Low-carbohydrate diets and type 2 diabetes treatment: a meta-analysis of randomized controlled trials.

AIM: To assess whether LC diets are associated with long-term improvement in glycemic control and weight loss in people with T2DM, and their cardiovascular and renal safety. METHODS: Meta-analysis of randomized controlled trials lasting more than 3 months, retrieved through extensive search on PubMed, Embase, ClinicalTrial.gov, Cochrane databases up to March 1st, comparing LC diets and balanced carbohydrate diets in people with T2DM. RESULTS: We retrieved 37 trials, including 3301 patients. Average carbohydrate intake in LC diets was 36% of total energy. LC diets were associated with significant reduction of HbA1c at 3 months (MD - 0.17%, 95% CI - 0.27, - 0.07), no difference at 6 and 12 months, and significant increase at 24 months (MD 0.23%, 95% CI MD 0.02, 0.44). VLC diets were associated with significant HbA1c reduction at 3 and 6 months (MD - 0.43% - 0.60, - 0.26%, and MD - 0.40% 95% CI - 0.59, - 0.22, respectively), but not at 12 and 24 months. LC diets were associated with significant BMI reduction at 6 months (- 1.35 kg/m2 95% CI, - 2.18, - 0.52), but not at other time points. Only a minority of trials reported data on renal function, so renal safety could not be assessed. No significant differences in body weight, lipid profile, or blood pressure were found in the long term. CONCLUSION: LC diets may produce small short-term improvements in HbA1c and weight, which are not maintained in the long term. Data on their renal safety are insufficient.

The influence of residents in the outcome of elective laparoscopic surgery: a prospective study comparing a teaching hospital and a private community hospital in Italy.

OBJECTIVES: We compared the outcome of elective laparoscopic cholecystectomy (LC) in a teaching hospital and a private communityhospital to assess the impact of the involvement of residents. MATERIALS AND METHODS: The following parameters were studied prospectively in patients who underwent elective LC during the period from September 2014 to February 2016 in a teaching university hospital (group A) and in a private community hospital (group B): age, sex, body mass index (BMI), comorbidities, American Society of Anaesthesiologists (ASA) score, length of surgery from skin incision to skin closure, use of drain, 30-day perioperative morbidity and mortality, and length of postoperative hospital stay. RESULTS: The group A consisted of 93 elective LC and the group B of 167 elective LC. Operative time was significantly longer in group A. Intraoperative complications were similar and no conversion was necessary in both groups. An increased rate of postoperative complications was observed in group A. All postoperative complications were managed with conservative therapy. No mortality occurred. At logistic regression analysis, the only factor favouring the occurrence of complications was the hospital type. CONCLUSIONS: Our study shows that elective LC can be performed in a teaching hospital with comparable intraoperative morbidity and increased postoperative complications. The greater rate of morbidity found in the teaching hospital may be due to an increased vigilance linked to the presence of residents and not to the lack of expertise.

Biliodigestive fistulae and gallstone ileus: diagnostic and therapeutic considerations. Our experience.

The biliodigestive fistula is not a rare affection in the context of acute pathology of the gastrointestinal tract. It often affects patients between 63 and 85 years old , particularly the female sex, and the most common cause is acute or chronic cholecystolithiasis. Open issues are the delayed in the pre-operative diagnosis, and controversies exist regarding the best surgical approach. The choice of treatment options is influenced by the age of the patients and their clinical conditions and also by the presence of comorbidities and of a delayed right diagnosis. In the 1 to 3% of cases, the biliodigestive fistula presents a gallstone ileus as complication, whose diagnosis is particularly difficult for the lack of specific signs and symptoms. The contrast-enhanced CT is considered the gold standard for a specific pre-operative diagnosis, as it directly shows the fistula. Surgical treatments include one-stage procedure or two-stage procedure. Many studies seem to favor a deferred definitive procedure. The Authors describe 4 cases: in 3 cases, women between 70 and 80 years old presenting an history of recurrent cholecystitis, in 2 cases, and in 1 case presenting a bowel obstruction; in 1 case a 50-years-old man, with no significant past medical history, presenting a bowel obstruction. The Authors have performed in the 2 cases of gallstone ileus an enterolithotomy with cholecysto-duodenal fistula repair and cholecystectomy, in one-stage, and this has been possible because of the good clinical conditions of the patients and their low operative risk. In the case of fistula without the complication of gallstone ileus, the treatment approach has been cholecysto-gastric fistula closure with a gastroplastic using separate stitches and cholecystectomy, in one-stage. We are in agreement with data in the literature regarding the delay into the diagnosis of biliodigestive fistula and with the importance to suspect it or gallstone ileus presence, although the clinical presentation is extremely non-specific. In our experience, cholangiopancreatography-CT and CECT have made easier the pre-operative diagnosis and so reducing the delay of the treatment.

