Early and long-term clinical outcomes of bilio-intestinal diversion in morbidly obese patients

Purpose

To evaluate the early and long-term postoperative results of malabsorptive surgery in morbidly obese patients.

Methods

Between 2000 and 2007, 102 morbidly obese patients were referred to the Department of Surgery “Pietro Valdoni”, “Sapienza” University of Rome, Policlinico “Umberto I°”, Rome, Italy for malabsorptive surgery. All patients underwent derivative biliodigestive surgery after they had been reviewed by a team of surgeons, physicians, dieticians, and psychologists.

Results

There were no intra-operative complications, but two patients suffered postoperative pulmonary embolisms, which resolved with medical treatment. The mean postoperative hospital stay was 7 days, with no early or late mortality. Maximum weight loss was reached 12–24 months after surgery, while the mean percentage excess weight loss at 3–5 years ranged from 45 to 64 %. Specific postoperative complications in the first 2 years after surgery were abdominal abscess (n = 2), gastroduodenal reflux (n = 4), and incisional hernia (n = 6). Diabetes resolved in 98 % of the diabetic patients within a few weeks after surgery and blood pressure normalised in 86.4 % of those who had had hypertension preoperatively. Obstructive sleep apnoea and obesity hypoventilation syndrome also improved significantly in 92 % of the patients.

Conclusions

Morbidly obese patients can undergo biliodigestive surgery safely with good long-term weight loss and quality of life expectancy.     

Characterization and clinical impact of antinuclear antibodies in primary biliary cirrhosis

OBJECTIVES: The clinical impact of antinuclear antibodies in primary biliary cirrhosis is uncertain. We analyzed in detail the antinuclear antibodies reactivity of primary biliary cirrhosis patients and correlated the fine specificities observed with clinical, biochemical, and immunologic parameters. METHODS: A total of 96 consecutive primary biliary cirrhosis patients and 283 pathologic controls were studied. To dissect the fine antinuclear antibodies specificities we used different techniques, such as indirect immunofluorescence on cryostat tissue sections and cell culture (HEp-2 cells), counterimmunoelectrophoresis with thymus and spleen extracts, ELISA assays with recombinant Sp100 and purified gp210 and Lamin B receptor, and immunoblot with several recombinant nuclear and cytoplasmic antigens. RESULTS: Antinuclear antibodies were detected in 53% of patients, with the following hierarchy of specificities: 27% anti-Sp100, 16% "multiple nuclear dots," 16% anti-gp210, 16% anti-centromere, 7% XR1, 6% anti-lamin B receptor, 5% anti-SS-A/Ro, 5% anti-ribonucleoprotein, 4% XR2, 2% anti-SS-B/La, 2% perinuclear antineutrophil cytoplasmic antibodies, and 1% anti-double-stranded deoxyribonucleic acid. Several patients showed multiple specificities. The "multiple nuclear dots" pattern was detected more often in antimitochondrial antibodies negative patients. In particular, primary biliary cirrhosis specific antinuclear antibodies (anti-Sp100, anti-gp210, and anti-lamin B receptor) were detected in nine of 13 antimitochondrial negative primary biliary cirrhosis cases. Anti-gp210 was more frequent in patients with more pronounced cholestasis and more impaired liver function. CONCLUSIONS: Antinuclear antibodies reactivities are present in more than half of primary biliary cirrhosis patients and target diverse autoantigens located in distinct subnuclear structures. Anti-gp210 identifies a subgroup of primary biliary cirrhosis patients with more serious liver disease. Positivity for anti-Sp100, anti-gp210, and anti-lamin B receptor, either alone or in combination, may act as a serologic marker of antimitochondrial antibodies negative primary biliary cirrhosis.     

