Fully covered,self-expandable metal stents for first-step endoscopic treatment of biliary leaks secondary to hepato-biliary surgery: A retrospective study

BackgroundFully covered self-expanding metal stents are now being used to treat benign biliary diseases.AimsTo assess the outcomes of these stents as first-step therapy in patients with biliary leaks secondary to hepato-biliary surgery.MethodsThirty patients (56.7% males; mean age: 60.2 ± 13 years) were retrospectively evaluated. The data collected included technical and clinical success, adverse events and follow-up findings (1, 3 and 6 months).ResultsTechnical and clinical success rates were 100%. One early mild post-procedure pancreatitis occurred and resolved spontaneously. Three late stent distal migrations occurred, however cholangiography showed correct leak sealing in all patients. Stents were removed after a mean of 55.9 days. During follow-up no other complications occurred.ConclusionIn our experience fully covered self-expanding metal stent placement was safe and efficacious as first-step therapy for post-operative biliary leaks. However, prospective comparative studies with plastic stents are required to validate these findings.     

Dietary intake and physical performance in healthy elderly women: A 3-year follow-up

Background

Aging is generally accompanied by changes in body composition, muscle mass and strength, leading to a decline in motor and functional performance. Physical activity and eating habits could be involved in modulating this paraphysiological deterioration. Aim of our study was to investigate changes in body composition, diet and physical performance in healthy, elderly females over a 3-year follow-up.

Methods

92 healthy elderly females (70.9 ± 4.0 years) attending a twice-weekly mild fitness program were eligible for the study. They were assessed at baseline and again after 3 years in terms of clinical history, diet, body composition by DEXA, resting energy expenditure, handgrip strength, knee extensor isometric/isotonic strength, and functional performance measured using the Short Physical Performance Battery (SPPB).

Results

After 3 years, women had a significant decline in muscle strength (? isotonic: − 1.4 ± 4.3 kg, ? isokinetic: − 2.0 ± 6.3 kg, ? handgrip: − 3.2 ± 5.0 kg; p < 0.001) and physical performance (? walking time: 0.71 ± 0.9 s, ? walking speed: − 0.25 ± 0.35 m/s; p < 0.001), while their weight and body composition parameters did not change, except for a small decrease in appendicular skeletal muscle mass (− 0.4 ± 1.4 kg). There was a significant drop in calorie (?:− 345.7 ± 533.1 kcal/d; p < 0.001) and protein intake (?:− 0.14 ± 0.23 g/d; p < 0.001), while resting energy expenditure remained stable. ? calorie intake correlated with the variation in 4-meter walking time (r: 0.34; p < 0.01).

Conclusions

With advancing age, physical performance declines even in healthy, fit females despite a spare of weight and body composition. This decline in physical activity could lead to a lower calorie intake, which would explain why there is no variation in body weight.     

MRI Tracking of Macrophages Labeled with Glucan Particles Entrapping a Water Insoluble Paramagnetic Gd-Based Agent

Purpose

This study is aimed at demonstrating the in vivo potential of Gd(III)-loaded glucan particles (Gd-GPs) as magnetic resonance imaging (MRI)-positive agents for labeling and tracking phagocytic cells.

Procedure

GPs were obtained from Saccharomyces cerevisae and loaded with the water-insoluble complex Gd-DOTAMA(C₁₈)₂. The uptake kinetics of Gd-GPs by murine macrophages was studied in vitro and the internalization mechanism was assessed by competition assays. The in vivo performance of Gd-GPs was tested at 7.05 T on a mouse model of acute liver inflammation.

Results

The minimum number of Gd-GPs-labeled J774.A1 macrophages detected in vitro by MRI was ca. 300 cells/μl of agar, which is the lowest number ever reported for cells labeled with a positive T₁ agent. Intravenous injection of macrophages labeled with Gd-GPs in a mouse model of liver inflammation enabled the MRI visualization of the cellular infiltration in the diseased area.

Conclusions

Gd-GPs represent a promising platform for tracking macrophages by MRI as a T₁ alternative to the golden standard T₂-based iron oxide particles.     

Cholesterol Metabolism After Bariatric Surgery in Grade 3 Obesity: Differences between malabsorptive and restrictive procedures

OBJECTIVE

Malabsorptive bariatric surgery (biliopancreatic diversion and biliointestinal bypass [BIBP]) reduces serum cholesterol levels more than restrictive surgery (adjustable gastric banding [AGB]), and this is thought to be due to greater weight loss. Our aim was to evaluate the changes of cholesterol metabolism induced by malabsorptive and restrictive surgery independent of weight loss.

