Gastrointestinal hemorrhage--hemorrhage from the upper digestive system

Upper gastrointestinal (GI) bleeding represents the commonest emergency managed by gastroenterologists utilizing substantial clinical and economic resources. Manifestations of GI bleeding depend uppon its localization, magnitude and co-morbidity. Although endoscopic haemostasis has significantly improved the outcome of patients with upper GI bleeding, in some cases patients continue to bleed or rebleed after initial control requiaring early elective surgery in order to decrease mortality. Despite recent advances in, both, endoscopic and surgical therapy, mortality rates have remained essentialy unchanged at 6-15%.     

Plasma ghrelin levels of gastrectomized and vagotomized patients are not affected by glucose administration

BACKGROUND: Ghrelin is a brain-gut peptide with GH-releasing and appetite-inducing activities, secreted mainly by the stomach. Circulating ghrelin concentrations fall rapidly after nutrient ingestion as well as after oral and intravenous glucose challenge. A number of gut hormones including ghrelin require an intact vagal system, which has been hypothesized to have a major role in initiating the postprandial fall in ghrelin levels. AIM: We aimed to investigate the effect of oral glucose challenge on ghrelin secretion in gastrectomized (GASTRX) and vagotomized patients. DESIGN: Interventional study. PATIENTS: Six GASTRX-vagotomized patients and 11 healthy sex- and body mass index (BMI)-matched subjects. METHODS: An oral glucose tolerance test (OGTT) was performed in all subjects. At baseline, circulating plasma total ghrelin, serum glucose, insulin and GH levels were measured. Serum glucose, insulin, GH and plasma ghrelin levels were determined every 30 min for 2 h. RESULTS: Plasma ghrelin levels at baseline were reduced by 55% in GASTRX-vagotomized patients compared to the control group (P < 0.01). In control subjects, plasma ghrelin levels decreased significantly during the OGTT whereas in GASTRX-vagotomized patients no reduction was registered (26.4 +/- 2.8% vs. 5.5 +/- 3.4%). The OGTT revealed a significantly greater increase in circulating glucose levels and serum insulin levels while GH response was not different in GASTRX-vagotomized patients compared to control subjects. CONCLUSIONS: Our data show that circulating ghrelin levels in GASTRX and vagotomized patients were not suppressed after oral glucose administration, unlike control subjects, suggesting that this effect could be due, at least in part, to the lack of contribution of the vagal nervous system to the regulation of ghrelin.     

Minimally invasive surgery in the treatment of gastric cancer

Unlike benign pathology, progress of laparoscopy in performing cancer surgery has been slow because of fear of safety and oncological adequacy. However, the initial fear has been replaced by optimism as the results from a numerous studies have shown equivalent if not superior results to open surgery. Laparoscopic gastrectomy is safe and oncologic adequate, but time consuming and technically demanding procedure. Laparoscopic surgery has gained wide acceptance in the treatment of early gastric cancer, especially of the distal stomach. The use of laparoscopic surgery for the treatment of advanced gastric cancer remains controversial. Another open question that need complete evaluation is cost-effectiveness analysis of minimally invasive and open approach.     

State Medicaid and private telemedicine coverage requirements and telemedicine use, 2013–2019

Objective

To examine the association between state Medicaid and private telemedicine coverage requirements and telemedicine use. A secondary objective was to examine whether these policies were associated with health care access.

Data Sources and Study Setting

We used nationally representative survey data from the 2013–2019 Association of American Medical Colleges Consumer Survey of Health Care Access. The sample included Medicaid-enrolled (4492) and privately insured (15,581) adults under age 65.

Study Design

The study design was a quasi-experimental two-way-fixed-effects difference-in-differences analysis that took advantage of state-level changes in telemedicine coverage requirements during the study period. Separate analyses were conducted for the Medicaid and private requirements. The primary outcome was the past-year use of live video communication. Secondary outcomes included same-day appointment, always able to get needed care, and having enough options for where to go to receive care.

Data Collection/Extraction Methods

N/A.

Principal Findings

Medicaid telemedicine coverage requirements were associated with a 6.01 percentage-point increase in the use of live video communication (95% CI, 1.62 to 10.41) and an 11.12 percentage-point increase in always being able to access needed care (95% CI, 3.34 to 18.90). While generally robust to various sensitivity analyses, these findings were somewhat sensitive to included study years. Private coverage requirements were not significantly associated with any of the outcomes considered.