Primary afferent plasticity following deafferentation of the trigeminal brainstem nuclei in the adult rat

Alpha-tyrosinated tubulin is a cytoskeletal protein that is involved in axonal growth and is considered a marker of neuronal plasticity in adult mammals. In adult rats, unilateral ablation of the left facial sensorimotor cortical areas induces degeneration of corticotrigeminal projections and marked denervation of the contralateral sensory trigeminal nuclei. Western blotting and real-time-PCR of homogenates of the contralateral trigeminal ganglion (TG) revealed consistent overexpression of growth proteins 15 days after left decortication in comparison with the ipsilateral side. Immunohistochemical analyses indicated marked overexpression of α-tyrosinated tubulin in the cells of the ganglion on the right side. Cytoskeletal changes were primarily observed in the small ganglionic neurons. Application of HRP-CT, WGA-HRP, and HRP to infraorbital nerves on both sides 15 days after left decortication showed a significant degree of terminal sprouting and neosynaptogenesis from right primary afferents at the level of the right caudalis and interpolaris trigeminal subnuclei. These observations suggest that the adaptive response of TG neurons to central deafferentation, leading to overcrowding and rearrangement of the trigeminal primary afferent terminals on V spinal subnuclei neurons, could represent the anatomical basis for distortion of facial modalities, perceived as allodynia and hyperalgesia, despite nerve integrity.     

The combination cytology/epichek test in non muscle invasive bladder carcinoma follow-up: Effective tool or useless expence?

ObjectiveTo identify in which cases after cytological diagnosis, the Bladder EpiCheck test could represent an effective tool in non-muscle invasive bladder carcinoma or an useless expence.Materials and methods375 patients diagnosed with non-muscle invasive bladder cancer, 269 with high grade urothelial carcinoma and 106 with carcinoma in situ, were treated and followed for 1 year. The treatment was an intravesical instillation of Bacillus Calmette-Guerin in 305 patients and Mitomycin-C in 70 patients.During the follow-up patients were evaluated by voided urine cytology and white-light cystoscopy, according to the European Association of Urology Guidelines. Bladder EpiCheck test was performed together with cytology in all cases.ResultsAnalyzing Bladder Epicheck results for each category defined by the Paris System for Reporting Urinary Cytology, we found that the Episcore >60 correlates with histological diagnosis of high grade urothelial carcinoma (HGUC) in atypical urothelial cells and Suspicious for High Grade Urothelial Carcinoma (P = 0.0002 Odds Ratio 0.05926 95% Confidence Interval from 0.01127 to 0.3116 and P = 0.0009 Odds Ratio 0.0315595% Confidence Interval from 0.001683 to 0.5914, Fisher's exact test, respectively), while in Negative for high grade urothelial carcinoma and HGUC patients Episcore is not helpful to identify cases with histological diagnosis of HGUC (P = 0.101 and P = 0.58 Fisher's exact test, respectively). Considering an Episcore ≥ 90 in the HGUC cytological group, this seems not to be correlated with a histological diagnosis of HGUC (P = 0.090 Fisher's exact test).ConclusionsCytology and Bladder EpiCheck test in combination may have the potential to reduce cystoscopies in the follow-up of non-muscle invasive bladder cancer only for cytological diagnoses of atypical urothelial cells and Suspicious for High Grade Urothelial Carcinoma . Moreover, in patients with a cytological diagnosis of Negative for high grade urothelial carcinoma or HGUC, cytology alone seems to be safe and cost-effective.     

The effectiveness of computerized clinical guidelines in the process of care: a systematic review

Background  

Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.     

Oronasal masks require higher levels of positive airway pressure than nasal masks to treat obstructive sleep apnea

Purpose

The purpose of this study was to compare the therapeutic pressure determined by an automated CPAP device (AutoCPAP) during the titration period, between nasal and oronasal mask and the residual apnea-hypopnea index (AHI) on a subsequent poligraphy performed with the established therapeutic CPAP.

Methods

As a retrospective study, 109 subjects with moderate and severe obstructive sleep apnea-hypopnea (apnea-hypopnea index?≥?15 events/h) were studied. CPAP titration was performed using an auto-titrating device.