Small bowel intussussception due to metastatic melanoma of unknown primary site. Case report.

Malignant melanoma is characterized by metastases also to the gastrointestinal tract, especially in the small bowel. The diagnosis is often delayed because unspecific clinical presentation (frequently as chronic iron deficiency anemia, rectal bleeding or intestinal obstruction). We present a case of melanoma of unknown primary site, with clinical presentation of intestinal obstruction. A segmental resection of the ileum was performed including mesentery with lymph nodes. Histology revealed metastatic melanoma from unknown primary. PET and MRI confirmed disseminated disease without brain metastasis.

Single-incision laparoscopic appendectomy is comparable to conventional laparoscopic and laparotomic appendectomy: our single center single surgeon experience.

Several studies have demonstrated the clinical and technical benefits of the laparoscopic surgery for complicated and uncomplicated appendicitis. Our retrospective study included 12 patient who underwent SILS appendectomy (SILS-A), 14 who received conventional laparoscopic surgery (VL-A), and 12 who received laparotomic appendectomy (OA); performed in all cases by the same surgeon (C.F.). The aim of this study was the comparison between this three different surgical techniques on same features: post operative leukocytosis, post operative pain, need abdominal drainage, esthetic viewpoint, incidence of complication, hospital stay. The results showed no significant differences between SILS-A and VLS-A, while an evident improvement shows versus O-A, even though not statistically significative. SILS was more effective in decreasing the risk of postoperative wound infection.

Cyclic treatment of chronic hepatic encephalopathy with rifaximin. Results of a double-blind clinical study.

BACKGROUND: Chronic hepatic encephalopathy (HE) represents a frequent and serious complication of chronic liver disease. Aim of the study is to comparatively evaluate the effect of rifaximin, lactitol and their combination in treating chronic HE. METHODS: Forty out-patients (29 males, 11 females, mean age: 59 years, range 40-70), with viral liver cirrhosis and chronic HE (1st-2nd degree) were studied. HE was assessed by considering: mental state, asterixis, number connection test (NCT), arterial blood ammonia levels. Patients were randomly assigned to the following treatments: rifaximin (plus sorbitol as placebo) (group R); lactitol (group L); rifaximin plus lactitol (group RL). All treatments were continued for 15 days for 3 cycles, intervalled by 15 days of washout. RESULTS: The 3 treatments reduced HE, but with different efficacy: patients of group R and RL significantly (p<0.05) documented a faster improvement in HE degree, a higher percentage of patients which normalized mental state and NCT, a faster improvement of asterixis and a longer persistence of normal ammonia levels than patients of group L. CONCLUSIONS: Rifaximin in combination with lactitol or sorbitol represents an effective and safe treatment of chronic HE.

Non-alcoholic fatty liver disease in an area of southern Italy: main clinical, histological, and pathophysiological aspects.

