The Importance of Routine Liver Biopsy in Diagnosing Nonalcoholic Steatohepatitis in Bariatric Patients

Background: Nonalcoholic Steatohepatitis (NASH) commonly occurs in obese patients and predisposes to cirrhosis. Prevalence of NASH in bariatric patients is unknown. Our aim was to determine the role of routine liver biopsy in managing bariatric patients. Methods: Prospective data on patients undergoing Roux-en-Y gastric bypass (RYGBP) was analyzed. One pathologist graded all liver biopsies as mild, moderate or severe steatohepatitis. NASH was defined as steatohepatitis without alcoholic or viral hepatitis. Consecutive liver biopsies were compared to those liver biopsies selected because of grossly fatty livers. Results: 242 patients underwent open and laparoscopic RYGBP from 1998-2001. Routine liver biopsies (68 consecutive patients) and selective liver biopsies (additional 86/174, 49%) were obtained. Findings of cirrhosis on frozen section changed the operation from a distal to a proximal RYGBP. The two groups were similar in age, gender, and BMI. The group with the routine liver biopsies showed a statistically significant larger preponderance of NASH (37% vs 32%). Both groups had a similar prevalence of cirrhosis. Neither BMI nor liver enzymes predicted the presence or severity of NASH. Conclusions: Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH. Liver biopsy remains the gold-standard for diagnosing NASH. We recommend routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures.     

Glomerulosclerosis: A paraneoplastic phenomenon?

Glomerulosclerosis is not classically considered a paraneoplastic glomerular lesion. Focal and segmental glomerulosclerosis (FSGS) has rarely been reported in association with solid tumours. We report three cases of FSGS and an additional case of collapsing glomerulosclerosis in patients presenting with nephrotic syndrome and malignancy.     

Evidence-Based Adjuvant Treatment of Resectable Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma (PAC) remains one of the most lethal cancers. The overall 5-year survival rate (all stages) remains <5%. Most people present with advanced disease and even the minority who present with resectable disease still, predominantly, die of recurrent metastatic cancer. Adjuvant treatment after surgical resection has been proposed as a method of increasing the cure rate of patients with PAC, but despite developments in new systemic and radiation treatment techniques, the optimal adjuvant therapy, according to the available evidence, is yet to be clearly defined. Adjuvant systemic chemotherapy, radiotherapy or chemoradiotherapy have all been investigated as strategies to improve locoregional and distant recurrence rates following resection of PAC. Whilst the early trials concentrated on combined modality adjuvant treatment, the large randomized controlled trials published to date have compared the various modalities and have concluded that chemoradiation therapy does not significantly improve survival, whereas adjuvant chemotherapy alone does. Despite the large numbers of patients involved in these trials, statistical and methodological flaws have lead to skepticism regarding these results. This review examines published trials of adjuvant therapy for resectable PAC, with particular emphasis on randomized studies. However, there is still ample room for further developments. Only a better understanding of the underlying biology contributing to the aggressive phenotype of PAC and the development of targeted molecular agents will finally allow significant progress to be made in the area of adjuvant therapy for resectable PAC.     

Obesity and outcomes in premenopausal and postmenopausal breast cancer.

