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Background/aims: In the attempt to establish the different incidence between cancer in anatomically whole stomachs and cancer in patients who have undergone a surgical procedure for morbid obesity, a review on the epidemiology of bariatric surgery and stomach cancer and a correlation with the global incidence of stomach cancer (comparing it with the median age of patients who developed neoplasms after bariatric surgery) have been conducted., Methodology: This was a descriptive study of the gastric neoplasms located at the gastric pouch, bypassed stomach or in the esophagogastric junction, following bariatric surgery described in the medical literature., Results: Twenty-one cases of gastric neoplasm located at the gastric pouch, in the bypassed stomach or in the esophagogastric junction were described after bariatric surgery., Conclusions: Bariatric surgery seems to produce a decrease in the incidence of cancer when comparing obese patients who were operated and obese patients who have not, so additional studies are needed to compare the cancer incidence between the general population and patients undergoing bariatric surgery. New studies will determine if it is necessary to focus on the early detection of pathological processes at the excluded digestive tract.

Introduction: Healthcare management is oriented toward single diseases, yet multimorbidity is nevertheless the rule and there is a tendency for certain diseases to occur in clusters. This study sought to identify comorbidity patterns in patients with chronic diseases, by reference to number of comorbidities, age and sex, in a population receiving medical care from 129 general practitioners in Spain, in 2007., Methods: A cross-sectional study was conducted in a health-area setting of the Madrid Autonomous Region (Comunidad Autónoma), covering a population of 198,670 individuals aged over 14 years. Multiple correspondences were analyzed to identify the clustering patterns of the conditions targeted., Results: Forty-two percent (95% confidence interval [CI]: 41.8-42.2) of the registered population had at least one chronic condition. In all, 24.5% (95% CI: 24.3-24.6) of the population presented with multimorbidity. In the correspondence analysis, 98.3% of the total information was accounted for by three dimensions. The following four, age- and sex-related comorbidity patterns were identified: pattern B, showing a high comorbidity rate; pattern C, showing a low comorbidity rate; and two patterns, A and D, showing intermediate comorbidity rates., Conclusions: Four comorbidity patterns could be identified which grouped diseases as follows: one showing diseases with a high comorbidity burden; one showing diseases with a low comorbidity burden; and two showing diseases with an intermediate comorbidity burden.

Rationale and Objectives: In 2007, the American Cancer Society (ACS) recommended that women at elevated risk of breast cancer be screened with breast magnetic resonance imaging (MRI) as an adjunct to mammography. This study estimates the proportion of women presenting for screening mammography who are at elevated lifetime risk of breast cancer as determined by the Gail model. This study provides preliminary information for a proposed follow-up study, including the proportion of women who completed the recommended MRI at the same clinic that had conducted the risk assessment., Materials and Methods: This study is an observational prospective cohort of 64,659 women presenting for mammographic screening at a single high-volume clinic. If a woman reported a first-degree maternal relative with breast cancer and had at least 20% lifetime risk on the Gail model, the radiologist's report included a recommendation that the primary care physician refer the woman for breast MRI screening. Records were examined to determine if women completed the recommended MRI at the clinic within one year of the initial risk assessment., Results: Of 64,659 women, 1,246 (1.9%) had a lifetime risk of breast cancer of 20% or greater, and 436 (0.7 %) had a lifetime risk of breast cancer 25% or greater. Of the women at elevated risk, 173 (13.9%) completed the recommended breast MRI screening at the clinic within a year., Conclusion: The effectiveness of matching screening intensity to risk on cancer detection, biopsy rate, and cost should be evaluated by studying multiple clinics and multiple risk assessment tools., (Copyright © 2012 AUR. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the impact of the expression of epidermal growth factor receptor (EGFR) on disease-free survival (DFS) and on pelvic relapse in patients with advanced cancer of the cervix receiving concurrent chemoradiotherapy., Methods: In 112 consecutive patients with advanced cancer of the cervix (11 stage IB2-IIA, 25 IIB, 63 IIIB, 13 IVA) treated with chemoradiotherapy between December 1994 and September 2004, the expression of EGFR using histoimmunochemistry was measured and used in univariate and multivariate analysis, along with variables such as age, International Federation of Gynecology and Obstetrics Staging System for Epithelial Ovarian Cancer (FIGO) stage, histology, Eastern Cooperative Oncology Group (ECOG), tumor size, and ganglia involvement diagnosed with computerized axial tomography, treatment with cisplatin to evaluate its impact on DFS and pelvic relapse., Results: Of the 112 biopsies, 32 (28.6%) were negative or slightly positive (EGFR±) and 80 (71.4%) were moderate or intensely positive (EGFR++/+++). The overexpression of EGFR (++/+++) was significantly associated with an epidermoid histology (P < 0.0001), with a higher rate of pelvis relapse and a decreased DFS (hazard ratio [HR]: 2.31 [1.08-4.96]; P = 0.03). Overall, treatment with cisplatin increased DFS (HR: 0.51 [0.26-0.97]; P = 0.04)., Conclusions: Patients with tumors of the cervix and overexpression of the EGFR++/+++ show a higher probability of pelvic relapses and a decreased disease-free survival. The poor prognosis of these tumors may be a consequence of an increase in radio-resistance.

