Insulin resistance in morbid obesity: reversal with intramyocellular fat depletion.

Obesity is a frequent cause of insulin resistance and poses a major risk for diabetes. Abnormal fat deposition within skeletal muscle has been identified as a mechanism of obesity-associated insulin resistance. We tested the hypothesis that dietary lipid deprivation may selectively deplete intramyocellular lipids, thereby reversing insulin resistance. Whole-body insulin sensitivity (by the insulin clamp technique), intramyocellular lipids (by quantitative histochemistry on quadriceps muscle biopsies), muscle insulin action (as the expression of Glut4 glucose transporters), and postprandial lipemia were measured in 20 morbidly obese patients (BMI = 49 +/- 8 [mean +/- SD] kg x m(-2)) and 7 nonobese control subjects. Patients were restudied 6 months later after biliopancreatic diversion (BPD; n = 8), an operation that induces predominant lipid malabsorption, or hypocaloric diet (n = 9). At 6 months, BPD had caused the loss of 33 +/- 10 kg through lipid malabsorption (documented by a flat postprandial triglyceride profile). Despite an attained BMI still in the obese range (39 +/- 8 kg x m(-2)), insulin resistance (23 +/- 3 micromol/min per kg of fat-free mass; P < 0.001 vs. 53 +/- 13 of control subjects) was fully reversed (52 +/- 11 micromol/min per kg of fat-free mass; NS versus control subjects). In parallel with this change, intramyocellular-but not perivascular or interfibrillar-lipid accumulation decreased (1.63 +/- 1.06 to 0.22 +/- 0.44 score units; P < 0.01; NS vs. 0.07 +/- 0.19 of control subjects), Glut4 expression was restored, and circulating leptin concentrations were normalized. In the diet group, a weight loss of 14 +/- 12 kg was accompanied by very modest changes in insulin sensitivity and intramyocellular lipid contents. We conclude that lipid deprivation selectively depletes intramyocellular lipid stores and induces a normal metabolic state (in terms of insulin-mediated whole-body glucose disposal, intracellular insulin signaling, and circulating leptin levels) despite a persistent excess of total body fat mass.     

Management of Appendicitis Globally Based on Income of Countries (MAGIC) Study

Background

Our aim is to compare the management approaches and clinical outcomes of acute appendicitis according to annual Gross National Income per Capita (GNI/Capita) of countries.

Methods

Consecutive patients who were diagnosed to have acute appendicitis from 116 centers of 44 countries were prospectively studied over a 6-month period (April–September 2016). Studied variables included demography, Alvarado score, comorbidities, radiological and surgical management, histopathology, and clinical outcome. Data were divided into three groups depending on the GNI/Capita.

Results

A total of 4271 patients having a mean (SD) age of 33.4 (17.3) years were studied. Fifty-five percent were males. Two hundred and eighty patients were from lower–middle-income (LMI) countries, 1756 were from upper–middle-income (UMI) countries, and 2235 were from high-income (HI) countries. Patients in LMI countries were significantly younger (p?<?0.0001) and included more males (p?<?0.0001). CT scan was done in less than 8% of cases in LMI countries, 23% in UMI countries, and 38% in HI countries. Laparoscopy was performed in 73% of the cases in the HI countries, while open appendectomy was done in more than 60% of cases in both LMI and UMI countries (p?<?0.0001). The longest mean hospital stay was in the UMI group (4.84 days). There was no significant difference in the complication or death rates between the three groups. The overall death rate was 3 per 1000 patients.

Conclusions

There is great variation in the presentation, severity of disease, radiological workup, and surgical management of patients having acute appendicitis that is related to country income. A global effort is needed to address this variation. Individual socioeconomic status could be more important than global country socioeconomic status in predicting clinical outcome.

     

Bispectral Index in ICU: correlation with Ramsay Score on assessment of sedation level

Objective.The assessment of sedation level in critically ill patient remains a challenge for the intensivists in order to avoid over- or under-sedation phenomena. Scoring systems commonly used still show some limitation; the introduction of Bispectral Index (an EEG parameter) could bring potential advantages in monitoring sedation. According to the reports, Bispectral Index correlates with levels of sedation on the Ramsay Scale. We report our personal experience in this topic. Methods.Twenty patients, diagnosed with chronic obstructive pulmonary disease (COPD), were involved in the study. For an optimal adaptation to respiratory prothesis, they were sedated (with Propofol by continuous infusion at an initial dose of 2 mg/kg/h, which could be modulated with steps of 0.5 mg/kg/h), in order to maintain a Ramsay score of 4–5. BIS value was continuously recorded, and manually calculated on a mean average of a minute during the measuring of Ramsay score (T0) and every 30 for 24 hours on par with Ramsay score. EEG, SpO₂, non invasive arterial pressure, ventilatory module, ETCO₂, FIO₂ were also recorded. For the statistic analysis, Friedman test and Spearman coefficient were utilized. Values of p< 0.05 were considered significant. Results.980 observations were carried out. The variation range of Ramsay Score was between 2 and 6. BIS range varied from 34 to 98. Statistic analysis of the data obtained pointed out some significative correlations, particularly between Ramsay Score and BIS (p< 0.01), and between BIS and dosage of Propofol (p< 0.01). Conclusions.The results of the study are consistent with those found in the literature on this topic of study. In fact, this study demonstrates the utility of BIS to track levels of consciousness in ICU patients while still maintaining the use of the score systems to care for ICU patients.     

Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer: technical notes

Background  

With increasing experience, sentinel node navigation has been applied even to gastric cancer. Sentinel lymph nodes are identified by injecting lymphatic tracer dye and radioisotope-labeled particles around a gastric tumor into the submucosa endoscopically. The aim of this video was to demonstrate the feasibility of laparoscopic sentinel node navigation (SLN) in gastric cancer.     

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic? A scoping review

BACKGROUNDAcute colonic diverticulitis (ACD) is common in Western countries, with its prevalence increasing throughout the world. As a result of the coronavirus disease 2019 (COVID-19), elective surgery and in-patients’ visits have been cancelled or postponed worldwide. AIMTo systematically explore the impact of the pandemic in the management of ACD.METHODSMEDLINE, Embase, Scopus, MedxRiv, and the Cochrane Library databases were searched to 22 December 2020. Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible. For cross sectional studies, outcomes of interest included the number of hospital admission for ACD, as well as key features of disease severity (complicated or not) across two time periods (pre- and during lockdown).RESULTSA total of 69 papers were inspected, and 21 were eligible for inclusion. Ten papers were cross sectional studies from seven world countries; six were case reports; three were qualitative studies, and two review articles. A 56% overall decrease in admissions for ACD was observed during lockdown, peaking 67% in the largest series. A 4%-8% decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase. An initial non-operative management was recommended for complicated diverticulitis, and encouraged to an out-of-hospital regimen. Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination, societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained.CONCLUSIONDuring the COVID-19 pandemic, fewer patients presented and were diagnosed with ACD. Such decline may have likely affected the spectrum of uncomplicated disease. Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.