Granulomatosis With Polyangiitis in Untreated Graves' Disease: A Rare Event.

Antithyroid medications can cause antineutrophil cytoplasmic antibody (ANCA) vasculitis. However, no literature in English describes the coexistence of granulomatosis with polyangiitis (GPA) and untreated Graves' disease. We present a 19-year-old female with thyroid storm and additional complaints of cough, hemoptysis, nasal discharges, polyarthralgia, and skin lesions. Imaging showed peri-hilar cavities and acute-on-chronic sinusitis. Elevated cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA) and anti-proteinase-3 antibody levels plus histopathology of the nasal and skin biopsies suggested GPA. Propranolol, methimazole, and potassium-iodide resolved the thyroid storm. Induction therapy (steroids, rituximab) for GPA provided relief of chronic symptoms stressing the importance of early recognition and swift initiation of treatment.

The Digestive Function of Pseudoplatystoma punctifer Early Juveniles Is Differentially Modulated by Dietary Protein, Lipid and Carbohydrate Content and Their Ratios.

Pseudoplatystoma punctifer is an Amazonian catfish highly appreciated for its high flesh quality, size, and commercial value. Its aquaculture is pursued to satisfy the demands of an increasing population in the region. However, knowledge of the nutritional needs during the early life stages is necessary for improving growth and reducing the incidence of cannibalism, factors that limit the success of its commercial farming. This study aimed at evaluating the influence of four diets containing different protein and lipid levels (30:15, 30:10, 45:15, or 45:10 in %) in the digestive physiology and performance of early juveniles. The results showed that the dietary protein:lipid as well as carbohydrate levels and ratios influenced differently the whole-body proximate composition, the digestive physiology and development, and hence growth and survival. The 45:15 diet promoted the best growth, survival, and the most rapid development of the digestive system, as shown at histological (higher number of hepatocytes, goblet cells in the anterior intestine and enterocytes in all intestinal portions, and longer folds in the posterior intestine), molecular (highest amylase, lipoprotein lipase, phospholipase, trypsinogen, and pepsinogen gene expression), and biochemical (highest lipase and pepsin activities and higher alkaline phosphatase:leucine alanine peptidase activity ratio) levels. Lipids were favored over carbohydrates as source of energy, with lipids promoting a protein-sparing effect at adequate energy:protein ratio. Carbohydrate content higher than 25% was excessive for this species, leading to unbalanced lipid metabolism and fat deposition in the liver.

COVID-19 effect on herding behaviour in European capital markets.

This article investigates whether COVID-19 pandemic had an effect on herding behaviour in Europe. Using a sample from the stock exchanges of France (Paris), Germany (Frankfurt), Italy (Milan), United Kingdom (London) and Spain (Madrid), over the period from January 03, 2000 to June 19, 2020, we found robust evidence that COVID-19 pandemic increased herding behaviour in the capital markets of Europe.

Use of Heart Rate Index to Predict Oxygen Uptake - A Validation Study.

An equation that uses heart rate index (HRI) defined as HR/HRrest to predict oxygen uptake (VO2) in METs (e.g., METs = 6 × HRI - 5) has been developed retrospectively from aggregate data of 60 published studies. However, the prediction error of this model as used by an individual has not been established. Therefore, the purpose of this study was to examine the predictive validity of the HRI equation by comparing submaximal and maximal VO2 predicted by the equation (VO2-Pred) with that measured by indirect calorimetry (VO2-Meas). Sixty healthy adults (age 20.5 ± 2.4 yr., body mass 69.4 ± 13.4 kg, height 1.7 ± 0.1 m) underwent a VO2max test and an experimental trial consisting of a 15-min resting measurement and three successive 10-min treadmill exercise bouts performed at 40%, 60% and 80% of VO2max. VO2 and HR were recorded during both the submaximal and maximal exercises and used to obtain VO2-Pred and VO2-Meas for each intensity and for VO2max. Validation was carried out by paired t-test, regression analysis, and Bland-Altman plots. A modest but significant (p < 0.05) correlation was observed between VO2-Meas and VO2-Pred at 40% (r = 0.58), 60% (r = 0.53), and 80% of VO2max (r = 0.56) and at VO2max (r = 0.50). No differences between VO2-Pred and VO2-Meas were found at 40% (5.53 ± 1.21 vs. 5.28 ± 0.98 METs, respectively) of VO2max, but VO2-Pred was higher (p < 0.05) than VO2-Meas at 60% (8.42 ± 1.77 vs. 7.96 ± 1.39 METs, respectively) and 80% (10.79 ± 2.13 vs. 10.29 ± 1.81 METs, respectively) of VO2max. In contrast, VO2-Pred was lower (p < 0.05) than VO2-Meas at VO2max (12.32 ± 2.30 vs. 13.38 ± 2.24 METs, respectively). Standard errors of the estimate were 0.81, 1.20, 1.54, and 1.97 METs at 40%, 60%, 80% of VO2max and at VO2max, respectively. These results suggest that further investigation aimed to establish the accuracy of using HRI to predict VO2 is warranted.

