Ambispective comparative study of two surgical strategies for liver hydatidosis

AIM: To investigate the morbidity, mortality, recurrence and technical aspects of two distinct surgical strategies that were implemented in successive periods.METHODS: Ninty-two patients with 113 cysts underwent surgical procedures. The study was divided into 2 periods. Data from first period (P1) were compiled retrospectively. The surgical strategy was conservative surgery. The second period (P2) included a prospective study conducted according to a protocol following the criterion that radical procedures should be performed whenever it is technically feasible.RESULTS: Patients of both periods showed no statistically significant differences in age, gender, cyst location or mortality. Among the P2 group, patients exhibited more preoperative jaundice, and cyst size was smaller (P < 0.05). Changes in surgical strategy increased the rate of radical surgery, decreases morbidity and in-hospital stay (P < 0.001). A negative result in P2 was the death of two old patients (4.8%) who had undergone conservative treatments. The rate of radical surgery in P2 was around 75%.CONCLUSION: Radical surgery should be the technique of choice whenever it is feasible, because it diminishes morbidity and in-hospital stay. Conservative surgery must be employed only in selected cases.     

Remission of Type 2 Diabetes Mellitus Should Not Be the Foremost Goal after Bariatric Surgery

Background

Remission of type 2 diabetes (T2D) is a desired outcome after bariatric surgery (BS). Even if this goal is not achieved, individuals who do not strictly fulfill remission criteria experience an overall improvement. The aim of this study was to evaluate the metabolic control status in patients considered as diabetes “non-remitters.”

Methods

A retrospective study of 125 patients (59.2 % women) with preoperative diagnosis of T2D who underwent BS in a single center (2006–2011) was conducted. We collected anthropometric and metabolic parameters before surgery and at 1-year follow-up. T2D remission was defined according to the 2009 consensus statement: glycosylated hemoglobin (HbA1c) <6 %, fasting glucose (FG) <100 mg/dLs, and absence of pharmacologic treatment. We evaluated metabolic status of non-remitters, according to the American Diabetes Association's (ADA) target recommendations: HbA1c <7 %, LDL-c <100 mg/dL, triglycerides <150 mg/dL, and HDL-c >40 (male) or >50 mg/dL (female). Statistics: analysis of variance.

Results

Baseline characteristics (mean ± SD): age 53.5?±?9.7 years, BMI 43.5?±?5.6 kg/m², time since diagnosis of T2D 7.7?±?7.9 years, FG 162.0?±?56.3 mg/dL, HbA1c 7.7?±?1.6 %. ADA's target recommendations were present in 12 patients (9.6 %) preoperatively, and in 45 (36.0 %) at 1-year follow-up (p <0.001). Sixty-two (49.6 %) patients did not achieve diabetes remission; 26 (41.9 %) had now diet treatment, 30 (48.4 %) oral medications, and 6 (9.7 %) required insulin. Of the non-remitters, 57 (91.9 %) had HbA1c <7 % and 18 (40.0 %) achieved ADA's target recommendations. There were no differences between remitters and non-remitters in the number of individuals reaching ADA's combined metabolic control.

Conclusions

Although almost 50 % of the patients may not be classified as diabetes remitters, their significant improvement in metabolic control should be regarded as a success, according to most scientific societies' target recommendations.     

Clinical Utility and Economic Impact of Conventional Transbronchial Needle Aspiration of Mediastinal Lymphadenopathies in Bronchogenic Carcinoma

ObjectivesTo analyse the clinical utility and economic impact of conventional transbronchial needle aspiration (TBNA) in patients with diagnosis of bronchogenic carcinoma (BC) and mediastinal lymphadenopathies in thoracic computed tomography (CT). To assess the predictive factors of valid aspirations.Patients and methodsRetrospective observational study between 2006 and 2011 of all TBNA performed in patients with final diagnosis of BC and accessible hilar or mediastinal lymphadenopathies on thoracic CT.ResultsWe performed TBNA on 267 lymphadenopathies of 192 patients. In 34.9% of patients, two or more lymph nodes were biopsied. Valid aspirations were obtained in 153 patients (79.7%) that were diagnostic in 124 patients (64.6%). Multivariate analysis showed that factors associated with valid or diagnostic results are the diameter of the lymph node and the number of lymph nodes explored. TBNA was the only endoscopic technique that provided the diagnosis of BC in 54 patients (28.1%). Staging mediastinoscopy was avoided in 67.6% of patients. The prevalence of mediastinal lymph node involvement was 74.4%, sensitivity of TBNA was 86.2% and negative predictive value was 63.6%. Including mediastinoscopy and other avoided diagnostic techniques, TBNA saved 451.57 € per patient.ConclusionsTBNA is a clinically useful, cost-effective technique in patients with BC and mediastinal or hilar lymphadenopathies. It should therefore be performed on a regular basis during diagnostic bronchoscopy of these patients.     

