I fattori intestinali della secrezione insulinica con particolare riguardo al ruolo del glucagone

Riassunto Vengono passate in rassegna le prove sperimentali addotte a sostegno di un controllo della secrezione insulinica da parte degli ormoni intestinali, secretina, gastrina, pancreozimina e del glucagone. Una risposta insulino-secretrice viene evocata con la somministrazione di gastrina, secretina e pancreozimina esogene. Non ancora sufficientemente dimostrato è invece il ruolo della secrezione endogena dei tre fattori intestinali, durante l'ingestione dei cibi, nella regolazione della secrezione insulinica. Più ampia è la documentazione raccolta intorno alle proprietà insulino-stimolanti del glucagone. L'intervento di questo ormone nel controllo della liberazione insulinica dalle cellule sembra accertato con sufficiente fondatezza. E' invece ancora oggetto di indagine la possibile esistenza di forme diverse del glucagone, e, in particolare, di un glucagone enterico.

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Summary The experimental evidence suggesting the existence of a control of insulin secretion by gut hormones, gastrin, secretin, pancreozymin and by glucagon, is reviewed. An insulin-secretory response is evoked by the administration of exogenous gastrin, secretin and pancreozymin. On the contrary, the role of endogenous secretion of the three intestinal factors, during food ingestion, in the regulation of insulin secretion, is not yet sufficiently demonstrated. Evidence obtained on insulin-stimulating properties of glucagon is based on wider grounds. The intervention of this hormone in the control of insulin release from -cells seems to be demonstrated with sufficient certainty. The possible existence of different forms of glucagon, and particularly of enteric glucagon is still under study.

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Zusammenfassung Es werden die experimentellen Untersuchungen zu Gunsten einer Kontrolle der Insulinsekretion durch die Darmhormone Sekretin, Gastrin, Pankreozymin und Glukagon in Betracht gezogen. Eine insulinsezernierende Antwort wird durch die Verabreichung von exogenem Gastrin, Sekretin und Pankreozymin ausgelöst. Noch nicht genuegend bewiesen hingegen ist die Rolle der endogenen Sekretion der drei Darmfaktoren, während der Nahrungsmittelaufnahme, bei der Regulierung der Insulinsekretion. Zahlreicher ist die Dokumentation über die insulinstimulierenden Eigenschaften des Glukagons. Der Eingriff dieses Hormons in die Kontrolle der Insulinfreisetzung der -Zellen scheint genügendermassen festgelegt. Das mögliche Bestehen von vom Glukagon abweichenden Formen und insbesondere das Dasein eines enterischen Glukagons werden hingegen noch untersucht.

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Resumen Se reseñan las pruebas experimentales practicadas para comprobar el control de la secreción de insulina ejercido por las hormonas intestinales, secretina, gastrina, pancreozimina y glucagón. Se obtiene una respuesta insulino-secretora luego de administración de gastrina, secretina y pancreozimina exógenas. En cambio, todavia non ha sido demostrado suficientemente el papel de la secreción endógena de los tres factores intestinales, durante la ingestión de alimentos, en la regulación de la secreción insulínica. Más amplia es la documentación recogida sobre las propiedades insulino-estimulantes de glucagón. La participación de esta hormona en el control de la liberación de insulina de las células parece cierto con suficiente fundamento. En cambio, todavía está sujeta a investigaciones la existencia probable de formas distintas del glucagón, y, de manera particular, de un glucagón entérico.

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Resume Les épreuves expérimentales portées à soutien d'un contrôle de la sécrétion de l'insuline par les hormones intestinales, sécrétine, gastrine, pancréozymine et du glucagon sont passées ici en revue. L'administration de gastrine, sécrétine et pancréozymine exogènes déclenche une réaction déterminant une sécrétion d'insuline. Par contre le rôle de la sécrétion endogène des trois facteurs intestinaux dans la régulation de la sécrétion d'insuline au cours de l'ingestion des aliments n'est pas encore sufisamment démontré. La documentation réunie sur les propriétés du glucagon à stimuler l'insuline est plus étendue. L'intervention de cette hormone dans le contrôle de la libération de l'insuline à partir des cellules sembre prouvée avec un assez bon fondement. L'existence possible de formes différentes de glucagon, et en particulier d'un glucagon entérique, est au contraire encore objet de recherche.

