A look to the future in non-alcoholic fatty liver disease: Are glucagon-like peptide-1 analogues or sodium-glucose co-transporter-2 inhibitors the answer?

The increasing prevalence of diabetes and non-alcoholic fatty liver disease (NAFLD) is a growing public health concern associated with significant morbidity, mortality and economic cost, particularly in those who progress to cirrhosis. Medical treatment is frequently limited, with no specific licensed treatments currently available for people with NAFLD. Its association with diabetes raises the possibility of shared mechanisms of disease progression and treatment. With the ever-growing interest in the non-glycaemic effects of diabetes medications, studies and clinical trials have investigated hepatic outcomes associated with the use of drug classes used for people with type 2 diabetes (T2D), such as glucagon-like peptide-1 (GLP-1) analogues or sodium-glucose co-transporter-2 (SGLT2) inhibitors. Studies exploring the use of GLP-1 analogues or SGLT2 inhibitors in people with NAFLD have observed improved measures of hepatic inflammation, liver enzymes and radiological features over short periods. However, these studies tend to have variable study populations and inconsistent reported outcomes, limiting comparison between drugs and drug classes. As these drugs appear to improve biomarkers of NAFLD, clinicians should consider their use in patients with NAFLD and T2D. However, further evidence with greater participant numbers and longer trial durations is required to support specific licensing for people with NAFLD. Larger trials would allow reporting of major adverse hepatic events, akin to cardiovascular and renal outcome trials, to be determined. This would provide a more meaningful evaluation of the impact of these drugs in NAFLD. Nevertheless, these drugs represent a future potential therapeutic avenue in this difficult-to-treat population and may beget significant health and economic impacts.     

Infektionen (septische Komplikationen) nach endoskopischen Eingriffen

Bacterial infections after endoscopic interventions originate from contamination by inadequate reprocessing of instruments or bloodstream translocation of bacteria from the gastrointestinal tract. Standardized reprocessing protocols have considerably reduced the risk of transmission of microorganisms. Antibiotic prophylaxis is strongly recommended in individual patients with high intervention and organ-related risk. Methicillin-resistant Staphylococcus aureus (MRSA) and other multiresistant bacteria represent a new potential danger for endoscopic institutions. Hygiene protocols should be orientated to these new risks and infection potentials.     

Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

Objectives : To investigate rates of and reasons for second and subsequent stent procedures in an unselected, “real‐world” population. Background : Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. Method : All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Results : Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow‐up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent‐related indication. Functional assessment before repeat stenting was used in one‐third of stable patients. Mortality was 2.5% per annum. Conclusions : In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow‐up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent. © 2012 Wiley Periodicals, Inc.     

Optimal projection for transcatheter aortic valve implantation determined from the reference projection angles

Introduction : An optimal fluoroscopic working view projection (OP) with all three aortic sinuses aligned is crucial during trans‐catheter aortic valve implantation (TAVI). The aim of this study was to identify simple reference projection angles, which would act as a starting point for the operator to help determine OP for patients undergoing TAVI. Methods : During the period under consideration, 50 patients underwent TAVI. Procedural data and outcomes were collected prospectively on a dedicated database. Optimal angiographic deployment angles were achieved for all patients by starting in an anteroposterior caudal 15 degrees projection and then adjusting according to the initial image, with multiple small volume contrast injections undertaken to determine when all three aortic cusps were aligned (OP). Results : OP angles for the 50 cases were plotted on a graph. After normality testing confirmed that all angles were normally distributed, regression analysis enabled a regression line to be calculated. The equation for the regression line was defined as cranial/caudal intercept ?16.4 ± 1.5 (SE of the coefficient), P < 0.0001, slope of regression line LAO/RAO + 0.53 ± 0.1 (SE of the coefficient SE), P < 0.0001). Conclusions : As the regression line and its equation represents an acceptable estimate of the true relationship between Cranial/Caudal and LAO/RAO, to determine OP while remaining close to the regression line we suggest starting in LAO = 8.9, Caudal = ?11.4 (which represent the mean values of these two variables), and then increasing the caudal angle by approximately 0.5 degrees for every increase of 1 degree of the LAO angle or decreasing the caudal angle by 0.53 degrees for every decrease of 1 degree in LAO until all three aortic sinuses are in line which represents OP. © 2012 Wiley Periodicals, Inc.     

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Asian Patients: 100 Consecutive Patients in a Single Institution

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in selected patients with peritoneal carcinomatosis. We review our institutional experience with the procedure and evaluate the overall survival (OS) and disease-free survival (DFS) rates in 100 consecutive patients.

Methods

Data were prospectively collected from 100 consecutive patients with peritoneal carcinomatosis treated by CRS and HIPEC at the National Cancer Centre Singapore between April 2001 and May 2012. Our primary end points were OS and DFS.

Results

Of the 100 patients, 84 were of Chinese ethnicity, 3 were Malay, 6 were Indian, and 7 were of other ethnicities. Primary tumors were ovarian cancer (n = 39), colorectal cancer (n = 28), primary peritoneal (n = 6), appendiceal cancer (n = 20), and mesothelioma (n = 7). Median follow-up duration was 21 months. At 5 years, the DFS was 26.3 % and OS was 50.9 %. Factors influencing OS and DFS were cytoreductive score, primary cancer, and disease-free interval of more than 12 months on univariate analysis. The only factors that remained significant for prognosis after multivariate analysis were primary cancer and cytoreductive score. Thirty-day morbidity was 56 %, and there were no 30-day mortalities.

Conclusions

CRS and HIPEC can be safely carried out in Asian patients with peritoneal carcinomatosis from ovarian, colorectal, appendiceal, mesothelioma, and primary peritoneal origins. Overall, the ovarian, appendiceal, mesothelioma, and primary peritoneal cancer patients tended to do better than the colorectal patients, but careful patient selection ensuring that optimal cytoreduction can be achieved is essential for the success of this procedure.