Thoracic epidural anaesthesia reduces insulin resistance and inflammatory response in experimental acute pancreatitis

Abstract

Aims: The activity of the sympathetic nervous system (SNS) is crucial at an early stage in the development of an inflammatory reaction. A study of metabolic events globally and locally in the early phase of acute pancreatitis (AP), implying hampered SNS activity, is lacking.

We hypothesized that thoracic epidural anaesthesia (TEA) modulates the inflammatory response and alleviates the severity of AP in pigs.

Material and methods: The taurocholate (TC) group (n?=?8) had only TC AP. The TC?+?TEA group (n?=?8) had AP and TEA. A control group (n?=?8) underwent all the preparations, without having AP or TEA. Metabolic changes in the pancreas were evaluated by microdialysis and by histopathological examination.

Results: The relative increase in serum lipase concentrations was more pronounced in the TC group than in TC?+?TEA and control groups. A decrease in relative tissue oxygen tension (PtiO₂) levels occurred one hour later in the TC?+?TEA group than in the TC group. The maintenance of normoglycaemia in the TC group required a higher glucose infusion rate than in the TC?+?TEA group. The relative decrease in serum insulin concentrations was most pronounced in the TC?+?TEA group.

Conclusion: TEA attenuates the development of AP, as indicated by changes observed in haemodynamic parameters and by the easier maintenance of glucose homeostasis. Further, TEA was associated with attenuated insulin resistance and fewer local pathophysiological events.     

Diagnostic criteria of cancer cachexia: relation to quality of life, exercise capacity and survival in unselected palliative care patients

Purpose

Cachexia is associated with adverse outcomes. There is limited information on the impact of different diagnostic criteria of cachexia on patient centered outcomes.

Methods

We compared the prevalence of reduced quality of life (QoL), physical function and survival in palliative care cancer patients classified by different cachexia criteria. Four hundred and five patients with advanced cancer were included. Cachexia criteria were BMI, weight loss, fatigue, Karnofsky performance score, low handgrip strength, lean tissue depletion (DXA or arm muscle circumference) and abnormal biochemistry (inflammation, anemia or low serum albumin). QoL was assessed with a cancer specific questionnaire (EORTC QLQ-C30) and classified by cluster analysis. Dietary intake was obtained from a 4-day food record. Physical function was measured on a treadmill.

Results

Weight loss >2 %, BMI <20, fatigue and CRP >10 mg/L were associated with adverse QoL, function and symptoms (odds ratios: 2.1, 2.9, 4.0 and 3.1 respectively, P?<?0.05 for all). Fatigue, low grip strength and markers of systemic inflammation were associated with short walking distance (P?<?0.05). Weight loss?>?2 %, fatigue, CRP?>?10 mg/L and S-albumin?<?32 g/L were associated with shorter survival (hazard ratios: 1.4, 1.6, 2.2 and 2.0 respectively, P?<?0.05 for all). The prevalence of cachexia diagnosis varied from 12 to 85 % using different definitions.

Conclusions

Weight loss, fatigue and markers of systemic inflammation were most strongly and consistently associated with adverse QoL, reduced functional abilities, more symptoms and shorter survival. The prevalence of cachexia using different definitions varied widely; indicating a need to further explore and validate diagnostic criteria for cancer cachexia.     

Necrolytic acral erythema: a variant of necrolytic migratory erythema or a distinct entity?

BACKGROUND: Hepatitis C is a major health problem in Egypt. Necrolytic acral erythema (NAE) is a recently described necrolytic erythema that has a distinctive acral distribution and a uniform association with hepatitis C. Some authors believe that NAE is a distinct entity and others consider it as a variant of necrolytic migratory erythema (NME). METHODS: Five patients with clinical features consistent with NAE were included in this study. The patients were subjected to skin biopsy examination, CT scan of the pancreas and a liver biopsy. Liver function tests, serum glucagon, glucose, amino acids and zinc were measured. All patients were tested for hepatitis C by enzyme-linked immunosorbent assay (ELISA) and by polymerase chain reaction (PCR). RESULTS: Three patients presented with early (acute) lesions and two patients with chronic lesions. The distribution of the lesions was almost exclusively on the dorsae of the feet. Histopathological findings were similar to those of other necrolytic erythemas. Hepatitis C virus was uniformly detected in all patients. Serum glucagon was high in two patients, serum glucose was high in four patients, serum amino acids were low in three cases and serum zinc and albumin were low in two cases. Little or no improvement was reported after oral amino acid supplementation, while the response to oral zinc sulfate was moderate to good. CONCLUSION: Necrolytic acral erythema is closely associated with hepatitis C infection. Many findings indicate that NAE seems to be a variant of NME rather than a distinct entity. Hence, an alternative proposed term could be acral NME.     