Histologic evaluation of an allogeneic mineralized bone matrix in the treatment of periodontal osseous defects

The aim of this study was to evaluate the potential of an allogeneic bone matrix to regenerate new bone, cementum, and periodontal ligament around a previously diseased root surface. Four patients with severe chronic periodontitis and teeth with hopeless periodontal or restorative prognoses participated in this study. One tooth with a severe intraosseous defect was selected per patient. At baseline, measurements of probing depth, gingival recession, and clinical attachment level were obtained. Following flap reflection, a root notch was placed at the apical extent of the calculus; the root was debrided, and the allogeneic bone graft material was placed into the defect. After a minimum of 6 months of healing, the teeth were removed en bloc and prepared for histologic examination. Two of four teeth demonstrated regeneration of new bone, cementum, and periodontal ligament. One tooth healed by new connective tissue attachment, and another by junctional epthelium.     

Sclerostin Expression in Bile Ducts of Patients With Chronic Cholestasis May Influence the Bone Disease in Primary Biliary Cirrhosis

Sclerostin is involved in the regulation of osteoblastogenesis and little is known about its role in the development of bone disease in primary biliary cirrhosis (PBC), characterized by low bone formation. Therefore, we have assessed the circulating levels and the liver expression of sclerostin in this cholestatic disease. Serum sclerostin levels were measured in 79 women with PBC (mean age 60.6 ± 1.2 years) and in 80 control women. Lumbar and femoral bone mineral density (BMD), as well as parameters of mineral metabolism and bone remodeling, were measured. Moreover, sclerostin gene (SOST) expression in the liver was assessed by real‐time PCR in samples of liver tissue taken by biopsy in 11 PBC patients and in 5 normal liver specimens. Presence and distribution of sclerostin was evaluated in liver slices from 11 patients by immunohistochemistry. The severity of histologic lesions was assessed semiquantitatively in the same liver samples. PBC patients had higher sclerostin levels than controls (75.6 ± 3.9 versus 31.7 ± 1.6 pmol/L, p < 0.001). Serum sclerostin correlated inversely with markers of bone formation and resorption. Sclerostin mRNA in the liver was overexpressed compared with control samples (2.7‐fold versus healthy liver). Sclerostin was detected by immunohistochemistry in 7 of the 11 liver samples, mainly located in the bile ducts. Liver sclerostin was associated with the severity of cholangitis (p = 0.02) and indirectly with the degree of lobular inflammation (p = 0.03). Sclerostin mRNA expression was higher in samples that tested positive by immunohistochemistry and particularly in those with lobular granuloma (p = 0.02). The increased expression of sclerostin in the liver and the association with histologic cholangitis may explain the high serum levels of this protein in patients with PBC, thus suggesting that sclerostin may influence the decreased bone formation in this cholestatic disease. © 2016 American Society for Bone and Mineral Research.     

Functional status and use of health care services: longitudinal study on the older adult population in Spain

BACKGROUND: Follow-up studies on the association between functional status and use of health care services among the older people are scarce and have studied only a few types of service. OBJECTIVE: To examine prospectively the relationship between limitation in instrumental activities of daily living (IADL) and utilization of a wide variety of health care services among older adults in Spain. METHODS: Prospective study from 2001 to 2003 of a cohort of 2806 persons, representative of the non-institutionalized Spanish population aged 60 years and over. Limitation in IADL was measured in 2001 using the Lawton and Brody's test. Data on the use of health care services were collected in 2003 and classified into home services (home visits by physicians and nurses) and non-home services (visits to primary care physicians, visits to hospital specialists, hospital admissions, emergency care, and influenza vaccination). Analyses were performed with logistic regression and adjusted for the main confounders. RESULTS: Compared to men with no limitation in IADL, a higher percentage of those with limitation in one IADL in 2001 made use of both home (odds ratio [OR] 2.64; 95% confidence interval [95% CI] 1.73-4.03) and non-home services (OR 2.02; 95% CI 1.04-3.93) in the period 2001-2003. Limitation in one IADL among women was associated with a greater utilization of home services (OR 1.50; 95% CI 1.05-2.14) and visits to hospital specialists (OR 1.61; 95% CI 1.21-2.15). In women, however, a greater number of limited IADL at baseline was inversely associated with visits to primary care physicians in the 2-year follow-up (p for linear trend <0.001). CONCLUSION: Population aging will increase the demand for health services in general, and for home services in particular.