The aim of this study was to investigate the effect of risedronate (RIS) on bone loss and bone turnover markers after liver transplantation (LT). Patients with osteopenia or osteoporosis within the first month after LT were randomized to receive RIS 35 mg/week plus calcium 1000 mg/day and vitamin D(3) 800 IU/day (n = 45) or calcium and vitamin D(3) at same dosages (n = 44). Primary endpoint was change in bone mineral density (BMD) 6 and 12 months after LT. Secondary endpoints included changes in serum β-CrossLaps (β-CTX) and procollagen type 1 amino-terminal peptide (P1NP) and fracture rate. Spine X-rays were obtained at baseline and after 12 months. There was no significant difference in BMD changes between both treatment groups at any sites; either at 6 or 12 months. Spine BMD increased in both groups at 12 months vs. baseline (P = 0.001). RIS patients had a significant increase in intertrochanteric BMD at 12 months (P < 0.05 vs. baseline). Serum β-CTX decreased in both groups (P < 0.01), with significant differences between groups at 3 months. No significant difference in vertebral fracture incidence was found. After 12 months, BMD improved at lumbar spine and did not change at hip in both groups. Significant differences between both groups were not found. Other factors (calcium and vitamin D replacement, early prednisone withdrawal) seem to have also positive effects in BMD., (© 2011 The Authors. Transplant International © 2011 European Society for Organ Transplantation.)

Objectives: To determine the effectiveness and safety of saturation biopsies for prostate cancer detection of and to identify predictive variables for cancer., Methods: We conducted a retrospective transversal study in which we analyzed 144 saturation biopsies (January '06 - July '09)., Inclusion Criteria: at least two sets of biopsies without evidence of malignancy and Prostate Specific Antigen (PSA)levels >10 ng/ml or PSA kinetics suggestive of malignancy (rate >0.75 ng/ml/year)and patients with atypia in a previous biopsy.The variables analyzed were: age, abnormal digital rectal examination (DRE), total PSA, free/total PSA ratio, prostate volume, PSA density, previous histopathology, number of cylinders obtained and complications. Statistical analysis was performed using the Chi-square test, Student's t-test and logistic regression., Results: Mean age was 66 years (SD ± 6.4), mean total PSA 14.4 ng/ml (SD ± 12.6), mean free/total PSA ratio 0.09 (SD ± 0.09), mean prostate volume 61.6 cc (SD ± 27.4), mean PSA density 0.27 (SD ± 0.26) and mean number of cylinders obtained 30.45 (SD ± 3.8). We diagnosed 32% of the patients with prostatic adenocarcinoma. We observed PSA density was higher in the prostate cancer group, 0.39 (SD ± 0.36), compared to 0.21 (SD ± 0.18) in patients without cancer (p=0.003). Adenocarcinoma was found in 58% of the biopsies in patients with suspicious DRE, compared to 28% with normal DRE (p=0.009). Mean prostate volume in the prostate cancer group was 52.5 (SD ± 24.7)compared to 66.0 (SD ± 27.7)in the group without cancer (p=0.006). In the multivariate analysis, the PSA density (p=0.02; 95% CI 1.36 - 37.36) was the only variable that independently predicted the presence of adenocarcinoma. No statistically significant differences were found in either univariate or multivariate analysis for the remaining variables analyzed. The incidence of complications was similar to that described in the literature for other series., Conclusions: Saturation biopsy is safe and effective for detection of prostate cancer. PSA density was the only factor that was shown to be independent predictive variable for tumor diagnosis.

Background and Objectives: Liver steatosis in chronic hepatitis C (CHC) is related to viral and metabolic factors and likely to genetic factors. The aim of this study was to know if hyperhomocysteinemia and methylenetetrahydrofolate reductase (MTHFR)-C677T polymorphisms are associated with liver steatosis in nonalcoholic patients with CHC., Patients and Method: In 54 consecutive patients with CHC, alcohol consumption less than 40g/week, and no other causes of liver disease, a liver biopsy was performed. All variables were obtained at the time of biopsy. MTHFR-C677T was also performed in 128 healthy subjects, with age and gender similar to the patients., Results: Liver steatosis was found in 33 patients (61%), 30 of them having a mild degree. Hyperhomocysteinemia was more prevalent in patients with steatosis (61% vs 24%; p=0.008) and overweight tended to be more prevalent in the same patients (61% vs 33%; p=0.05). All patients with virus C genotype 3 had steatosis. Viral load, liver inflammatory and fibrosis score were not different in patients with and without steatosis. MTHFR-C677T polymorphism was similar in controls and cases and in cases with and without steatosis. A multiple logistic regression showed that hyperhomocysteinemia was associated with liver steatosis after adjustment for age and sex (OR: 3.94; 95% CI: 1.09-14.29), and adjustment for overweight (OR: 4.43; 95% CI: 1.27-15.51)., Conclusions: In nonalcoholic patients with CHC mild liver steatosis is frequent, and is associated with hyperhomocysteinemia. An association between steatosis and MTHFR-C677T polymorphism was not found., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