Nonalcoholic fatty liver disease: predisposing factors and the role of nutrition.

More than 20% of Americans have nonalcoholic fatty liver disease (NAFLD), and this is, by far, the leading cause of abnormal liver enzymes in the United States. Nonalcoholic steatohepatitis (NASH), a more serious form of NAFLD, can proceed to cirrhosis and even hepatocellular carcinoma. These liver diseases represent the hepatic component of the metabolic syndrome, and this spectrum of liver disease represents a major health problem both in the United States and worldwide. Hepatic steatosis is closely linked to nutrition, including obesity, possibly high-fructose corn syrup consumption and consumption of certain types of fats. There are a variety of second insults or "hits" that appear to transform simple steatosis into NASH, with some of these second hits including certain proinflammatory cytokines, oxidative stress and possibly industrial toxins. In certain underdeveloped countries, it appears likely that industrial toxins play a role in NASH, and there is increasing interest in the potential interaction of industrial toxins and nutrients. Moreover, optimal therapy for NAFLD appears to include lifestyle modification with exercise, diet and weight loss. Certain nutrients may also be of benefit. Important areas for future research are the effect(s) of nutritional supplements on NAFLD/NASH and the effects of industrial toxins.

Albumin therapy in clinical practice.

Albumin is the predominant product of hepatic protein synthesis and one of the more abundant plasma proteins. Among its multiple physiologic roles, it plays an essential part in the generation of colloid-oncotic pressure. In the United States, the indications for which albumin therapy are considered include hypovolemia or shock, burns, hypoalbuminemia, surgery or trauma, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, and sequestration of protein-rich fluids. The use of this relatively expensive therapy accounts for up to 30% of the total pharmacy budget in certain hospitals. The use of albumin therapy in different clinical situations and its influence in morbidity and mortality have been reviewed in multiple randomized controlled trials and meta-analyses. Despite frequent reviews, the use of albumin remains controversial in several clinical situations. At the same time, these valuable reviews seem to have documented the advantages of albumin therapy in the management of ascites and clarified the use of albumin in volume resuscitation. More studies have been recommended to investigate the use of albumin in different doses and its role in hypoalbuminemia. This article will provide an overview of albumin metabolism, use of albumin for volume expansion, the potential therapeutic role of albumin in liver disease, and the role of albumin therapy in nutrition.

Clinical impact of upper endoscopy in the management of patients with gastroesophageal reflux disease.

OBJECTIVE: Esophago-gastro-duodenoscopy (EGD) is frequently performed in patients with heartburn. However, the benefit of an EGD is unclear. The objective is to determine the clinical impact of performing an EGD in the management of GERD. METHODS: Patients with alarm symptoms or persistent heartburn from primary care and gastroenterology clinics were invited to participate. Patients with known reflux complications or an EGD procedure within 3 yr were excluded. Endpoints for EGD-improving management were prospectively defined: change in medical therapy, dilating esophageal stricture, identifying Barrett's esophagus (BE), finding severe esophagitis (Hetzel-Dent grade 3 or 4), or finding cancer. RESULTS: Two hundred and six patients (59 M/147 F; median age, 48 yr) were enrolled, in which, 124 had alarm symptoms and 82 had persistent heartburn. EGD improved the overall management in 40% of patients with alarm symptoms and 29% with persistent heartburn (p= NS). Medical therapy was altered in only 5% of patients, and no cancer was identified. EGD was more likely to improve management in males with alarm symptoms. CONCLUSIONS: It was uncommon for an EGD to alter antireflux therapy. The management was improved in approximately one-third of the patients by dilating esophageal stricture, finding BE to initiate surveillance, or finding severe esophagitis. EGD should be performed when alarm symptoms are present, especially in males.

Advances in alcoholic liver disease.