BACKGROUND/AIMS: Studies on non-alcoholic fatty liver disease (NAFLD) have included chronic liver damage attributed to various causes. Our investigation was held to observe the main clinical, histological, and pathophysiological aspects of NAFLD in patients not exposed to any known cause of chronic liver disease. METHODS: We evaluated, in 84 in-patients (male/female, 66/18; median age, 36 years), the clinical and biochemical characteristics of NAFLD, and particularly its association with diabetes, dyslipidemia, hyperinsulinemia and/or with the increase of parameters of oxidative stress (blood levels of malonyldialdehyde, 4-hydroxynonenal and total plasma antioxidant capacity). RESULTS: Ninety percent of patients had an increased body mass index (BMI), 35% had dyslipidemia, 40% had sub-clinical diabetes (only 3% had overt diabetes), 60% had hyperinsulinemia, and more than 90% had enhanced levels of lipid peroxidation markers. In 48 patients who had consented to liver biopsy, we found: 14 with simple steatosis, 32 with steatohepatitis, and two with cirrhosis. CONCLUSIONS: Our data indicate that in our country, NAFLD may occur in young males with an increased BMI, with or without hyperinsulinemia, dyslipidemia and diabetes, generally associated with disorders of redox status, and that it may be differentiated from steatosis to steatohepatitis or cirrhosis only with a liver biopsy.

Relationship of blood trace elements to liver damage, nutritional status, and oxidative stress in chronic nonalcoholic liver disease.

Trace elements are involved in chronic liver diseases because these elements may have a direct hepatic toxicity or may be decreased as a consequence of the impaired liver function, particularly in patients with alcoholic cirrhosis and/or malnutrition. In this study, we determined plasma and erythrocytes trace elements in 50 inpatients with nonalcoholic chronic liver disease (11 with biopsy-proven chronic hepatitis, 39 with cirrhosis [16 in stage A according to Child-Pugh criteria, 23 Child B+C]), and in a control group of 10 healthy subjects by the proton induced x-ray emission method. The relationship between trace element concentration and the extent of liver damage, the nutritional status (by anthropometric evaluations), and various blood markers of oxidative stress--reduced glutathione, total lipoperoxides and malonyldialdehyde--was investigated. We found that cirrhotics had a significant decrease of Fe, Zn, Se, and GSH levels in the plasma and of GSH and Se in the erythrocytes with respect to the control and chronic hepatitis groups. GSH levels were related to the degree of liver damage; a significant direct correlation was observed among Se, Zn, and GSH plasma values and between GSH and Se in the erythrocytes. The trace element decrease was, on the contrary, independent of the degree of liver function impairment and only partially affected by the nutritional status. Data indicate that liver cirrhosis, even if not alcohol related, induces a decrease of Se and Zn and that, in these patients, an oxidative stress is present, as documented by the significant correlation between Se and GSH. The plasma Br level was higher in cirrhotics with respect to the control and chronic hepatitis groups.

Quantitative and functional study of breast cancer axillary lymph nodes and those draining other human malignant tumors.

Lymphocyte functional activity from lymph nodes draining human malignancies reflects the host immune response against tumour. Breast cancer is the neoplasia with the greatest amount of identified antigens but a weak inducer of a host efficient immune response. In our study we compared the mitogen stimulated-proliferative response of cells isolated from metastases-free lymph nodes draining breast cancer (Group 1), other malignant tumours (Group 2), and those obtained from patients without malignancies (Control group). A significant decrease of the proliferative response in cells isolated from lymph nodes draining breast cancer was observed comparing it to the other groups. Quantitative analysis of B and T cells showed a higher number of B cells than T cells in Groups 1 and 2. Moreover, Group 1 presented a two fold increase of T cells compared with Group 2. Our results suggest that the immunosuppression observed in lymph nodes draining breast cancer is higher than the inmunosuppression presented in other malignant tumours and that impaired function is not correlated with the increased number of T cells.

Can dietary intake influence plasma levels of amino acids in liver cirrhosis?

BACKGROUND: Modifications in plasma amino acid patterns in cirrhotics are attributed to impaired liver function, being more evident in alcoholic than in viral cirrhosis. AIM: To evaluate whether diet influences plasma amino acid concentrations in different aetiological groups of cirrhotics. PATIENTS: Study population comprised 40 patients with cirrhosis (25 virus- and 15 alcohol-related], all Child A, and 30 healthy subjects (controls). METHOD: A food frequency and quality questionnaire was utilized to determine dietary history and alcohol intake. Nutritional status was evaluated by anthropometric method. Amino acids were determined, on venous blood samples, using a specific analyzer while cysteine was evaluated by fluorescent high power liquid chromatography RESULTS: The total daily intake of calories, proteins, lipids, and carbohydrates was similar in all individuals. Food quality distinguished the cirrhotics from the controls, but not the different aetiological groups of cirrhotics. Plasma cysteine levels were significantly lower, while aromatic amino acids and methionine were significantly higher, in all cirrhotics (p<0.001 and p<0.01, respectively, versus controls). The decrease in cysteine and the increase in other amino acids were more marked in alcoholics (p<0.01). CONCLUSIONS: Ethanol intake, but not diet, further enhances the changes in plasma aromatic amino acids, methionine and cysteine induced by impaired liver function in patients with cirrhosis, suggesting a direct interference of alcohol in their metabolism.