     

Bacteriology of the anal wound after open hemorrhoidectomy

The purpose of this study is to analyze the size of the bacterial colonies in anal wounds after open hemorrhoidectomy. Twenty patients were studied during predetermined postoperative time periods. Material was collected from the surface and from within the tissue of each patient's three open wounds, intraoperatively, on the 6th, 13th and 20th postoperative days for bacteriologic examination in aerobic, microaerophilic, and anaerobic media. The bacterium most commonly identified was Escherichia coli,followed by Staphylococcus aureus and Staphylococcus epidermidis. Pseudomonas aeruginosa, Enterococcus faecalis, Klebsiella pneumoniae, Proteus vulgaris,and Proteus mirabilis were also identified. Critical indexes of colonization were present since the intraoperative stage (>10 ⁵ bacteria/g of tissue and >10 ⁶ bacteria/ml); obligate anaerobic bacteria were not identified; neither the species nor the number of bacteria, even when critical indexes were present, prevented proper healing. The same bacteria were not necessarily present on the surface and in the tissue; the bacterial load observed among the three wounds (left lateral, right posterior, and right anterior), was the same.Presented at the Postgraduate Course, Surgical Technique and Experimental Surgery, offered by the Escola Paulista de Medicina (Paulista Medical School) and the Department of Biomedical Sciences of the University of Taubaté, São Paulo, Brazil.     

The AIMAR recommendations for early diagnosis of chronic obstructive respiratory disease based on the WHO/GARD model*

Respiratory diseases in Italy already now represent an emergency (they are the 3^rd ranking cause of death in the world, and the 2^nd if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as: 1) actions of primary (universal) prevention targeted at the general population with the aim to control the causes of disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual’s risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document “Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)” of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document – produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise –after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,‘case-finding’approach; assessment of the individual’s level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the “systemic”, consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.     

NHETS ? Necropsy Heart Transplantation Study

Background

Discrepancies between pre and post-mortem diagnoses are reported in the literature, ranging from 4.1 to 49.8 % in cases referred for necropsy, with important impact on patient treatment.

Objective

To analyze patients who died after cardiac transplantation and to compare the pre- and post-mortem diagnoses.

Methods

Perform a review of medical records and analyze clinical data, comorbidities, immunosuppression regimen, laboratory tests, clinical cause of death and cause of death at the necropsy. Then, the clinical and necroscopic causes of death of each patient were compared.

Results

48 deaths undergoing necropsy were analyzed during 2000-2010; 29 (60.4 %) had concordant clinical and necroscopic diagnoses, 16 (33.3%) had discordant diagnoses and three (6.3%) had unclear diagnoses. Among the discordant ones, 15 (31.3%) had possible impact on survival and one (2.1%) had no impact on survival. The main clinical misdiagnosis was infection, with five cases (26.7 % of discordant), followed by hyperacute rejection, with four cases (20 % of the discordant ones), and pulmonary thromboembolism, with three cases (13.3% of discordant ones).

Conclusion

Discrepancies between clinical diagnosis and necroscopic findings are commonly found in cardiac transplantation. New strategies to improve clinical diagnosis should be made, considering the results of the necropsy, to improve the treatment of heart failure by heart transplantation.     

Mycobacterium tuberculosis resistance to antituberculosis drugs in Mozambique,

OBJECTIVE:

To determine the drug resistance profile of Mycobacterium tuberculosis in Mozambique.

METHODS:

We analyzed secondary data from the National Tuberculosis Referral Laboratory, in the city of Maputo, Mozambique, and from the Beira Regional Tuberculosis Referral Laboratory, in the city of Beira, Mozambique. The data were based on culture-positive samples submitted to first-line drug susceptibility testing (DST) between January and December of 2011. We attempted to determine whether the frequency of DST positivity was associated with patient type or provenance.

RESULTS:

During the study period, 641 strains were isolated in culture and submitted to DST. We found that 374 (58.3%) were resistant to at least one antituberculosis drug and 280 (43.7%) were resistant to multiple antituberculosis drugs. Of the 280 multidrug-resistant tuberculosis cases, 184 (65.7%) were in previously treated patients, most of whom were from southern Mozambique. Two (0.71%) of the cases of multidrug-resistant tuberculosis were confirmed to be cases of extensively drug-resistant tuberculosis. Multidrug-resistant tuberculosis was most common in males, particularly those in the 21-40 year age bracket.

CONCLUSIONS:

M. tuberculosis resistance to antituberculosis drugs is high in Mozambique, especially in previously treated patients. The frequency of M. tuberculosis strains that were resistant to isoniazid, rifampin, and streptomycin in combination was found to be high, particularly in samples from previously treated patients.     