Conclusions

Medicaid telemedicine coverage during 2013–2019 was associated with significant and meaningful increases in telemedicine use and health care access. We did not detect any significant associations for private telemedicine coverage policies. Many states added or expanded telemedicine coverage policies during the COVID-19 pandemic, but states will face decisions about whether to maintain these enhanced policies now that the public health emergency is ending. Understanding the role of state policies in promoting telemedicine use may help inform policymaking efforts going forward.     

Modified stapling technique of esophagojejunal anastomosis

The most dangerous complication of total gastrectomy, often causing postoperative death, is dehiscence of esophagojejunal anastomosis. After analyzing more then 300 patients undergoing surgery for gastric and/or cardiac carcinoma at our department in the period 1992-96, we concluded that the main cause of anastomotic dehiscence was a technically insufficient anastomosis, and the main risk factor was hypertrophied muscular layer of the esophagus (predominantly in advanced cardiac carcinoma). In this paper we discuss indications for, and the surgical technique of, our own modification of mechanical esophagojejunal anastomosis. In the period between 1 January 1997 and 1 March 2001, 148 procedures were performed using the modified anastomotic technique. In only two patients (1.35%) were radiological signs of small anastomotic leakage observed. The described modification of mechanical esophagojejunal anastomosis is safe and is not a time-consuming procedure. It is highly recommended in the treatment of the obstructive cardiac carcinoma with a compensatory hypertrophied muscular layer of the esophagus.     

West Nile virus population genetics and evolution

West Nile virus (WNV) (Flaviviridae: Flavivirus) is transmitted from mosquitoes to birds, but can cause fatal encephalitis in infected humans. Since its introduction into North America in New York in 1999, it has spread throughout the western hemisphere. Multiple outbreaks have also occurred in Europe over the last 20 years. This review highlights recent efforts to understand how host pressures impact viral population genetics, genotypic and phenotypic changes which have occurred in the WNV genome as it adapts to this novel environment, and molecular epidemiology of WNV worldwide. Future research directions are also discussed.     

Micrometastasis of hypopharyngeal cancer

Purpose

The aim of this study is to estimate the incidence and clinical impact of lymph node micrometastases in hypopharyngeal squamous cell cancer (HSCC).

Materials and methods

In this retrospective study, we enrolled 58 patients who have undergone surgery for HSCC (between January 2004 and January 2011). Pharyngolaryngectomy and oesophagectomy with selective bilateral neck dissection was performed in all patients. Based on standard histological examination, 17 patients met N0 and 8 patients met N1 criteria and were further evaluated for the presence of micrometastases and isolated tumour cells (ITC). Following immunohistochemical analysis, the patients were grouped according to the presence of micrometastases and ITCs.

Results

In the pN0 group, cytokeratin-positive cells were detected in five patients, and they were marked as N0/CK+. Among these five patients, two were found to harbour micrometastases and ITCs, whilst in three, only ITCs were found. Two patients (11.75 %) were upstaged to pN1. The patients marked as N0/CK+ had a statistically significant worse overall survival rates than pN0 patients with tissue samples read as negative for cytokeratin immunostaining (p?=?0.019, p?<?0.05). In the pN1 group, cytokeratin-positive cells were detected in two patients, with one patient showing micrometastases and ITC, and the other showing ITC only. One patient was upstaged to pN2.

Conclusion

Patients with lymph node micrometastases and ITC had worse overall survival rates, which may indicate that more aggressive post-operative treatment regimens should be considered for these HSCC patients.     

Atrophic chronic gastritis and esophagogastric anastomotic leak after resection and reconstruction for esophageal carcinoma.

The incidence of anastomotic leakage after esophagectomy for cancer and reconstruction with the stomach was analyzed with respect to the presence of coexistent atrophic chronic gastritis (ACG). Of a total of 28 operated esophageal cancer patients with ACG, 6 patients developed an anastomotic leak at the cervical esophagogastrostomy (21%). Of a total of 8 operated esophageal cancer patients none of the patients developed an anastomotic leak. The ACG positive and the ACG negative patients were found to be well matched for age, sex, type of operation, transplant route, level of the anastomoses, and suture technique, and all were operated on by the same surgeons. The difference in leakage rate did not reach statistical significance.