Ethanol consumption, amino acid and glutathione blood levels in patients with and without chronic liver disease.

BACKGROUND: Ethanol abuse and liver cirrhosis cause a reduction of glutathione blood levels; liver cirrhosis induces an alteration of the plasma amino acid pattern. We evaluated whether or not ethanol abuse affects amino acid levels, particularly those that are involved in metabolizing glutathione in the plasma and erythrocytes of chronic alcohol abusers with or without liver cirrhosis. METHODS: We studied 10 chronic alcohol abusers without liver cirrhosis, 10 with alcoholic cirrhosis, 10 affected by hepatitis C virus-related cirrhosis, and 10 healthy subjects. Glutathione, y-glutamyl-cysteine, and cysteine were determined by fluorescent HPLC, glutamic acid, glycine, and other free amino acids by cation exchange chromatography both in the plasma and erythrocytes of all studied subjects. RESULTS AND CONCLUSIONS: In both alcoholics and cirrhotics, we found a significant increase of plasma-aromatic amino acid and methionine levels, whereas glutathione was significantly reduced. The erythrocytes of these patients showed a significant increase of cysteine, glutamic acid, and glycine; gamma-glutamylcysteine was normal; and glutathione and other free amino acids were significantly decreased. Data suggest that, independent of liver cirrhosis, ethanol abuse affects the metabolism of amino acids and glutathione in both the plasma and the erythrocytes.

Determination of plasma alpha-glutathione-S-transferases in chronic alcohol abusers: relationship with alcohol intake and liver involvement.

UNLABELLED: Alpha-gluthathione-S-transferases (alpha-GSTs) are enzymes involved in the cellular detoxifying processes; elevated circulating alpha-GSTs activity is considered to be an early index of liver damage. Glutathione (GSH) is the substrate for alpha-GST action. THE AIMS OF OUR STUDY WERE: (1) to evaluate plasma GSH levels and alpha-GST activity in chronic alcohol abusers with or without liver cirrhosis; (2) to define the relationship between these two biochemical parameters; (3) to establish their clinical relevance in patients with alcohol abuse and/or liver damage. We studied 69 subjects (18 healthy subjects and 51 chronic alcohol abusers: 29 without liver cirrhosis and 22 with). Plasma alpha-GST activity was determined on baseline samples and every following day for a total of 10 days in five alcoholics by HEPKIT (Alpha-Biotech, Biotrin International, Dublin, Ireland). GSH was determined on all subjects' baseline samples by fluorescent high-performance liquid chromatography. Alcohol intake was evaluated in all patients by determining blood-alcohol concentrations. Significant increases in plasma alpha-GSTs were observed in 9/29 (31%) alcoholics and 3/22 (13.6%) cirrhotics irrespective of their alcohol intake. GSH was significantly lower than normal values (P < 0.001) in all alcoholics with or without cirrhosis (controls 10.4 +/- 4.8; alcoholics without cirrhosis 3.9 +/- 1.4; alcoholics with cirrhosis 3.3 +/- 1.6). No correlation was observed between plasma alpha-GST and GSH levels. Our data indicate that: (1) alpha-GST activity does not correlate with GSH levels in the plasma; (2) alpha-GSTs do not have clinical relevance as markers of recent alcohol intake; (3) in cirrhotics, alpha-GST does not provide more information than other liver function tests. However, plasma alpha-GST determination may be useful in selecting a subgroup of alcoholics in whom routine biochemical markers of liver damage are within reference ranges.