Comparison of safety and efficacy of bivalirudin versus unfractionated heparin in high-risk patients undergoing percutaneous coronary intervention (from the Anti-Thrombotic Strategy for Reduction of Myocardial Damage During Angioplasty-Bivalirudin vs Heparin study)

Bivalirudin, a direct thrombin inhibitor, is as effective as unfractionated heparin (UFH), with decreased bleeding in patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI). The aim of this study was to evaluate the effectiveness of bivalirudin versus UFH in selected PCI patients at high bleeding risk. Four hundred one consecutive patients who underwent PCI fulfilling ≥ 1 enrollment criterion (age >75 years, chronic renal failure, and diabetes mellitus) were randomized to bivalirudin (bolus 0.75 mg/kg followed by infusion during the procedure; n = 198) or UFH (75 IU/kg; n = 203). In the overall population, 39% were aged >75 years, 22% had renal failure, 63% had diabetes, and 29% had acute coronary syndromes. The primary efficacy end point was the 30-day incidence of major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, or target vessel revascularization). The primary safety end point was the occurrence of any bleeding or entry-site complications after PCI. All patients were preloaded with clopidogrel 600 mg. Glycoprotein IIb/IIIa inhibitors were used at the operators' discretion. Thirty-day major adverse cardiac event rates were 11.1% in the bivalirudin group and 8.9% in the UFH group (p = 0.56); the primary efficacy end point was reached mainly because of periprocedural myocardial infarction; 1 patient in the bivalirudin group had stent thrombosis. Occurrence of the primary safety end point was 1.5% in the bivalirudin group and 9.9% in the UFH group (p = 0.0001); this benefit was essentially driven by the prevention of entry-site hematomas >10 cm (0.5% vs 6.9%, p = 0.002). In conclusion, Anti-Thrombotic Strategy for Reduction of Myocardial Damage During Angioplasty-Bivalirudin vs Heparin (ARMYDA-7 BIVALVE) indicates that bivalirudin, compared with UFH, causes significantly lower bleeding and has a similar incidence of major adverse cardiac events in patients with older age, diabetes mellitus, or chronic renal failure who undergo PCI.     

Cardiovascular disease in asthma and COPD: a population-based retrospective cross-sectional study

We conducted a large population-based retrospective cross-sectional study for determining the extent of clinically recognized chronic obstructive pulmonary disease (COPD) and asthma, and the prevalence of associated cardiovascular diseases (CVDs), using information obtained from the Health Search Database (HSD) owned by the Italian College of General Practitioners (SIMG). Our study provides further evidence that patients with the diagnosis of COPD are at increased association with the diagnosis of most CVDs. It also documents that age clusters between 35 and 54 years are those at highest association of simultaneous presence of the diagnosis of CVD and that of COPD, with a progressive significant reduction in older age clusters. Moreover, it shows that the diagnosis of asthma is modestly associated with the diagnosis of different CV morbidities.     

Improvement in PET myocardial perfusion image quality and quantification with flurpiridaz F 18

Rubidium-82 ((82)Rb), the currently commercially available radiotracer for positron emission tomography (PET) myocardial perfusion imaging (MPI), has led to wide availability of PET-MPI for stress-rest imaging. Compared to SPECT MPI, myocardial perfusion PET images have higher spatial and contrast resolution, are less affected by radiotracer scatter, benefit from more precise attenuation correction, and allow dynamic first pass imaging. In addition, PET imaging allows assessment of myocardial function at peak stress and measurement of absolute myocardial blood flow, thus providing critical data not available with SPECT imaging. Further enhancements of the high quality of PET perfusion images may be realized by technologies under development such as respiratory gating, combined respiratory, and ECG gating to generate "motion-frozen" cardiac images, automated patient motion correction software, and high-definition PET, which reduces distortions introduced by the circular geometry of the scanner. Early studies indicate that the experimental PET radiopharmaceutical flurpiridaz F 18 provides high-quality, high-resolution myocardial perfusion images that may enable improved clinical MPI, and has properties well suited to optimized performance by application of these quantitative analytic technologies.     

Inveterated Facial Palsy Correction with Endoscopically Assisted Multiple Muscle Transposition and Lifts: The EMTL Procedure

Introduction  The aim of the present analysis was to study the safety and efficacy associated with reanimation in facial nerve palsy by the endoscopically assisted multiple muscle transposition and lifts (EMTL). Patients and Methods  The study sample included all patients who had undergone a facial reanimation by EMTL procedure from September 2015 to May 2019. The patients were analyzed retrospectively, with more than 1 year of follow-up, and were evaluated in terms of functional-aesthetic results and postoperative complications. The outcome was evaluated with the Sunnybrook scale. Results  Fourteen patients were included in the present study. They were all inveterate palsies with minimum 4 years from the initial injury. The preoperative Sunnybrook score ranged from 0 to 5 and the postoperative ranged from 30 to 65. Spontaneous smile achievement was obtained in 10 patients and only mild restoration in one patient. The scar and static correction were satisfactory in all patients. Eye protection was improved in all cases with some form of active blinking in six cases. Conclusion  This study showed that facial palsy correction with EMTL procedure offers a promising alternative treatment for patients with facial palsy not suitable for microsurgical muscle transposition.