Beyond the three P's: adrenal involvement in MEN1.

Adrenal lesions (ALs) are often detected in patients with multiple endocrine neoplasia type 1 (MEN1). However, they are not well described in MEN1, making their clinical management unclear. This study examined the prevalence and outcomes of ALs found in MEN1. We performed a retrospective chart review of patients diagnosed with MEN1 from 1990 to 2021. ALs were diagnosed using abdominal or thoracic imaging and classified as being unilateral or bilateral, having single or multiple nodules, and as having diffuse enlargement or not. Measurable nodular lesions were analyzed for their size and growth over time. Patients' clinical and radiographic characteristics were collected. We identified 382 patients with MEN1, 89 (23.3%) of whom had ALs. The mean age at detection was 47 ± 11.9 years. We documented 101 measurable nodular lesions (mean size, 17.5 mm; range, 3-123 mm). Twenty-seven nodules (26.7%) were smaller than 1 cm. Watchful waiting was indicated in 79 (78.2%) patients, of whom 28 (35.4%) had growing lesions. Functional lesions were diagnosed in 6 (15.8%) of 38 that had functional work-up (diagnoses: pheochromocytoma (n = 2), adrenocorticotropic hormone-dependent hypercortisolism (n = 2), hyperandrogenism (n = 1), hyperaldosteronism (n = 1)); surgery was indicated for 5 (83.3%; n = 12 nodules), 2 of whom had bilateral, diffuse adrenal enlargement. Two patients were diagnosed with adrenocortical carcinoma and two with neoplasms of uncertain malignant potential. Radiographic or clinical progression of ALs is uncommon. Malignancy should be suspected on the basis of a lesion's growth rate and size. A baseline hormonal work-up is recommended, and no further biochemical work-up is suggested when the initial assessment shows nonfunctioning lesions.

Comparison of benign and malignant insulinoma.

BACKGROUND: How malignant insulinomas present relative to benign insulinomas is unknown. METHODS: A single-institution retrospective study identified patients with insulinoma. Malignancy was defined by distant metastases, positive lymph node(s), T stage of 4, direct invasion into surrounding peripancreatic tissue, or presence of lymphovascular invasion. Wilcoxon Rank Sum tests and Kaplan-Meier analysis were used. RESULTS: A total of 311 patients were identified: 51 malignant and 260 benign. Patients with malignant insulinoma presented with higher levels of insulin, proinsulin, and c-peptide. Malignant lesions were larger: 4.2 ± 3.2 vs 1.8 ± 0.8 cm in benign lesions, p < 0.01. Overall survival at 5 years was 66.8% vs 95.4% for malignant and benign insulinoma respectively, p < 0.01. CONCLUSIONS: Larger size of insulinoma and increased serum ß-cell polypeptide concentrations were associated with malignancy. Malignant insulinoma has poorer survival. Further work-up to rule out malignancy may be indicated for larger pancreatic lesions and for patients with higher pre-operative insulin and pro-insulin.

Outcomes of Duodenal Switch with a Moderate Common Channel Length and Roux-en-y Gastric Bypass: Does One Pose More Risk?

BACKGROUND: Traditional duodenal switch (DS) typically leaves a short common channel and is infrequently performed in part due to increased risk of malnutrition. We compared nutritional deficiencies between DS with a moderate channel length and standard proximal Roux-en-Y gastric bypass (RYGB). METHODS: We conducted a retrospective review of 61 matched pairs who underwent DS or RYGB using our institutional database; patients were matched on sex, age, race, and BMI. DS was performed with a common channel length between 120 and 150 cm. Thirty-day complications, total body weight loss (TBWL) %, and nutritional labs up to 24 months were compared using paired t test and Wilcoxon rank sum tests. RESULTS: Weight loss was similar at each time point (all p > 0.1). DS patients had lower vitamin D levels at 6 months, lower calcium levels at 6 and 12 months, and lower hemoglobin at 12 months and otherwise equivalent (all p < 0.05). Revision was rare (1 DS; 0 RYGB). There were no differences in short-term complications (p = 0.28). CONCLUSION: DS with a moderate common channel length is safe with a low revision rate. Weight loss and nutritional outcomes appear to be comparable to RYGB, and it may be considered an effective RYGB alternative.