Free radicals and not acetaldehyde influence the circulating levels of glutathione after acute or chronic alcohol abuse: in vivo and in vitro studies.

BACKGROUND: The oxidation of ethanol and acetaldehyde enhances the production of various free radicals involved in membrane lipoperoxidation, and decreases glutathione levels. AIMS: We evaluated the effects of acute and chronic ethanol use in vivo, with or without the administration of S-adenosyl-methionine (SAME, 2 g I.v.), and the effects of ethanol and acetaldehyde in vitro, on the erythrocyte levels of malonyldialdehyde and glutathione, and of its principal synthesizing enzymes, gamma-glutamyl-cysteine-synthetase and glutathione-synthetase. METHODS: Twelve healthy volunteers (age range 26-44 years, median 32 years) and 20 chronic alcohol abusers without liver disease (age range 26-57 years, median 44 years) were studied. Malonyldialdehyde was evaluated by thiobarbituric acid; glutathione and its enzymes by high performance liquid chromatography using a fluorescent detector. RESULTS: In the healthy subjects, an acute load of ethanol induced a significant decrease in plasma levels of glutathione, which was inhibited by the infusion of S-adenosyl-methionine. In the erythrocytes of alcoholic patients, glutathione and glutathione-synthetase were decreased while malonyldialdehyde was increased. In vitro, acetaldehyde did not affect either the glutathione or the glutathione-related enzyme levels. CONCLUSIONS: Our data suggest that the alterations in glutathione metabolism in the erythrocytes of alcoholics may be due principally to the production of free radicals, as supported by the high levels of malonyldialdehyde observed.

Trace elements and chronic liver diseases.

The relationships between chronic liver diseases and trace element (TE) contents are debated. Particularly, no defined data are available about the TE levels in viral liver disease patients with or without malnutrition. In this study we evaluated blood and plasma levels of various trace elements in patients with HCV-related chronic liver disease, at different stages of liver damage (8 patients with chronic hepatitis and 32 with liver cirrhosis) with or without malnutrition. We also studied 10 healthy volunteers as control group. We found that cirrhotic subjects had a significant decrease of blood levels of Zn and Se, independently on the nutritional status, whereas plasma levels of Fe were significantly reduced only in malnourished cirrhotic patients. Our data indicate that liver impairment is the main cause of the blood decrease of Se and Zn levels in patients with non alcoholic liver disease, whereas the malnutrition affects Fe levels only.

Effect of alcohol abuse and glutathione administration on the circulating levels of glutathione and on antipyrine metabolism in patients with alcoholic liver cirrhosis.

Glutathione (GSH) is a principal cellular scavenger of free radicals. Chronic alcohol abuse, as well as liver disease, induces a decrease of hepatic GSH. We evaluated the effect of GSH administration (2.4 g day-1 in saline i.v. for 15 days) on the concentration of GSH in plasma and erythrocytes and on liver function tests, including galactose and antipyrine tests. We studied 40 alcoholic cirrhotic patients: 22 treated with GSH (10 persistent alcohol abusers and 12 weaning from alcohol during the study) and 18 treated with saline only (8 persistent alcohol abusers and 10 abstainers). Treatment with GSH improved the concentration of GSH in plasma and erythrocytes only in abstainers from alcohol; it did not affect liver function tests or galactose clearance. Persistent alcohol consumption significantly prolonged antipyrine metabolism; GSH administration counteracted this effect.

[Identification of a tumor antigen associated to the estrogen receptor in axillary lymph nodes of breast cancer patients]. / Identificación de un antigeno tumoral asociado al receptor estrogénico en ganglios linfáticos axilares de pacientes con cáncer mamario.

Sixteen axillary lymph nodes were incubated with sera from patients with mammary carcinoma. Using immunofluorescence staining sera recognized antigenic determinants on follicular dendritic cells (FDC) within the follicle centers. These results were confirmed with isolated and cultured FDC that were incubated with the same sera. All the results were negative with normal sera. We also found a cell population positively reacting with a monoclonal antibody against an estrogen receptor associated protein (ERAP) in subcapsular and cortical sinusae and germinal centers. Phenotype identification of ERAP+ cells indicated that they presented characteristics of macrophages and FDC respectively. Lymph nodes from other malignancies were negative for ERAP. These findings suggest that the tumoral antigen could be either the protein associated with the estrogen receptor or the receptor itself. The ERAP could be transported by the macrophages from the tumor to the regional lymph nodes where it could be processed and maintained during a long time by FDC, since it is known that these are the most efficient antigen presenting cells.