PURPOSE: Obesity is associated with adverse outcomes in postmenopausal women with breast cancer. In premenopausal women, the association is less clear. METHODS: A population-based sample of 1,360 Australian women with breast cancer before the age of 60 years, 47% diagnosed before age 40, and 74% premenopausal, was studied prospectively for a median of 5 years (range, 0.2-10.8 years). Obesity was defined as a body mass index of > or =30 kg/m2. The hazard ratio (HR) for adverse clinical outcome associated with obesity was estimated using Cox proportional hazard survival models. RESULTS: Obesity increased with age (P < 0.001) and was associated with increased breast cancer recurrence (P = 0.02) and death (P = 0.06), larger tumors (P = 0.002), and more involved axillary nodes (P = 0.003) but not with hormone receptor status (P > or = 0.6) or with first cycle adjuvant chemotherapy dose reductions (P = 0.1). Adjusting for number of axillary nodes, age at diagnosis, tumor size, grade, and hormone receptor status, obese women of all ages were more likely than nonobese women to have disease recurrence [HR, 1.57; 95% confidence interval (95% CI), 1.11-2.22; P = 0.02] and to die from any cause during follow-up (HR, 1.56; 95% CI, 1.01-2.40; P = 0.05). In premenopausal women, the adjusted HRs were 1.50 (95% CI, 1.00-2.26; P = 0.06) and 1.71 (95% CI, 1.05-2.77; P = 0.04), respectively. CONCLUSIONS: Obesity is independently associated with poorer outcomes in premenopausal women, as it is in postmenopausal women, and this is not entirely explained by differences in tumor size or nodal status. Given the high and increasing prevalence of obesity in western countries, more research on improving the treatment of obese breast cancer patients is warranted.     

Management of intracranial infectious aneurysms: a series of 16 cases

OBJECTIVE: The purpose of this study was to better define the management of intracranial infectious aneurysms. METHODS: We present a retrospective review of the management of 16 patients with intracranial infectious aneurysms. The mean follow-up period was 86 months. RESULTS: None of the patients had a rehemorrhage during antibiotic treatment. The mortality and long-term outcome from ruptured intracranial infectious aneurysms may be better than previously thought. There was no significant difference in long-term outcome between patients with single or multiple infectious aneurysms or between patients who underwent surgical resection and those who were treated only with antibiotics. CONCLUSION: Operative treatment should be pursued for patients with ruptured infectious aneurysms. Patients with unruptured intracranial infectious aneurysms should be observed during antibiotic therapy and followed up with cerebral angiography. Surgical resection should be considered if the aneurysm enlarges and the patient's general medical condition allows general anesthesia to be tolerated.     

The prevalence of reproductive tract infections in Hue,Vietnam

A study was conducted in central Vietnam to measure the prevalence of reproductive tract infections among clients of a family planning clinic, and to determine the usefulness of simple, clinic-based diagnostic tests. The prevalence of such infections was moderate, with the majority being endogenous. Few cases of cervical infection were identified, and no clinical or sociodemographic variables proved to be good predictors of such infection. Most vaginal infections could be identified through simple, clinic-based diagnostic tests, although further research into the cost-effectiveness of establishing and maintaining these services would be useful. Comparison of the results from laboratory tests and the presumptive diagnosis of the clinician indicate that the current practice of presumptive treatment is leading to significant overtreatment. Use of the World Health Organization flowcharts would reduce the overtreatment of vaginal infection but not of cervical infection. The importance of adapting the flowcharts to local epidemiology is highlighted.     

OCRL mutation analysis in Italian patients with Lowe syndrome

The oculocerebrorenal syndrome of Lowe (OCRL, also called OCRL1) is a rare X-linked disorder characterized by major abnormalities of eyes, nervous system, and kidneys. The gene responsible for OCRL was identified by positional cloning and encodes an inositol polyphosphate-5-phosphatase. We performed the molecular analysis in 9 Italian patients and 26 relatives and we detected the mutations in all the examined patients. Eight mutations out of nine had never been described and consisted of truncating mutations (frameshift, nonsense, splice site and genomic deletion), and missense mutations. The mutations were distributed in the second half of the gene as previously described in other populations. In three cases the mutations were absent in the mothers confirming the occurrence of novel mutations in this disorder. Our results on the Italian population are similar to the data previously obtained in other populations.     

Agenesis of the corpus callosum, infantile spasms, spastic quadriplegia, microcephaly and severe mental retardation in three siblings

A sibship consisting of three siblings, one male and two females with unrelated parents, showed a clinical syndrome including: infantile spasms with hypsarrhythmia, microcephaly, severe mental retardation and spastic quadriplegia. The pneumoencephalogram performed in two sibs showed agenesis of the corpus callosum and aqueductal stenosis with tri-ventricular dilatation. The disorder did not show a progressive course with deterioration of mental and neurologic functions. No biochemical or cytogenetic defect could be identified. Complement fixation for cytomegalovirus was negative. This syndrome complex is probably inherited as an autosomal recessive trait. The clinical and the genetic aspects of the syndrome are discussed.     