Alcoholic liver disease (ALD) remains a major cause of morbidity and mortality worldwide. For example, the Veterans Administration Cooperative Studies reported that patients with cirrhosis and superimposed alcoholic hepatitis had a 4-year mortality of >60%. Interactions between acetaldehyde, reactive oxygen and nitrogen species, inflammatory mediators and genetic factors appear to play prominent roles in the development of ALD. The cornerstone of therapy for ALD is lifestyle modification, including drinking and smoking cessation and losing weight, if appropriate. Nutrition intervention has been shown to play a positive role on both an inpatient and outpatient basis. Corticosteroids are effective in selected patients with alcoholic hepatitis and pentoxifylline appears to be a promising anti-inflammatory therapy. Some complementary and alternative medicine agents, such as milk thistle and S-adenosylmethionine, may be effective in alcoholic cirrhosis. Treatment of the complications of ALD can improve quality of life and, in some cases, decrease short-term mortality.

Association of metallothionein expression and lack of apoptosis with progression of carcinogenesis in Barrett's esophagus.

Barrett's esophagus is the transformation of normal esophageal squamous epithelium to specialized intestinal metaplasia (SIM). Among the Barrett's specialized cells, those that can develop protective mechanisms against apoptosis may have potential to become malignant. Studies have shown that overexpression of metallothionein (MT), low molecular protein that protects cells from apoptotic stimuli, appears to be associated with more advanced, highly malignant tumors. We thus investigated the relationship between MT expression and apoptosis in different stages of Barrett's carcinogenesis. Terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end labeling and immunohistochemical dual-staining assay were performed in human biopsy samples of normal, SIM, dysplasia, and adenocarcinoma. Apoptotic index and MT expression were quantified by using an image system to analyze the converted digital data. A negative correlation between MT expression and apoptotic index was found. MT expression was significantly increased along with the histologic progression towards adenocarcinoma. This study thus suggests that MT may contribute to cytoprotection, thereby inhibiting apoptosis and leading to carcinogenesis of Barrett's esophageal cells.

Diagnosis and treatment of alcoholic liver disease and its complications.

Alcoholic liver disease (ALD) is a serious and potentially fatal consequence of alcohol use. The diagnosis of ALD is based on drinking history, physical signs and symptoms, and laboratory tests. Treatment strategies for ALD include lifestyle changes to reduce alcohol consumption, cigarette smoking, and obesity; nutrition therapy; and pharmacological therapy. The diagnosis and management of the complications of ALD are important for alleviating the symptoms of the disease, improving quality of life, and decreasing mortality.

Hemorragia digestiva en el Hospital Nacional Cayetano Heredia / Gastrointestinal bleeding in patients admitted to the Cayetano Heredia Public Hospital

Se realizó un estudio prospectivo, descriptivo, entre agosto de 1994 y mayo de 1995, en el Hospital Nacional Cayetano Heredia, con el objetivo de evaluar las características clínicas, demográficas, evolutivas y diagnóstico endoscópico de pacientes con hemorragia digestiva. Ingresaron 100 pacientes, 86 correspondieron a hemorragia digestiva alta y 14 a hemorragia baja. En el primer grupo la edad media fue de 45.24 años (rango de 10 a 93), con una relación masculino/femenino de 3.5 a 1. Se presentó melena y hematemesis en 56.9 por ciento y sólo melena en 26.7 por ciento. Un 46.5 por ciento de los pacientes acudieron con historia de días de sangrado (2.07 días), con un rango de 1 a 8 días. El antecedente de consumo de antiinflamatorios no esteroideos en las 48 horas previas a la hemorragia estuvo presente en 19:7 por ciento y un porcentaje similar había consumido bebidas alcohólicas en dichoperíodo. Un 36 por ciento tenía antecedente de hemorragia digestiva previa. Las causas más frecuentes de hemorragia digestiva alta fueron úlcera duodenal en 38.3 por ciento , lesiones agudas de mucosa gástrica (gastritis erosiva) en 20.9 por ciento, úlceragástrica en 11.6 por ciento, várices esofágicas en 5.8 por ciento, síndrome de Mallory Weiss en 4.6por ciento.adenocarcinoma gástrico 2.3 por ciento, gastropatía por prolapso 2.3 por ciento, esofagitis 2.3 por ciento, úlceraen esófago 1.1 por ciento, duodenitis 1.1 por ciento y malformación arteriovenosa 1.1 por ciento. No se precisó la causa de la hemorragia en 8 por ciento. La endoscopía permitió determinar la causa delsangrado en 91.7 por ciento y en 66 por ciento de los casos se realizó dentro de las primeras 24 horas del ingreso. En 20.9por ciento coexistieron dos o más lesiones potencialmente sangrantes.9.1por ciento resangraron durante la hospitalización y un 11.6 por ciento de los pacientes fue intervenido quirúrgicamente. Siete pacientes (8.13 por ciento)fueron sometidos a terapia endoscópica: ...