Results

There was significant difference in the mean pressure delivered with autoCPAP between the group of patients using the nasal mask (mean 10.0 cmH₂O?±?2.0 SD) and the group which used the oronasal mask (mean 11.2 cmH₂O?±?2.1) (p?p?r?=?0.245, p 0.008).

Conclusions

Therapeutic CPAP level for OSAH is higher when administered via oronasal mask, leaving more residual events. These findings suggest that nasal mask should be the first choice for OSAH treatment.     

Sodium hypochlorite penetration into dentinal tubules after manual dynamic agitation and ultrasonic activation: a histochemical evaluation

The aim of this study was to compare the effects of Manual Dynamic Agitation and Passive Ultrasonic Irrigation on sodium hypochlorite (NaOCl) penetration into dentinal tubules using its bleaching ability. Thirty-four single-rooted teeth with round-shaped root canals were distributed in two homogeneous groups and one control group, characterized by different NaOCl activation systems: Manual Dynamic Agitation and Passive Ultrasonic Irrigation. After instrumentation, all root canals were stained with 10% copper sulphate solution followed by 1% rubeanic acid alcohol solution under vacuum. Final irrigation was performed with 5 mL of 5.25% NaOCl solution for 1 min and activated with Manual Dynamic Agitation or Passive Ultrasonic Irrigation for another 1 min depending on the treatment group. The teeth were transversely sectioned at the middle portion of the apical, middle, and coronal thirds and observed under light microscope. NaOCl solution penetration was evaluated by measuring the percentage of bleached circumference of the root canal relative to the stained circumference, bleached areas, mean, and maximum penetration depth. No differences in the evaluated parameters were observed between groups (p?>?0.05). Within groups, an increase of values was recorded from apical to coronal direction as for percentage of staining, percentage of bleaching and bleached area. NaOCl penetration into dentinal tubules did not significantly vary among the three levels. No significant differences in penetration of sodium hypochlorite into dentinal tubules when activated by means of Manual Dynamic Agitation or Passive Ultrasonic Irrigation were observed in the apical, middle, and coronal thirds of teeth with single straight round root canals.     

Toll-like receptor and antiphospholipid mediated thrombosis: in vivo studies

OBJECTIVE: A study was undertaken to investigate the in vivo pathogenic role of Toll-like receptor 4 (TLR-4) in the antiphospholipid syndrome (APS) by studying the thrombogenic antiphospholipid (aPL) activity in lipopolysaccharide (LPS) non-responsive (LPS-/-) mice and the association between tlr4 gene polymorphisms and APS in patients. METHODS: IgGs from two patients with APS, one with aPL negative systemic lupus erythematosus (SLE) and one with normal human serum (NHS), were evaluated for thrombosis, tissue factor (TF) activity and endothelial cell activation in LPS-/- mice displaying a tlr4 spontaneous mutation vs LPS responsive (LPS+/+) mice. Human tlr4 Asp299Gly and Thr399Ile polymorphisms were evaluated by allele-specific PCR in 110 patients with APS with arterial/venous thrombosis and in 220 controls of the same ethnic origin. RESULTS: IgG-APS produced significantly larger thrombi and more leucocytes (WBC) adhering to endothelial cells in the cremaster muscle microcirculation of LPS+/+ mice than IgG-NHS or aPL negative SLE-IgG. These effects were abrogated after absorption of the anti-beta(2)glycoprotein I activity by an affinity column. The two IgG-APS induced significantly smaller thrombi and fewer WBC adhering to endothelial cells in LPS-/- mice than in LPS+/+ mice. IgG-APS induced higher TF activity in carotid artery homogenates of LPS+/+ mice than in LPS-/- mice. The prevalence of Asp299Gly and Thr399Ile tlr4 polymorphisms was significantly lower than in controls. CONCLUSIONS: These findings in LPS-/- mice and the reduction in the "protective" polymorphism in patients with APS with thrombosis suggest that TLR-4 is involved in the interaction of aPL with endothelial cells in vivo.