Video-thoracoscopic sympathectomy in the treatment of Raynaud's disease and palmar hyperhidrosis

BACKGROUND AND AIM: Raynaud's syndrome is a clinical entity characterised by episodic vascular spasm, digital ischemia in response to cold or emotional stimuli and hyperhidrosis. Many patients suffering from Raynaud's syndrome are successfully treated using medical therapy alone. Those patients who do not respond to medical treatment undergo surgery but the indications continue to be a source of controversy. A modern approach to thoracic sympathectomy requires a video-assisted technique. The aim of this study is to attempt to use mini-invasive type surgery to treat Raynaud's disease and hyperhidrosis in order to evaluate the real efficacy of thoracic sympathectomy in a large number of patients. The results of this method were compared for the two different pathologies in question. METHODS: The methodology used by this study is based on instrumental and clinical tests performed before and after surgery on treated patients using a comparative criterion and with a minimum 5-year follow-up. The pre- and postoperative diagnostic tests were performed by the vascular surgery laboratory and using a C.W. Doppler and a reflected light photoplethysmograph. Capillaroscopy and laboratory evaluations relating to secondary Raynaud's disease were carried out by internist type structures. The patients enrolled in the study responded to the following criteria: primary Raynaud's disease, palmar hyperhidrosis and associated syndromes. The population came from a mixed sociodemographic background, albeit within a strictly regional zone (Sardinia). A total of 42 patients were studied. The surgical technique used consisted of the ablation of thoracic ganglia from the 2nd to the 4th. RESULTS: The results showed a resolution of symptoms in 95% of patients treated for hyperhidrosis, whereas a 50% recidivation rate was observed in patients with Raynaud's disease alone, although symptoms were less intense. The results for Raynaud's disease were more disappointing, but it is important to remember that surgery is the ultimate choice for cases with advanced lesions which do not respond to medical treatment. Under these circumstances, the possibility of halting the evolution of the pathology represents an auspicious achievement. CONCLUSIONS: The authors affirm that mini-invasive surgical treatment of hyperhidrosis was resolutive during a mean follow-up of 3 years. It therefore represents a valid method which causes minimum esthetic damage to the patient and the greatest functional benefit. The postoperative period is short (about 3 days) and free of major complications. There is virtually no post-surgical pain.     

The Quality of Life of People with Solid Cancer is Less Worse than Other Diseases with better Prognosis,Except in the Presence of Depression

Background:Suffering from Solid Cancer (SC) may adversely impact the Health-related Quality of Life (H-QoL). The aims of this study are to measure the H-QoL in a sample of people suffering from SC and to clarify the role of the co-occurrence of depressive episodes. Results were compared with a healthy control group and with groups of other disorders.Methods:In 151 patients with SC (mean±sd age 63.1±11.5; female 54.3%), H-QoL was assessed by SF-12, depressive episodes were identified by PHQ-9. The attributable burden of SC in impairing H-QoL was calculated as the difference between SF-12 score of a community sex and age ¼ matched healthy control group and that of the study sample. The attributable burden of SC was compared with other chronic diseases using specific diagnostic groups drawn from case-control studies that used the same database for selecting control samples.Results:H-QoL in people with SC was significantly worse than in the healthy control group (p<0.0001). The attributable burden in worsening the H-QoL due to SC was similar to those of severe chronic diseases, but lower than Multiple Sclerosis (p<0.0001) or Fibromyalgia (p<0.00001). Having a depressive episode was a strong determinant of decreasing H-QoL, regardless of the severity of cancer.Conclusion:The findings confirm a strong impact of SC but showed that H-QoL in SC was higher than in chronic diseases with better “quoad vitam” outcome. Since depression was a strong determinant, its prevention, early detection and therapy are the main objectives that must be reached in cancer patients.