Background/aims: The mitotic index and tumor size are currently the main prognostic indicators of gastrointestinal stromal tumors (GIST). The purpose of this study is to investigate the expression of different immunohistochemical markers and their relation to mortality and relapse, and especially concerning high-risk tumors., Methodology: We did a retrospective study of 68 patients who underwent surgery from 1997 to 2007 with a diagnostic of gastrointestinal stromal tumor., Results: The median follow-up period was 29 months. Relapse and mortality rates were 35.3% (24 cases) and 41.2% (28 cases), respectively. The mitotic index was related to p53 and the cellular proliferation index -Ki67- (p = 0.006 and p = 0.003, respectively). Considering both high and intermediate-risk neoplasms, a significant relation to Ki67 was obtained (p = 0.008). Relapse was related to the mitotic index (p = 0.032) and Ki67 (p = 0.024). Concerning mortality, statistically significant results were obtained with necrosis variables (p = 0.02), mitotic index (p = 0.013), p53 (p = 0.024) and Ki67 (p = 0.033)., Conclusions: Ki67 could be considered a prognostic marker for both relapse and mortality. Concerning high risk GIST, the usefulness the p53 protein and Ki67 nuclear antigen markers was also evident concerning relapse and mortality.

Introduction: Second-trimester fetal screening for congenital heart defects (CHD) included in routine obstetric care provides relevant information for decision making. The aim of this study was to describe the clinical practice of prenatal detection of CHD in terms of the process and results., Methods: The characteristics and results of ultrasound screening for major CHD were documented using data provided by hospitals for a national survey in Spain over the period of 2004-2006. Sixty-seven percent of eligible centers (56/83), covering 36% of total births nationwide, responded to the survey; 33 of these returned complete data regarding the screening results., Results: The number of major CHD occurring in the centers which provided data with results of screening was 1,060. The overall prenatal detection rate of major CHD was 65.7% (95% CI 57.8-74.7), but the detection rate in the routine second-trimester scan was 52.6% (95% CI 45.6-60.8). In 61% of these cases the parents chose to terminate the pregnancy. Two independent predictors of increased detection by center were identified: first, the uniformity and systematic character of the examination of the heart showing at least the 4-chamber view and outflow tracts (prevalence ratio 1.3, 95% CI 1.0-1.8) and second, the local availability of specialists in fetal echocardiography (prevalence ratio 1.4, 95% CI 1.1-1.9)., Conclusions: The detection of major CHD in the first half of pregnancy has an important impact on parental decision making. The prenatal screening program for CHD should be globally strengthened in terms of qualifications and methodological approaches. To improve its performance locally, close collaboration with fetal heart specialists should be promoted., (Copyright © 2010 S. Karger AG, Basel.)

Francisella tularensis is a zoonotic infection that can be acquired in multiple ways, including a bite from an arthropod, the handling of animal carcasses, consumption of contaminated food and water, or inhalation of infected particles. The most virulent subspecies of F tularensis is type A, which is almost exclusively seen in North America. Pneumonia can occur in tularemia, as either a primary process from direct inhalation, or as a secondary manifestation of ulceroglandular or typhoidal disease. This article describes the history of this infection, epidemiology, methods of diagnosis and treatment, and its potential as a bioterrorism weapon., (Published by Elsevier Inc.)

