Minimal-invasive approach for penetrating Crohn’s disease is not associated with increased complications

Background

Laparoscopic surgery for penetrating Crohn’s disease (CD) still remains highly conflicting due to a lack of sufficient data. Therefore, the following large study was designed to compare postoperative outcomes after minimal-invasive resections for penetrating and non-penetrating CD.

Methods

Consecutive patients, who underwent laparoscopic intestinal resection for symptomatic CD at a tertiary academic referral center, were included. Patients were divided according to perioperative findings in penetrating and non-penetrating type of disease. All clinical data were obtained from an institutional database and analyzed retrospectively.

Results

Of 234 patients enrolled, 101 patients [females: n = 54 (53.5 %)] were operated on for non-penetrating CD and 133 patients [females: n = 50 (37.6 %)] for penetrating CD. Fistulas (p < 0.001), inflammatory mass (p < 0.001) and abscess formation (p < 0.001) were observed more frequently in the perforating group. Ileocolic resections were performed predominantly in both groups [perforating CD: n = 110 (82.7 %), non-perforating CD: n = 82 (81.2 %)], with more complex resections (>1 intestinal resection) found in perforating CD (p < 0.001). Conversion rates did not differ significantly. Notably, 30-day postoperative morbidity was comparable for both groups [perforating CD: n = 20 (15 %), non-perforating CD: n = 19 (18.8 %), p = 0.44]. Postoperative complication rates graded according to the Clavien–Dindo classification showed no difference too (p = 0.49).

Conclusion

Laparoscopic surgery can be conducted safely in selected patients with penetrating CD without increasing the risk of postoperative complications. This finding needs to be implemented in future guidelines.

     

Liver cirrhosis but not alcohol abuse is associated with impaired outcome in trauma patients – A retrospective,multicentre study

IntroductionLiver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. We therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients.Materials and methodsUsing the multi-centre population-based Trauma Registry of the German Society for Trauma Surgery, we retrospectively compared outcome in patients (ISS ≥ 9, ≥18) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis. Means were compared using Student's t-test and analysis of variance (ANOVA) and categorical variables using χ² (p < 0.05 = significant).ResultsOverall 13,527 patients met the inclusion criteria and were, thus, analyzed. 713 (5.3%) patients had a documented alcohol abuse and 91 (0.7%) suffered from liver cirrhosis. Patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. More specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted (35% vs. predicted 19%) and increased single- and multi-organ failure rates. While alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality.ConclusionsPatients suffering from liver cirrhosis presented impaired outcome after multiple injuries. Pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile.     

Intraoperative enteroscopy detects more lesions but is not predictive of postoperative recurrence in Crohn’s disease

Background: The aim of this investigation was to elucidate the clinical value of intraoperative enteroscopy (IOE) for Crohn's disease, and to determine the value of IOE in predicting recurrent disease. Methods: In this study 27 patients requiring surgery were examined by both preoperative radiography and IOE. The findings obtained by these procedures in the remnant small intestine were compared. In 19 patients, the clinical course and colonoscopic or radiographic findings after surgery were analyzed. Results: Intestinal lesions were identified in 23 patients by IOE, and in 19 patients by radiography. Longitudinal ulcers were equivalently detected by IOE (63%) and radiography (56%), whereas small ulcers and inflammatory polyps were less frequently detected by radiography than by IOE (37% vs 74% and 19% vs 33%, respectively). Neither the presence nor the distribution of IOE findings was related to postoperative recurrence. Conclusions: Whereas IOE demonstrates small intestinal lesions in detail, the procedure alone cannot predict postoperative recurrence in Crohn's disease. apd: 3 April 2001     

Accelerated bone loss,but not low periosteal expansion,is associated with higher all-cause mortality in older men – prospective MINOS study

BackgroundLow bone mineral density (BMD), high bone resorption, fragility fractures and, possibly, accelerated bone loss are associated with higher mortality. However, it is not known if the higher mortality is related to lower volumetric BMD or lower bone width, to faster bone loss on endosteal surfaces (inside bone) or to slower periosteal apposition (formation of bone on the outer bone surface).MethodsWe assessed the association of 10-year mortality with bone width and bone loss in 782 men aged 50–85 years.ResultsLow bone width and slow periosteal apposition at the femoral neck, distal radius and distal ulna were not associated with higher mortality. Accelerated apparent bone loss (decrease in BMD), net bone loss (decrease in bone mineral content) and estimated endosteal bone loss were associated with a higher 10-year all-cause mortality after adjustment for age and other confounders. Accelerated apparent bone loss at the total hip (lowest quartile) was associated with a two-fold higher mortality (Hazard Ratio (HR)=1.96, 95% Confidence interval (CI): 1.33, 2.89, p<0.001).ConclusionLack of association between bone size and mortality shows that periosteal expansion is not an artifact induced by the selective mortality of men with narrow bones. We confirmed that poor bone status reflects poor health. These data should be interpreted with caution because of the study limitations, especially the lack of representativity of the cohort and dropout of older and sick men. However, they suggest that older men with low BMD or accelerated bone loss should obtain detailed diagnostic assessment to establish general factors that can contribute to their poor bone status.     