RESEARCH DESIGN AND METHODS

In a nonrandomized, self-selected, unblinded, active-comparator, bicenter, 6-month study, glucose metabolism (blood glucose and serum insulin levels and homeostasis model assessment of insulin resistance [HOMA-IR] index) and cholesterol metabolism (absorption: serum campesterol and sitosterol levels; synthesis: serum lathosterol levels; catabolism: rate of appearance and serum concentrations of serum 7-α- and serum 27-OH-cholesterol after infusions of deuterated 7-α- and 27-OH-cholesterol in sequence) were assessed in grade 3 obesity subjects undergoing BIBP (n = 10) and AGB (n = 10). Evaluations were performed before and 6 months after surgery.

RESULTS

Subjects had similar values at baseline. Weight loss was similar in the two groups of subjects, and blood glucose, insulin levels, HOMA-IR, and triglycerides decreased in a similar way. In contrast, serum cholesterol, LDL cholesterol, non-HDL cholesterol, serum sitosterol, and campesterol levels decreased and lathosterol levels increased only in BIBP subjects, not in AGB subjects. A significant increase in 7-α-OH-cholesterol occurred only with BIBP; serum 27-OH-cholesterol decreased in both groups.

CONCLUSIONS

Malabsorptive surgery specifically affects cholesterol levels, independent of weight loss and independent of glucose metabolism and insulin resistance. Decreased sterol absorption leads to decreased cholesterol and LDL cholesterol levels, accompanied by enhanced cholesterol synthesis and enhanced cholesterol catabolism. Compared with AGB, BIBP provides greater cholesterol lowering.The epidemic of obesity has led to a dramatic increase of the number of bariatric procedures performed worldwide (1). Bariatric procedures are commonly divided into restrictive (adjustable gastric banding [AGB], vertical-banded gastroplasty, and sleeve gastrectomy), malabsorptive (biliopancreatic diversion [BPD] and biliointestinal bypass [BIBP]), and mixed procedures (gastric bypass and Roux-en-Y gastric bypass [RYGB]) (1–3). Malabsorptive procedures are associated with a far greater weight loss than restrictive procedures and with quicker metabolic changes, namely drop of blood glucose levels (2).Malabsorptive surgery also reduces serum cholesterol levels; in fact, it was originally intended for the treatment of hyperlipidemias and was highly effective even in patients without morbid obesity (the Program on Surgical Control of Hyperlipidemias study) (4). Malabsorptive surgery is more effective than restrictive surgery in reducing cholesterol levels (5), and our group has shown that by 1 year after surgery, both BPD and BIBP reduce cholesterol levels more than AGB, and this effect is associated with greater weight loss (6,7). In addition, the cholesterol decrease correlates with loss of fat mass (7). Therefore, the main factor considered responsible for decreased cholesterol levels is weight loss.However, up to 6 months, weight loss is similar with BIBP and AGB (7), and this led us to hypothesize that it was possible to study cholesterol absorption, as well as other aspects of cholesterol metabolism, independently of weight loss.Therefore, we planned a study on the intestinal absorption of sterols, cholesterol synthesis, and cholesterol catabolism via synthesis of biliary acids in obese subjects before and 6 months after BIBP or AGB.     

HbA1c Variability as an Independent Correlate of Nephropathy,but Not Retinopathy,in Patients With Type 2 Diabetes: The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study

OBJECTIVE

To examine the association of hemoglobin (Hb) A_1c variability with microvascular complications in the large cohort of subjects with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study.

RESEARCH DESIGN AND METHODS

Serial (3–5) HbA_1c values collected in a 2-year period before enrollment were available from 8,260 subjects from 9 centers (of 15,773 patients from 19 centers). HbA_1c variability was measured as the intraindividual SD of 4.52 ± 0.76 values. Diabetic retinopathy (DR) was assessed by dilated funduscopy. Chronic kidney disease (CKD) was defined based on albuminuria, as measured by immunonephelometry or immunoturbidimetry, and estimated glomerular filtration rate (eGFR) was calculated from serum creatinine.

RESULTS

Median and interquartile range of average HbA_1c (HbA_1c-MEAN) and HbA_1c-SD were 7.57% (6.86–8.38) and 0.46% (0.29–0.74), respectively. The highest prevalence of microalbuminuria, macroalbuminuria, reduced eGFR, albuminuric CKD phenotypes, and advanced DR was observed when both HbA_1c parameters were above the median and the lowest when both were below the median. Logistic regression analyses showed that HbA_1c-SD adds to HbA_1c-MEAN as an independent correlate of microalbuminuria and stages 1–2 CKD and is an independent predictor of macroalbuminuria, reduced eGFR, and stages 3–5 albuminuric CKD, whereas HbA_1c-MEAN is not. The opposite was found for DR, whereas neither HbA_1c-MEAN nor HbA_1c-SD affected nonalbuminuric CKD.