Objectives: To determine the impact of c-erb-B2 overexpression on disease-free survival (DFS) and local relapse in patients with advanced cervical cancer (CC) receiving concurrent chemoradiotherapy treatment., Methods: A total of 136 patients with advanced CC (FIGO stage: IB2-IIA [12]; IIB [34]; IIIB [71]; IVA [19]; including both epidermoid [86] and adenocarcinoma [14]) were analyzed to determine c-erb-B2 levels by immunohistochemistry (c-erb-B2 antibody; Dako, Glostrup, Denmark). Only c-erb-B2+++ biopsies were considered positive. All patients received pelvic radiotherapy, brachytherapy, and concurrent chemotherapy with 2 different regimens: 48 patients were treated with tegafur (800 mg/d orally) and 88 with tegafur (same doses) plus 5 cycles of weekly cisplatin 40 mg/m/wk intravenously., Results: A total of 32 (23.5%) biopsies were considered c-erb-B2-positive. Three-year and 5-year DFS were 61% and 58% for c-erb-B2-negative patients and 36% and 36% for c-erB2-positive patients, respectively (P = 0.02). Patients were stratified in 4 groups according to their c-erb-B2 status and whether they received cisplatin. The group of patients with c-erb-B2 overexpression that did not receive platinum treatment had a higher rate of pelvic relapse (P < 0.0001), associated with a decreased DFS (P = 0.0014)., Conclusions: c-erb-B2 overexpression may imply a poor prognosis for patients with advanced CC. Treatment with cisplatin-based radiochemotherapy improved outcome in these patients.

Regulatory T lymphocytes (Treg) suppress activation of the immune system and prevent pathological autoreactivity, giving them a relevant role in transplantation. In this study, we compared the proportion of Treg in a group of kidney transplant recipients with those in a control group. We used flow cytometry and labeling with monoclonal CD4, CD25, and FoxP3 antibodies to analyze the percentage of Treg lymphocytes in peripheral blood in a group of 68 patients at more than 12 years since transplantation and in 16 untransplanted healthy controls. In addition to the laboratory determinations, we analyzed the effect of some clinical parameters on the percentage of Treg in the transplanted group with a previous history of hepatitis C virus infection and undergoing immunosuppressive treatment. The percentage of Treg levels observed in the transplanted group was significantly lower than that in the control group (1.53% vs 2.89% CD4+ T cells; P = .0022). The percentage of Treg cells was significantly lower among patients treated with mycophenolate mofetil (1.12%) than other drug combinations. We also compared the percentage of Treg between transplant recipients treated with immunosuppressive monotherapy and those treated with combined immunosuppression, observing a higher percentage among patients with monotherapy.

Objective: The objective was to determine the impact of the coexpression of epidermal growth factor receptor (EGFR) and tumor marker c-erbB-2 on disease-free survival (DFS) and pelvic relapse-free survival (PRFS) in patients with locally advanced cervical cancer (LACC) receiving concurrent chemoradiotherapy., Methods: The expression of EGFR and c-erbB-2 was assessed by immunohistochemistry, which was centralized and blinded to outcome. Univariate and multivariate analyses were used to evaluate the impact of EGFR and c-erbB-2 on DFS and PRFS., Results: 170 patients with LACC were included and received concurrent chemoradiotherapy. 25 (15%) biopsies were considered EGFR and c-erbB-2 positive; 100 (59%) were either EGFR or c-erbB-2 positive, and 45 (26%) were EGFR and c-erbB-2 negative. The 3- and 5-year DFS was 39% each for EGFR- and c-erbB-2-positive patients, 54 and 49%, respectively, for EGFR- or c-erbB-2-positive patients, and 76 and 72%, respectively, for EGFR- and c-erbB-2-negative patients (p = 0.006). EGFR- and c-erbB-2-positive tumors were significantly associated with a decrease in PRFS (hazard ratio, HR, 3.99; 95% confidence interval, CI, 1.44-11.05, p = 0.007), and DFS (HR 2.9; 95% CI, 1.26-6.66, p = 0.01)., Conclusion: Patients with LACC coexpressing EGFR and c-erbB-2, and treated with concurrent chemoradiotherapy, had a worse clinical prognosis with shorter DFS and PRFS.

Background: Pediatric units, especially neonatal units, are highly vulnerable to error generally and to medication error in particular. Potential failures are distributed across the entire medication process, occurring mostly at the time of medication prescription and during preparation for drug administration., Objective: To estimate the prevalence of violations of good prescribing practice before and after the implementation of several measures aimed at improving the quality of the medical prescription., Methods: Before and after evaluation study with prospective data collection in a third level neonatal unit. 6,320 handwritten medical prescriptions for neonates admitted in the first study period and 1,435 in the second period were analyzed. Training on good prescribing practice and the implementation of a pocket PC-based automatic dosage calculation system were the interventions. The main outcome measure was the proportion of prescriptions with violations of good prescribing practice: incorrect dose, units, dose interval, route of administration or legibility., Results: Incorrect prescriptions decreased from 39.5% before the intervention to 11.9% after, with an adjusted prevalence ratio of 0.29 (0.25-0.34). The number of wrongly specified items on a single prescription decreased from 11.1% of the prescriptions with two or more wrongly specified items in the first period to 1.3% in the second period, with a prevalence ratio of 0.09 (0.05-0.14)., Conclusions: Violations of good prescribing practice are common in neonatal units. A simple intervention should improve the quality of handwritten medical prescriptions for newborns admitted to intensive care settings., ((c) 2007 S. Karger AG, Basel.)