Recurrence of primary sclerosing cholangitis after liver transplantation is associated with specific changes in the gut microbiome pretransplant – a pilot study

Primary sclerosing cholangitis (PSC) is a common indication for liver transplantation (LT). Up to 25% of patients experience recurrence of PSC (rPSC) after LT, which is associated with significant morbidity and mortality. To date, it is not possible to predict which patients are at risk for rPSC. The aetiology of PSC is complex and is speculated to involve translocation of intestinal bacteria to the liver, because of its frequent co-occurrence with inflammatory bowel diseases (IBD). Here, we investigate whether the mucosal intestinal microbiome of PSC patients (n = 97) at time of first LT can identify those patients who will develop rPSC. 16S gene sequencing of bacterial DNA isolated from formalin-fixed paraffin-embedded biopsies showed that PSC patients with Crohn’s disease (n = 15) have a reduced microbial diversity and that inflammation of the mucosa is associated with beta-diversity changes and feature differences. No differences in alpha- or beta diversity were observed between patients with rPSC (n = 14) and without rPSC (n = 83). However, many over-represented bacterial features were detected in patients with rPSC, while surprisingly, those without recurrence of disease were characterized by an increased presence of the Gammaproteobacteria Shigella. This pilot study warrants further investigation into bacterial differences between rPSC and non-rPSC patients.     

BMI change is associated with fracture incidence, but only in non-smokers. The Tromsø Study

Summary  

Few studies have examined the association between body mass index (BMI) change and fracture in a general population. We observed that BMI loss was associated with increased fracture risk in non-smoking men and women, but not in smokers. BMI gain was associated with decreased fracture risk in women.     

Recovery of Bone Mineral Density after Surgical Cure, but not by Ketoconazole Treatment, in Cushing’s Syndrome

The aim of our study was to retrospectively assess the effect of treatment on bone mineral density (BMD) in patients with Cushing’s syndrome. Nineteen patients (17 women, 2 men; mean age ± SD, 41 ± 10 years; preoperative duration of disease 20 ± 15 months) were studied. Six patients had a cortisol-producing adenoma and 13 had pituitary-dependent bilateral adrenal hyperplasia. BMD of the lumbar spine (L2–L4) was measured by dual-energy X-ray absorptiometry just before and 1–10 years after adrenalectomy or pituitary adenomectomy. Patients were divided in two groups. The first group of 9 patients (6 adrenal and 3 pituitary adenomas; group A) included those treated successfully by surgery (>5 years follow-up in the case of pituitary surgery). The second group of 10 patients (group B) included those treated with the steroidogenesis inhibitor ketoconazole, 300–600 mg/day, after unsuccessful pituitary surgery. In group A, restoration of normal cortisol was associated with a significant increase in BMD (from 829 ± 112 mg/cm² to 952 ± 107 mg/cm²; p = 0.002). In group B, no changes in BMD were observed (from 857 ± 160 to 847 ± 163 mg/cm²), in spite of markedly decreased or normalized cortisol levels during ketoconazole treatment. These findings indicate that definitive correction of hypercortisolism restores BMD to normal levels in patients with Cushing’s syndrome. In patients treated with ketoconazole after unsuccessful pituitary surgery, even when normalization of cortisol levels was achieved, BMD remained low. This would suggest an interfering effect of this drug on bone metabolism. Received: 26 February 2001 / Accepted: 11 June 2001     

Circulating irisin is associated with osteoporotic fractures in postmenopausal women with low bone mass but is not affected by either teriparatide or denosumab treatment for 3 months

Summary

In vitro data suggest that myokine irisin may affect bone metabolism by promoting osteoblast differentiation while inhibiting osteoclast differentiation. In this study, circulating irisin levels were associated with previous osteoporotic fractures but not with bone mass and were not affected by denosumab or teriparatide treatment for 3 months.

Introduction

This study aimed to evaluate predictors of circulating irisin in postmenopausal women with low bone mass and to assess a potential effect of denosumab or teriparatide treatment for 3 months.

Methods

Serum samples for irisin measurement were obtained from (a) postmenopausal women with low bone mass (lumbar spinal [LS] or femoral neck [FN] bone mineral density [BMD] T-score ≤?2.0) and their age-matched controls at baseline and 3 months after denosumab (Dmab) injection (Dmab group, n?=?50; Dmab control group, n?=?25) and (b) women with more severe disease (LS or FN BMD T-score ≤?2.8) and their age-matched controls at the above-mentioned time points after teriparatide (TPTD) initiation (TPTD group, n?=?25; TPTD control group, n?=?25).

Results

At baseline, irisin levels were inversely correlated with age (partial coefficient (r _p )?=??0.24; p?=?0.009), parathyroid hormone (PTH) (r _p ?=??0.30; p?=?0.001), and creatinine (r _p ?=??0.23; p?=?0.016) in univariate analysis, and were lower in women with (n?=?26; 41.6?±?2.7 ng/dL) than without previous osteoporotic fracture(s) (n?=?99; 51.0?±?1.6 ng/dL; p?=?0.007). In multiple linear regression, previous osteoporotic fracture(s) and PTH were independently negatively associated with irisin [p?=?0.04, CI ?16.1 to ?0.4 and p?=?0.002, CI ?0.3 to ?0.07, respectively], but only the association with PTH remained after controlling for creatinine levels. Serum irisin levels were not different between women with or without low bone mass and were not affected by either Dmab or TPTD treatment for 3 months.

