Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.     

Chronic autoimmune thyroiditis and rheumatic manifestations

A variety of rheumatic manifestations have been described in association with autoimmune thyroiditis. In the past, most of these manifestations were attributed to the underlying thyroid dysfunction, in particular hypothyroidism. However, a responsibility of the mechanisms involved in the autoimmunity rather than a direct action of thyroid hormones seems supported by the evidences that some rheumatic manifestations may occur even in euthyroid patients, or that they are more frequent in hypothyroid patient with autoimmune thyroiditis than in those without this disease. Rheumatic manifestations could be sometimes attributable to the autoimmune rheumatic diseases frequently associated with autoimmune thyroiditis, such as Sj?gren's syndrome, rheumatoid arthritis, systemic lupus erythematosus, or scleroderma. Among the most important or frequent rheumatic manifestations there are a mild non-erosive variety of arthritis, polyarthralgia, myalgia, and sicca syndrome without a true Sj?gren's syndrome. Although the possible pathogenesis of these manifestations is not completely established, some hypotheses may be proposed, including a role of autoantibodies characteristics of autoimmune thyroiditis, a possible overlap between autoimmune thyroiditis and some autoimmune rheumatic diseases, and a systemic inflammatory reaction associated with thyroiditis.     

Traumatic subclavian arterial rupture: a case report and review of literature

ABSTRACT: Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-treatening haemorrages, pseudo-aneurysm formation and compression of brachial plexus. These clinical eveniences must be carefully worked out by accurate physical examination of the upper limb: skin color, temperature, sensation as well as radial pulse and hand motility represent the key points of physical examination in this setting. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury. Since the first reports of endovascular treatment for traumatic vascular injuries in the 90's, an increasing number of vascular lesions have been treated this way. We report a case of traumatic subclavian arterial rupture after blunt chest trauma due to a 4 meters fall, treated by endovascular stent grafting, providing a complete review of the past twenty years' literature.     

Effect of Rest Interval Length on the Volume Completed During Upper Body Resistance Exercise

The purpose of the current study was to compare the workout volume (sets x resistance x repetitions per set) completed during two upper body resistance exercise sessions that incorporated 1 minute versus 3 minute rest intervals between sets and exercises. Twelve trained men completed two experimental sessions that consisted of 5 upper body exercises (i.e. barbell bench press, incline barbell bench press, pec deck flye, barbell lying triceps extension, triceps pushdown) performed for three sets with an 8-RM load. The two experimental sessions differed only in the length of the rest interval between sets and exercises; one session with a 1-minute and the other session with a 3-minute rest interval. The results demonstrated that for each exercise, significantly greater workout volume was completed when resting 3 minutes between sets and exercises (p < 0.05). These results indicate that during a resistance exercise session, if sufficient time is available, resting 3 minutes between sets and exercises allows greater workout volume for the upper body exercises examined.

Key points

• The length of the rest interval between sets is an important variable when designing a resistance exercise program and may vary depending on the characteristic being emphasized (i.e. maximal strength, hypertrophy, localized muscular endurance, power).
• Although acknowledged, this variable is rarely monitored precisely in field settings.
• Previous studies that examined rest interval lengths from 1 to 5 minutes between sets for single exercises demonstrated significant differences in repetition performance and the exercise volume completed.
• There is a need for further research to compare the workout volume (sets x resistance x repetitions per set) completed over an entire resistance exercise session with different rest intervals between sets.
• The results of the current study indicate that during a resistance exercise session, if sufficient time is available, resting 3 minutes between sets and exercises allows greater workout volume for the upper body exercises examined.

Key words: Recovery, fatigue, strength, muscle endurance, weight training, strength training     

Prediction of improvement in global left ventricular function in patients with chronic coronary artery disease and impaired left ventricular function: rest thallium-201 SPET versus low-dose dobutamine echocardiography

Accurate assessment of myocardial viability permits selection of patients who would benefit from myocardial revascularization. Currently, rest-redistribution thallium-201 scintigraphy and low-dose dobutamine echocardiography are among the most used techniques for the identification of viable myocardium. Thirty-one consecutive patients (all men, mean age 60NJ years) with chronic coronary artery disease and reduced left ventricular ejection fraction (31%lj%) were studied. Rest ²⁰¹Tl single-photon emission tomography (SPET), low-dose dobutamine echocardiography and radionuclide angiography were performed before revascularization. Radionuclide angiography and echocardiography were repeated after revascularization. An a/dyskinetic segment was considered viable on ²⁰¹Tl SPET when tracer uptake was >65%, while improvement on low-dose dobutamine echocardiography was considered a marker of viability. Increase in global ejection fraction was considered significant at ̓%. In identifying viable segments, rest ²⁰¹Tl SPET showed higher sensitivity than low-dose dobutamine echocardiography (72% vs 53%, P<0.05), while specificity was not significantly different (86% vs 88%). In 17 patients, global ejection fraction increased ̓% (group 1) while in 14 it did not (group 2). A higher number of a/dyskinetic segments were viable on ²⁰¹Tl SPET in group 1 than in group 2 (2.6ǃ.9 vs 0.6ǃ.2, P<0.005), while no significant differences were observed on low-dose dobutamine echocardiography (1.7ǃ.6 vs 1.1ǃ.6). A significant correlation was found between the number of a/dyskinetic segments viable on ²⁰¹Tl SPET and post-revascularization changes in ejection fraction (r=0.52, P<0.05), but such a correlation was not observed for low-dose dobutamine echocardiography. Using as the cut-off the presence of at least one viable a/dyskinetic segment, rest ²⁰¹Tl SPET had a higher sensitivity (82% vs 53%, P=0.07) and showed a trend towards higher accuracy and specificity (77% vs 58%, and 71% vs 64%, respectively) as compared with low-dose dobutamine echocardiography. In conclusion, these findings suggest that when severely reduced global function is present, rest ²⁰¹Tl SPET evaluation of viability is more accurate than low-dose dobutamine echocardiography for the identification of patients who will benefit most from revascularization.     