Children with screening-detected coeliac disease show increased levels of nitric oxide products in urine

Aim: Increased concentration of nitric oxide (NO) metabolites, nitrite and nitrate, in the urine is a strong indication of ongoing small intestinal inflammation, which is a hallmark of the enteropathy of coeliac disease (CD). It has previously been shown that children with symptomatic, untreated CD have increased levels of NO oxidation products in their urine. The aim of this study was to investigate whether screening‐detected, asymptomatic coeliac children display the same urinary nitrite/nitrate pattern. Methods: In a multicenter screening study, serum samples were collected from 7208 12‐year‐old children without previously diagnosed CD. Sera were analysed for anti‐human tissue transglutaminase (tTG) of isotype IgA. Small bowel biopsy was performed in antibody‐positive children, yielding 153 new cases of CD. In the screening‐detected individuals, the sum of nitrite and nitrate concentrations in the urine was analysed and used as an indicator of NO production. For comparison, 73 children with untreated, symptomatic CD were studied. Results: The nitrite/nitrate levels in children with screening‐detected CD and those with untreated symptomatic CD did not differ significantly. Both groups had significantly increased urinary nitrite/nitrate concentrations compared to the children with normal small bowel biopsy (p < 0.001). Conclusion: Children with screening‐detected CD have increased production of NO just as children with untreated symptomatic CD. High NO metabolite levels in the urine may indicate a pathogenetic feature of CD and be a marker of major clinical importance.     

Transcutaneous blood gas monitoring during neonatal intensive care

Aim: To evaluate the accuracy in transcutaneous (Tc) blood gas monitoring in newborn infants, including extremely low birth weight infants, during neonatal intensive care. Methods: Tc PO₂/PCO₂ was monitored in the neonatal intensive care unit (NICU) during stable infant conditions. In comparison, simultaneous arterial PO₂ and PCO₂ was measured. Sixty measurements were taken in 46 infants with median (range) birth weight of 0.93 (0.53–4.7) kg and at median (range) age of 8.5 (1–44) days. Comparison of measurements was performed using Bland–Altman plots, and the mean (95% CI) of the difference was calculated. Comparison was also performed in relation to body weight, postnatal age and oxygen requirement. Results: The mean (95% CI) difference in PO₂ (TcPO₂–aPO₂) was 0.3 (?0.2–0.9) kPa, and the corresponding difference in PCO₂ (TcPCO₂–aPCO₂) was 0.4 (0.03–0.8, p < 0.05) kPa. Some differences were related to body weight, age and oxygen requirement, but these differences were small. Conclusion: There was good agreement between TcPO₂/TcPCO₂ and corresponding arterial measurements. The mean difference between the methods was small and clinically acceptable in a current NICU. Tc blood gas monitoring could be recommended as a valuable complement for blood gas monitoring also in extremely low birth weight infants.     

Longitudinal myocardial contribution to peak systolic flow and stroke volume in the neonatal heart

Systolic longitudinal myocardial function is important for cardiac ejection. Data describing hemodynamic determinants and the time course of myocardial longitudinal contraction as measured by tissue Doppler are lacking. Ten newborn pigs were used for invasive hemodynamic investigation. Tissue Doppler assessment of the lateral part of the mitral valve annulus during systole was performed during pharmacological modulation of inotropy, cardiac pacing, and modulations of loading conditions. The strongest association was found between peak systolic velocity (S') and peak systolic flow (PSF) and end-systolic pressure (ESP), respectively (β = 0.09 cm/mL, p < 0.001 and β = -0.07 cm/mL, p = 0.003). Displacement (D) was mostly influenced by stroke volume (SV) (β = 0.05 cm/mL, p < 0.001). Ejection time, SV, ESP, maximum first derivative of pressure (dP/dtmax), and PSF were all associated with S' and D under different states of hemodynamic modulation; however, the ratio between PSF and S', SV, and D were stable during hemodynamic modulations. Normalized cross correlations indicate that S' and D follow the same trajectory as flow and SV, respectively. In conclusion, this study provides validity of accounting systolic D in the long axis as the longitudinal contribution to SV and peak systolic tissue velocity as the longitudinal contribution to PSF.     

Prospective study of human papillomavirus seropositivity and risk of nonmelanoma skin cancer

Cutaneous human papillomaviruses (HPVs) have been associated with squamous cell carcinoma (SCC) in case-control studies, but there are limited data from prospective studies assessing whether virus exposure predicts risk of future cancer development. Two major biobanks, the Southern Sweden Microbiology Biobank (1971-2003) and the Janus Biobank (1973-2003) in Norway, containing samples from 850,000 donors, were searched for incident skin cancer for up to 30 years using registry linkages. Altogether, 2,623 donors with samples taken before diagnosis of SCC or basal cell carcinoma (BCC) of the skin were identified. Prediagnostic samples and samples from 2,623 matched controls were tested for antibodies against 33 types of HPV. Baseline seropositivity to HPV types in genus β species 2 was associated with SCC risk (odds ratio = 1.3, 95% confidence interval: 1.1, 1.7); this was also the case for samples taken more than 18 years before diagnosis (odds ratio = 1.8, 95% confidence interval: 1.1, 2.8). Type-specific persistent seropositivity entailed elevated point estimates for SCC risk for 29 HPV types and decreased point estimates for only 3 types. After multiple hypothesis adjustment, HPV 76 was significantly associated with SCC risk and HPV 9 with BCC risk. In summary, seropositivity for certain HPV types was associated with an increased risk for future development of SCC and BCC.