Conclusions

Circulating irisin levels were associated with previous osteoporotic fracture(s); whether this association is independent or is due to confounding by lower muscle mass, potentially reflected by lower creatinine levels, remains to be fully clarified.     

Only C-Reactive Protein, but not TNF-α or IL6, Reflects the Improvement in Inflammation after Bariatric Surgery

Background  

Increased C-reactive protein (CRP) levels strongly predict inflammatory diseases such as obesity and tissue damage. We wanted to study the CRP in plasma and tissue in morbidly obese patients before and after surgery and relate it with the expression of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in tissues.     

Nocturia is not associated with falls among the elderly: a population study in the city of São Paulo

Introductionthe present study aims to evaluate the association between nocturia and falls in a group of community-living elderly men in the city of São Paulo (Brazil).Material and methodsunder the coordination of the Pan American Health Organization and World Health Organization, a multicenter study named Health, Welfare and Aging (SABE Study) is being conducted to evaluate the living and health conditions of older people in Latin America and Caribbean. In Brazil, this study is evaluating the elderly population (60 years or more) in São Paulo since 2000. The presence of nocturia was taken as the response “yes” to the question “Do you need to void three times or more at night?” .The presence of falls was also taken as the response “yes” to the question “Did you have any fall during the last 12 months?” The intergroup analysis used was the logistic regression.Resultstotal of 865 men was interviewed, mean age 68 years. It was observed high prevalence of nocturia and falls in all groups, with higher prevalence of both in the eldest group (p < 0.001), however, the association of nocturia and falls was not statistically significant in any of the groups (p = 0.45).Conclusionthis is one of the pioneering studies that assess only the male population, showing that nocturia was not significantly associated with falls. Nocturia and falls are highly prevalent conditions in the elderly, but no association was found between both, so that these variables may be correlated to age and other clinical conditions.     

Isoniazid-related fulminant hepatic failure in a child: assessment of the native liver’s early regeneration after auxiliary partial orthotopic liver transplantation

We report the first case of auxiliary partial orthotopic liver transplantation (APOLT) in a patient with isoniazid (INH)-related fulminant hepatic failure (FHF) with the aim to determine the ability of the native liver (NL) to recover after this particular toxic event. A 10-year-old boy with INH-related FHF underwent APOLT after left hepatectomy on the NL. Neurological status and liver function rapidly improved, but, on postoperative day 22, urgent re-transplantation was needed for graft–hepatic artery thrombosis (HAT) and the NLs incapacity to sustain adequate liver function. Histological examination of the NL showed signs evident of its regeneration, however. In conclusion, though we faced the clinical failure of the NL functionally to sustain the patient in the presence of the graft HAT 3, weeks after APOLT, such a failure may be interpreted as time related. In fact, the histological picture in this particular case may suggest the potential for NL recovery after INH-related FHF.     

What is the biopsychosocial role of human immunodeficiency virus positivity in patients with end-stage liver disease who undergo orthotopic liver transplantation?

INTRODUCTION: Since 2003 the National Research Program for Solid Organ Transplantation in patients with human immunodeficiency virus (HIV) is active at our liver transplantation center. Patients with HIV who enter this protocol are assessed by the Consultation Liaison Psychiatry Service. The aim of the present study was to evaluate their psychiatric comorbidity. METHODS: An observational prospective study was conducted comparing end-stage liver disease (ESLD) patients with and without HIV. After the assessment, the psychiatrist compiled the Transplant Evaluation Rating Scale (TERS) and the Montgomery Asberg Depression Rating Scale (MADRS). Baseline evaluation was made before inclusion on the OLT waiting list and the follow-up evaluation was made 12 months later. RESULTS: From January 2003 to December 2006 we assessed 553 patients: 39 (6%) with HIV and 361 (94%) without HIV. The 2 groups were homogeneous for gender (75% of male patients; P=not significant [NS]) but not for age (46+/-5 vs 56+/-9; P=NS). Psychiatric history was negative in 176 (49%) patients without HIV and in 6 (15%) patients with HIV (P< .001). At baseline psychiatric comorbidity was present in 33 HIV patients (85%) and in 148 non-HIV patients (41%; P< .001). At follow-up MADRS highlighted an improvement in all of the items for HIV patients. In the non-HIV group, the variation was as follows: baseline, 7.10; follow-up, 8.15. In the HIV group, the variation was as follows: baseline, 10.20; follow-up, 4.09 (P< .001). The average score at TERS was higher among patients with HIV (43+/-9 vs 35+/-9; P=NS). CONCLUSIONS: At baseline HIV patients with ESLD showed a higher rate of psychopathology, but they improved at follow-up; the contrary happened in the non-HIV group.