Experimental animal model and RNA interference: a promising association for bladder cancer research

Animal models are at the centre of laboratory bladder cancer (BC) research and at the same time, the bridge to the clinic. A new and very promising therapeutical approach is to silence abnormally up-regulated genes in cancer, through small interfering RNA (siRNA) molecules. Therapeutic use and success of siRNAs will largely depend on their efficient and safe in vivo delivery and on avoiding accidental off-target effects. Intravesical siRNA is a strategy which may be the best deliver option to surperficial BC like intravesical immunotherapy. Its direct action might allow a continuous intracellular exposure to effective siRNA concentrations. While the procedure of transurethral siRNA administration is promising for BC research allowing detection of new targets in BC therapy, the optimal intravesical carrier and the best target(s) to siRNA are to be determined.     

Impact of 18F-fluoride PET-CT on implementing early treatment of painful bone metastases with Sm-153 EDTMP

This study evaluated the diagnostic impact of using skeletal ¹⁸F-fluoride PET/CT on patients with painful bone metastases to schedule an early palliative radionuclide treatment. Methods: The skeletal involvement from prostate cancer metastases was assessed by both ^99mTc-diphosphonate bone scan (BS) and ¹⁸F-fluoride PET/CT within four weeks in 24 patients (67.7 ± 5.1 years) suffering from a borderline degree of bone pain for which radionuclide palliation was not shortly planned for administration. The BS and ¹⁸F-fluoride PET/CT results were compared, assessing the number and extension of the skeletal sites involved. Afterward, the patients were randomly assigned either to the study group (N = 12) receiving radionuclide therapy (Samarium-153 EDTMP) or to the control group (N = 12) not receiving radionuclide therapy. The short-term results from the radionuclide palliation group (evaluated with a visual analogue scale) were compared with the controls. Results: Overall, at BS, 7.6 ± 1.4 sites were considered metastatic, involving at least 5 ± 1 body regions. At ¹⁸F-fluoride PET/CT, 116 ± 19 sites presented metastatic involvement with 12/12 body regions concerned. No differences were found in regards to either the number of metastatic sites or regions at both BS and ¹⁸F-fluoride PET/CT between the study group and controls (p = ns). At CT, 88 blastic metastases were identified, whereas 110 were mainly lytic. Most of mainly lytic lesions were not detectable at BS. The reduction in total discomfort and bone pain in the study group was significantly greater than in the controls (p < 0.0001). Conclusion: Sm-153 EDTMP therapy should be considered for patients with early bone pain from prostate cancer even if their BS only indicates a few metastases before the initiation of a severe pain syndrome. ¹⁸F-fluoride PET/CT may be helpful in deciding if the implementation of bone pain palliation using bone-seeking radionuclides at pain onset is necessary.     

Adenosine coronary vasodilation quantitative technetium 99m methoxy isobutyl isonitrile myocardial tomography in the identification and localization of coronary artery disease

Background

Exercise and dipyridamole ^99mTc-labeled methoxy isobutyl isonitrile (MIBI) myocardial scintigraphy have been widely used for the diagnosis of coronary artery disease (CAD). However, only limited data on adenosine ^99mTc-labeled MIBI cardiac imaging are currently available. This study was designed to assess the accuracy of quantitative adenosinerest ^99mTc-labeled MIBI tomography in the diagnosis and localization of CAD.

Methods and Results

Fifty-seven consecutive patients with suspected CAD who underwent coronary angiography and 22 normal volunteers were studied. All patients underwent ^99mTc-labeled MIBI tomography after administration of adenosine (140 μg/kg intravenously for 6 minutes) and at rest. A total of 171 vascular coronary territories were analyzed quantitatively. All patients with CAD (≥50% luminal stenosis) (n=55) had abnormal ^99mTc-labeled MIBI tomograms. The normalcy rate was 86% by quantitative analysis. Overall sensitivity, specificity, and diagnostic accuracy for detection of individual stenosed vessels were 84%, 87%, and 85%, respectively. In patients with one-vessel CAD (n=24), sensitivity and diagnostic accuracy in the detection of individual stenosed vessels were significantly (p<0.05) higher compared with patients with multivessel CAD (n=31). Moreover, 75% of patients with one-vessel disease showed a scintigraphic pattern characterized by the presence of perfusion defects in only one coronary artery territory, and 74% of patients with multivessel disease showed a scintigraphic pattern characterized by the presence of perfusion defects in two or more coronary artery territories. Sensitivity, specificity, and diagnostic accuracy for detecting individual diseased vessels were similar in patients without previous myocardial infarction (n=18) compared with those with previous myocardial infarction (n=39). In myocardial territories related to noninfarcted areas (n=124), sensitivity and specificity in the detection of stenosed vessels were 75% and 88%. In infarcted areas (n=47), sensitivity and specificity in the detection of stenosed vessels were 98% and 80% (differences not significant vs noninfarcted areas).

Conclusions

Adenosine-controlled coronary vasodilation combined with quantitative ^99mTc-labeled MIBI tomography is accurate for identifying patients with CAD and localizing individual stenosed coronary arteries.