CONCLUSIONS

In patients with type 2 diabetes, HbA_1c variability affects (albuminuric) CKD more than average HbA_1c, whereas only the latter parameter affects DR, thus suggesting a variable effect of these measures on microvascular complications.Compelling evidence shows that long-term glycemic control, as expressed by hemoglobin (Hb) A_1c levels, is the main risk factor for the development of microvascular complications in type 1 (1) and type 2 diabetes (2), with risk rising exponentially as HbA_1c increases. Another risk factor related to hyperglycemia is variability of glycemic control that comprises “glucose variability” and “HbA_1c variability.” Glucose variability relates to within-day fluctuations of glycemia, especially as a consequence of meals (3), and may eventually reflect in increased HbA_1c levels. Conversely, HbA_1c variability relates to changes in glycemia over longer periods of time that result in change in HbA_1c from one visit to the next (4).Retrospective analyses of data from the Diabetes Control and Complications Trial (DCCT) have not confirmed that within-day glucose variability predicts the development of microvascular complications (5–7), although this was not a prespecified end point of the study. However, a prospective study specifically addressing this issue did not show any effect of within-day glucose fluctuations on cardiovascular events (8). Conversely, retrospective analyses of the DCCT (9) and the Finnish Diabetic Nephropathy (FinnDiane) Study (10) have suggested that HbA_1c variability is an independent risk factor for the development of diabetic retinopathy (DR) and nephropathy (DN) in individuals with type 1 diabetes. Moreover, HbA_1c variability was shown to be an independent variable that added to the effect of HbA_1c on the risk of microalbuminuria in adolescent patients with type 1 diabetes from the Oxford Regional Prospective Study and the Nephropathy Family Study (11). Very recently, two prospective cohort studies from Japan and Taiwan, the Tsukuba Kawai Diabetes Registry 2 (12) and the Diabetes Management through an Integrated Delivery System project (13), have shown that HbA_1c variability is associated with microalbuminuria, even after adjustment for known predictors of albuminuria, in 812 and 821 patients with type 2 diabetes, over a 4.3-year and a 6.2-year follow-up, respectively.To further address this issue, we used the large cohort of Caucasian subjects with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study to assess whether the baseline status of DN and DR was independently associated with HbA_1c variability as assessed retrospectively from HbA_1c values obtained during the 2-year period preceding the enrollment. This study assessed DN by albuminuria and the estimated glomerular filtration rate (eGFR), and patients were stratified by chronic kidney disease (CKD) stage or phenotype.     

Human Health Risk Assessment Related to Cyanotoxins Exposure

This review focuses on the risk assessment associated with human exposure to cyanotoxins, secondary metabolites of an ubiquitous group of photosynthetic procariota. Cyanobacteria occurr especially in eutrophic inland and coastal surface waters, where under favorable conditions they attain high densities and may form blooms and scums. Cyanotoxins can be grouped according to their biological effects into hepatotoxins, neurotoxins, cytotoxins, and toxins with irritating potential, also acting on the gastrointestinal system. The chemical and toxicological properties of the main cyanotoxins, relevant for the evaluation of possible risks for human health, are presented. Humans may be exposed to cyanotoxins via several routes, with the oral one being by far the most important, occurring by ingesting contaminated drinking water, food, some dietary supplements, or water during recreational activities. Acute and short-term toxic effects have been associated in humans with exposure to high levels of cyanotoxins in drinking and bathing waters. However, the chronic exposure to low cyanotoxin levels remains a critical issue. This article identifies the actual risky exposure scenarios, provides toxicologically derived reference values, and discusses open issues and research needs.     

Carotid eversion endarterectomy: perioperative outcome and restenosis incidence

Carotid endarterectomy (CEA) for stroke prevention can be performed with minimal perioperative mortality and morbidity rates. The type of surgical technique used is important to achieve optimal outcome from CEA. The purpose of this study was to analyze the perioperative and late results of carotid eversion endarterectomy (CEE) in more than 400 procedures. From August 1992 to December 1999, 402 primary CEEs were performed in 388 selected patients for symptomatic (235/58.4%) and asymptomatic (167/41.6%) carotid lesions. During the same period, 234 primary CEAs with patch closure were performed in 229 selected patients. All CEAs were carried out with continuous electroencephalographic monitoring for selective shunting, using deep general anesthesia. All patients underwent postoperative duplex ultrasound study and clinical follow-up at 1, 6, and 12 months and every year thereafter. The mean follow-up was 50 months (range 3-88). Main end points were perioperative stroke and death, and restenosis. Our results showed that use of the CEE procedure can reduce perioperative mortality and stroke risk rates to around zero and results in no restenosis.