Single-center experience with Indigo aspiration thrombectomy for acute lower limb ischemia.

OBJECTIVE: Acute lower limb ischemia (ALLI) is a challenging vascular emergency with notable morbidity. Aspiration mechanical thrombectomy (AMT) devices are an alternative approach to remove thrombus in the peripheral arterial system and to restore limb perfusion, but data are limited. We evaluated the outcomes of AMT for the treatment of ALLI at our institution. METHODS: We performed a single-center retrospective review of patients with ALLI treated with Indigo (Penumbra Inc, Alameda, Calif) AMT device from 2014 to 2017. The primary outcome was technical success (restoration of blood flow with <50% residual thrombus without need for catheter-directed thrombolysis [CDT] or open surgery) as main treatment or adjunctive treatment (after failure of another modality). Indications, anatomic segments treated, outcomes, and complications were reviewed. RESULTS: There were 41 patients (68% male, 32% female; mean age, 67 years; range, 27-90 years) who underwent 43 procedures. The cause of ALLI was embolism (18), native vessel thrombosis (13), bypass thrombosis (7), intraluminal thrombus due to pseudoaneurysm (1), stent thrombosis (1), intraprocedural embolization (1), recurrent thrombosis of native vessel (1), and chronic thrombosis (1). AMT was the main treatment in 29 cases and adjunctive in 14. Technical success was 52% (15/29) as main treatment and 50% (7/14) as adjunctive treatment. Thrombolysis was avoided in 53% of patients (23/43). There were six thrombotic recurrences, one after successful isolated AMT. The other five required multiple modalities after AMT failure. There were no 30-day deaths. Five patients required amputations, but only one after successful AMT. Complications included intraoperative distal embolization (two), access site hematoma (one), pseudoaneurysm (one), acute kidney injury (one), and spontaneous calf hematoma (one). There were no blood transfusions required or severe bleeding complications. CONCLUSIONS: With an overall success rate of 51% in selected patients, the Indigo AMT device avoided the need for CDT or open surgery in about half of patients with ALLI. The device has a favorable safety profile, particularly in high-risk cases. Given its moderate effectiveness, the role of Indigo AMT in the management of ALLI will further be defined by the description of optimal technique, the determination of treatment indications, and a direct comparison with CDT.

ProCura - a arte da vida: um projeto pela humanização na saúde / ProCura - the art of living: a project for the humanization of health care

As modificações da medicina tornaram o conhecimento biomédico soberano, gerando a perda da relação médico-paciente, o que fomentou o movimento pela humanização. Na Universidade Federal do Paraná (UFPR), formou-se o projeto de extensão "ProCura - a arte da vida", a fim de implementar a humanização entre os alunos e em suas relações profissionais. Seus objetivos se baseiam nos pilares: relação estudante-paciente, relação estudante-estudante e formação teórico-reflexiva, e se subdividem nos grupos Cineclube, Clown e Contação de Histórias. De 2010 a 2012, 79 alunos participaram e atenderam 905 pacientes, 505 acompanhantes e 107 funcionários. Apesar de limitações de alcance no que concerne a atingir todos os alunos do Setor de Ciências da Saúde, o projeto pretende fomentar a discussão entre grupos e que seus ideais e atividades se espalhem e permeiem o meio acadêmico.

Changes in medicine have promoted biomedical knowledge to a position of sovereignty. Coupled with the decline of the physician-patient relationship, this has brought about the the humanization movement. At the Federal University of Paraná (UFPR), a community outreach project entitled "ProCura - the art of living" has been created to implement humanization among students and in their professional relationships. Its objectives are based on three pillars: student-patient relationship, student-student relationship and theoretical-reflexive training, subdivided into groups named Cineclube, Clown and Contação de Histórias. Between 2010 and 2012, 79 students participated in the project, attending to 905 to patients, 505 companions and 107 employees. Despite its limited scope as regards reaching all Department of Health Sciences students, the Project aims to promote discussion between groups and disseminate their ideals and activities throughout academic circles.