Calorie Malnutrition after Bariatric Procedures

Background: Serious nutritional complications after Roux-en-Y gastric bypass (RYGBP) are infrequent. In a retrospective study of patients operated during a 68-month period, malnutrition was investigated to analyze circumstances associated with nutritional failure. Methods: In 236 consecutive RYGBPs, 11 patients with severe malnutrition were identified (4.7%) with age 45.1 ± 10.6 years (10 females/1 male) and initial BMI 54.6 ± 8.4 kg/m². Results: In these 11 patients, the derangement was diagnosed 17.9 ± 15.8 months after RYGBP, following defined events in 63.6% (gastric stenosis, associated diseases ) or mostly exaggeration of expected symptoms in 36.4% (vomiting without endoscopic abnormalities). BMI then was 31.4 ± 8.6 kg/m² (42.5 ± 9.9% total reduction, or 2.4 ± 2.1% decrease/month), and serum albumin and hemoglobin were 24.0 ± 8.2 g/L and 97.0 ± 23.0 g/L respectively. Edema was present in 45.4% (5/11), hospitalization was required in 54.5% (6/11), and 18.2% (2/11) eventually died. Conclusions: Serious malnutrition was unusual but not exceedingly rare in this series. Exogenous precipitating factors were clearly identified in 63.6% of the patients. Careful clinical and nutritional follow-up is recommended to prevent these uncommon but potentially dangerous complications.     

Improving resident research in physical medicine and rehabilitation: impact of a structured training program

OBJECTIVE: This study describes a research training program that implemented several processes and structures with the aim of increasing the quality and quantity of resident research in physical medicine and rehabilitation. Another aim of the program was to address the Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency. DESIGN: Educational program. RESULTS: Data on resident research activity for 11 years before the implementation of the research program were compared with 4 years of data after implementation. There were statistically significant increases in both the total number of publications (P = 0.03) and the number of empirical, data-based publications after implementation of the program (P = 0.03). CONCLUSIONS: The findings from this study suggest that a structured research training program may have a salutary effect on increasing the quality and quantity of resident research.     

Proinflammatory Cytokines in the Treatment of Bacterial and Fungal Infections

Mortality due to severe bacterial infections has not been markedly effected by the introduction of new antimicrobial drugs over the last 30-40 years. This has emphasized the need for development of new therapeutic strategies to combat sepsis. The outcome of an infection depends on two factors: the growth of the microorganisms (including the effect of antibacterial drugs), and the host's defensive response to the invading organism. It is known that injection of bacterial products into experimental animals leads to enhanced nonspecific resistance to a variety of microorganisms. The discovery of the specific mediators responsible for modulation of host defense has created new possibilities for the development of alternative treatment strategies. Molecules such as interleukins, interferons, tumor necrosis factors and hematopoietic growth factors have become available in recombinant form, and their therapeutic potential in various infectious diseases has been tested in various experimental models of infections. Initial data in various patient groups indicate that adjunctive therapy with recombinant proinflammatory cytokines may have beneficial effects in the treatment of bacterial and fungal infections.     

Absorbable microparticulate cation exchanger for immunotherapeutic delivery

An absorbable microparticulate cation exchanger was synthesized as a versatile carrier for biologically active proteins. In this work, acid-terminated polyglycolide (or polyglycolic acid) microparticulates (PG-MP) were surface modified for either sustained release of cytokines or as a platform for immunomodulation. The intended goal was to achieve in situ recruitment/maturation of dendritic cells and activation of T cells for tumor immunotherapy. PG-MP were prepared with a volume weighted mean diameter of 7.02 micro (range: 2.09-14.58 micro). Accessible carboxylic acid groups were determined to be 0.3 mmol/g with a corresponding zeta potential of -21.87 mV in phosphate-buffered saline. Under low magnification, scanning electron microscopy (SEM) revealed a highly textured surface due to processing from repetitive jet milling. However, a moderately porous architecture was noted at higher magnification. Electron spectroscopy for chemical analysis was used to characterize the PG-MP surface before and after adsorption of human granulocyte-macrophage colony stimulating factor (GM-CSF). Adsorption of GM-CSF on PG-MP (PG-GMCSF) resulted in a modest increase in the surface atomic concentration of nitrogen (0.97%). Pretreating the surface with poly-L-lysine (PG/Lys-GMCSF) prior to adding GM-CSF produced a nearly threefold increase in the surface nitrogen concentration (4.20% compared to 1.47%). This manipulation not only increased loading content, but also prolonged the release of GM-CSF released from 6 days to 26 days. ESCA on the post-release PG-MP samples (PG-GMCSF and PG/Lys-GMCSF) revealed a similar residual surface nitrogen concentration (2.26% vs. 2.35%). The observation was consistent with irreversibly adsorbed GM-CSF. It is postulated that irreversibly bound GM-CSF is released over time as a function of microparticulate degradation. Biological activity of released GM-CSF was confirmed by the proliferation of a GM-CSF-dependent cell line (TF-1) in the presence of microparticulates. PG-MP mediated activation of T cells was achieved through irreversible adsorption of either antimouse cd3 plus antimouse cd28 monoclonal antibodies (alpha-cd3/cd28-MP) or antihuman CD3 plus antihuman CD28 monoclonal antibodies (alpha-CD3/CD28-MP) on PG-MP. Irreversibly adsorbed antibodies were capable of activating both resting mouse and human T cells. Intracellular flow cytometry on mouse T cells revealed that nearly 50% of the activated cells produced interferon-gamma (IFN-gamma). This was consistent with a TH-1 or cell-mediated response. In vivo efficacy was evaluated in a mouse flank tumor model showing a significant antitumor effect both alone and in combination. Combination therapy was most effective at preventing tumor implantation (8/8 mice) and was able induce tumor regression (4/7 mice) and/or stable disease (3/7 mice) in a regression model. In these studies, immunohistochemistry was used to confirm local recruitment of dendritic cells. In conclusion, the PG-MP represents a novel absorbable cation exchanger that can be readily manipulated to deliver biologically active proteins for immunotherapy.     

Contribution of functional neuroimaging to understanding neuropsychiatric side effects of interferon in hepatitis C

Patients with hepatitis C who are treated with interferon may develop neuropsychiatric symptoms, including fatigue and depression. The authors discuss the potential use of functional neuroimaging in the identification and treatment of these patients. The authors provide an overview of functional neuroimaging studies of fatigue and depressive symptoms in various medical and psychiatric conditions and suggest future directions for research that may increase understanding of the specific neural substrates of neuropsychiatric side effects associated with hepatitis C and interferon treatment. This knowledge may help consultation-liaison psychiatrists identify patients at high risk for developing side effects related to hepatitis C and interferon, which would allow for implementation of validated strategies for prophylactic treatment of these patients.     

Electroencephalographic peak alpha frequency correlates of cognitive traits

EEG peak alpha frequency (PAF) has been shown to differentiate groups of adults with higher memory performance from those of lower performance, groups of children with advanced reading ability from matched controls, and to predict state-dependent working memory. The present study attempted to explore PAF as a predicting variable for verbal and attentional cognitive trait abilities in young adults. Nineteen undergraduate students had their EEG recorded during initial rest, reading, and post-reading rest, and at a different day were evaluated on reading, vocabulary, and attentional performance. Results showed significant correlations of reading vocabulary and response control with PAF during reading and post-reading recordings, but not during initial rest. PAF may reflect some general cognitive ability that is not necessarily memory or reading, possibly response control or the ability to acquire vocabulary. It is suggested that cognitive ability traits may reflect the ability to induce cognitive states.