[Evaluation of the total hepatic function after treatment with fosinopril in hypertensive patients with liver cirrhosis]. / Valutazione della funzionalità epatica globale dopo trattamento con fosinopril in pazienti ipertesi affetti da cirrosi epatica.

Fosinopril is distinguished from other ACE inhibitors by a pharmacokinetic pecularity in the sense that is can be metabolized either by liver or kidney. This was the rationale of the present research the aim of which was to verify if administered to patients with liver cirrhosis the drug was liable to alter global liver function and ability to metabolize drugs. Eight cirrhotic males, mean age 56 years, also suffering from high blood pressure, were studied. In these patients, liver and kidney function tests (BUN, creatinine blood level, serum and urinary electrolytes, creatinine clearance, calcium and phosphor blood level, transaminases, alkaline phosphatase prothrombin time, cholinesterase, gamma-glutamyl-transpeptidase) were carried out at baseline and after 30 days' fosinopril treatment (1 capsule every morning in the fasting state); in addition total functioning liver mass was assessed by the galactose test, and drug-metabolizing capacity by the antipyrine test. Treatment resulted in a significant improvement of pressure values in all patients (p < 0.01) and did not alter liver and kidney function parameters. Besides, no side effects were registered, especially no case of orthostatic hypotension. The antipyrine test was not influenced by fosinopril treatment. Therefore, short-term treatment with this ACE-inhibitor can be concluded to be effective and not to cause additional alterations of liver function in patients with liver cirrhosis.

Detubularized sigmoid colon for bladder replacement after radical cystectomy.

During the last 6 years 24 sigmoid colon neobladders were constructed at our institute according to a surgical technique that provides for an optimal spherical configuration of the orthotopic reservoir. All patients underwent radical cystectomy for locally advanced or superficial recurrent bladder cancer. The surgical complication rate was minimal. Mean followup was 38.3 months (range 7 to 70). Patients were evaluated at 9 and 18 months with urodynamic tests. Daytime continence was achieved in 20 of 21 (95.2%) and in 16 of 17 (94.1%) patients, respectively. Nocturnal incontinence was noted in 9 of 21 (42.8%) and 5 of 17 (29.4%) patients. The mean neobladder capacity was 414 cc and 492 cc, respectively. Endoluminal pressure at the maximum reservoir capacity was 31 cm. water (range 23 to 54) and this did not change significantly at 18 months. Minimal post-voiding residual volume was evidenced in all but 1 patient and was maintained at 18 months. Our modified sigmoid colon neobladder is an easy surgical procedure that provides satisfactory total bladder replacement in select patients.

Long term experience with the prostatic spiral for urinary retention due to benign prostatic hyperplasia.

Twenty high risk patients with benign prostatic hyperplasia and urinary retention were treated by insertion of an intraprostatic spiral. The device was positioned under fluoroscopic guidance using a technique developed by us. The procedure required only local anaesthesia and successfully relieved the obstruction in all patients. At the six-month follow-up full continence had been achieved in 15 patients (75%). Three patients (15%) complained of mild stress incontinence but this was not severe enough to require removal and repositioning of the spiral. A 92-year-old patient reported severe incontinence despite correct positioning of the spiral. Removal of the spiral was necessary in one of the continent patients who was receiving anti-coagulant drugs because of sudden, severe macrohaematuria with subsequent acute urinary retention. The spiral became displaced and required repositioning in one patient. Median residual urine volume was constantly lower than 50 ml and the median maximal flow rate at six-month follow-up was 13.2 ml/s. Our long term follow-up study shows the effectiveness and safety of the prostatic spiral as an alternative treatment for selected patients with urinary retention caused by benign prostatic hyperplasia.