A prospective study was performed to evaluate the epidemiological characteristics, clinical outcome and to determine the cause of bleeding in patients admitted to the Cayetano Heredia National Hospital with the diagnosis of gastrointestinal bleeding. Between August 1994 and May 1995, 100 patients were admitted , 86 patients with upper gastrointestinal bleeding and 14 with lower gastrointestinal bleeding. The meanage for the former was 45.25 years and the male/female ratio was 3.5/1 . The main complaints were tarry stools and haematemesis in 56.9 per cent ,and 26.7per cent only with melena. A history of non steroidal antiinflamatory drugs intake within 48 hours before thebleeding episode was obtained in 19.7 per cent and alcohol ingestion was observed in 19.7 per cent. In 36 per cent of the patients a history of a previous episode of bleeding was obtained. The major causes of bleeding were duodenal ulcer in 38.3 per cent, acute lesions of the gastric mucosa in 20.9 per cent, gastric ulcer in 11.6 per cent and esophageal varices in 5.8 per cent, Mallory Weiss syndrome in 4.6 per cent gastric carcinoma in 2.3 per cent, prolapse gastropaty 2.3 per cent, esophagitis in 2.3 per cent, esophageal ulcer 1.1 per cent, duodenitis 1.1 per cent, arteriovenus malformations in 1.1 per cent. The etiology of the hemorrhage could not be established in 8 per cent of cases. The diagnostic rate of endoscopy was 91.7 per cent. In 66 per cent of the patients the endoscopy was carried out within the 24 hours of admission. 20.9 per cent of the patients had other potential bleeding lesions. 9.1 per cent of the patients had anew episode of bleeding during hospitalization and surgery was needed in 11.6 per cent. Injectotheraphy was done in 7 (8.13 per cent) patients (4 for variceal , 2 for duodenal and 1 for gastric bleeding ). The overall mortality was 3.4 per cent. Fourteen patients with lower gastrointestinal bleeding were evaluated. ...

[GASTROINTESTINAL BLEEDING IN PATIENTS ADMITTED TO THECAYETADNO HEREDIA PUBLIC HOSPITAL] / Hemorragia Digestiva en el Hospital Nacional Cayetano Heredia.

A prospective study was performed to evaluate the epidemiological characteristics, clinical outcome and to determine the cause of bleeding in patients admitted to the Cayetano Heredia National Hospital with the diagnosis of gastrointestinal bleeding. Between August 1994 and May 1995, 100 patients were admitted, 86 patients with upper gastrointestinal bleeding and 14 with lower gastrointestinal bleeding. The mean age for the former was 45,25 years and the male/female ratio was 3.5/1. The main complaints were tarry stools and haematemesis in 56,9% and 26,7% only with melena. A history of non steroidal antiinflamatory drugs intake within 48 hours before the bleeding episode was obtained in 19,7% and alcohol ingestion was observed in 19,7%. In 36% of the patients a history of a previous episode of bleeding was obtained. The major causes of bleeding were duodenal ulcer in 38,3%, acute lesions of the gastric mucosa in 20,9%, gastric ulcer in 11,6% and esophageal varices in 5,8%, Mallory Weiss syndrome in 4,6%, gastric carcinoma in 2,3%, prolapse gastropaty 2,3%, esophagitis in 2,3%, esophageal ulcer 1,1 %, duodenitis 1,1%, arteriovenus malformations in 1,1%. The etiology of the hemorrhage could not be established in 8% of cases. The diagnostic rate of endoscopy was 91,7%.In 66% of the patients the endoscopy was carried out within the 24 hours of admission 20,9% of the patients had other potential bleeding lesions 9,1% of the patients had a new episode of bleeding during hospitalization and surgery was needed in 11,6%. Injectotheraphy was done in 7 (8,13%) patients (4 for variceal 2 for duodenal and 1 for gastric bleeding ) The overall mortality was 3,4% Fourteen patients with lower gastrointestinal bleeding were evaluated. The mean age was 53,14 years and the male/female ratio was 1.6/1. The main complaint was hematochezia. The major causes of bleeding were hemorrhoidal disease in 64,2% and rectal cancer in 14,28%.