The Use of Noninvasive Scores in Predicting NAFLD Progression After Bariatric Surgery.

BACKGROUND: Bariatric surgery has been postulated to impact liver function resulting in favorable effects on nonalcoholic fatty liver disease (NAFLD). We aimed to analyze the long-term impact of bariatric surgery on noninvasive scores predicting the progression of liver fibrosis in a bariatric population. METHODS: We retrospectively reviewed the records of patients without pre-existing liver disease who underwent sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) at our center between 2010 and 2018. Four predictive scores for liver fibrosis (AST/ALT, APRI, Fib-4, and BARD) were calculated preoperatively, 6 months post-operatively, and annually up to 5 years. Correlations were analyzed with Pearson R. Subgroup and sensitivity analyses were performed to identify populations at increased risk. RESULTS: A total of 2769 patients were included. The mean age was 40 years, and the majority was females (88.5%) and of Hispanic ethnicity (59.2%). There was a steady post-operative increase in the percentage of patients at increased risk of progression of liver fibrosis. The Fib-4 score showed the largest increase in the population at risk for liver fibrosis (11.3% preoperatively to 28.9% at 5 years). Patients with diabetes and those who underwent a sleeve gastrectomy continued to display a higher risk for liver fibrosis than did patients without diabetes and those who underwent RYGB, respectively. CONCLUSION: There was an overall trend to increased liver fibrosis scores over the 5-year post-operative follow-up, but this increase remained lower than that reported in previous literature. Bariatric surgery offers NAFLD risk reduction in a high-risk population.

Kikuchi-Fujimoto disease: the quandary continues.

Kikuchi-Fujimoto disease (KFD) is a rare lymphohistiocytic disorder with an unknown etiopathogenesis. Due to its non-specific lymphadenopathy presentation, treatment is complicated by the frequency by which it is misdiagnosed-for example up to one-third of cases are misdiagnosed as malignant lymphoma, leading to expensive clinical testing and overtreatment of this typically self-limiting illness. KFD has a strong association with SLE, although its transience and rarity make it difficult to investigate. We present a case of KFD to illustrate the variance in presentation and typical outcome of KFD. We want to increase awareness and shed some light on some typical and atypical clinical presentations of KFD to reduce the incidence of misdiagnosis.

Bariatric Surgery Improves Renal Function: a Large Inner-City Population Outcome Study.

BACKGROUND: Bariatric surgery is associated with improved renal dysfunction in general population studies. The study examined the effects of bariatric surgery on renal function in a predominantly Hispanic and African American population at a community hospital in New York, USA. METHODS: This retrospective study analyzed prospectively collected bariatric surgical data from 2247 patients (89% female) who underwent bariatric surgery at a single center. Changes in glomerular filtration rate (eGFR), urine albumin-creatinine ratio (UACR), micro- and macroalbuminuria, and hyperfiltration, which were measured preoperatively and then yearly for 3 years postoperatively, were evaluated with t tests and logistic regression analysis, after adjusting for confounding variables. The mean age of the patients at surgery was 37.1 years; the mean preoperative body mass index was 45 ± 7 kg/m2. RESULTS: The results obtained 3 years postoperatively showed the following significant improvements compared with the preoperative values: mean UACR decreased from 40.3 to 11.1 mg/g, mean eGFR improved from 79.4 to 87.3 mL/min, the prevalence of microalbuminuria decreased from 13.7 to 6.2%, the prevalence of macroalbuminuria decreased from 2.5 to 0%, and the prevalence of hyperfiltration decreased from 4.4 to 2.7% (all P < .0001). In adjusted multivariate regression analysis, these results remained significant after adjusting for age, sex, race, type of surgery, and presence of diabetes mellitus or hypertension. CONCLUSION: In this large study at an inner-city hospital, bariatric surgery was associated with significant improvements in renal dysfunction parameters. These results could assist with informed decisions regarding indications for bariatric surgery.

Weight Loss Outcomes following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in an Ethnically Diverse Bariatric Population: Which Is More Effective?

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) have comparable weight loss outcomes in a general bariatric population. OBJECTIVES: This study aimed to investigate whether similar outcomes can be observed in Hispanic and African American population. Settings. Community Hospital in New York, New York, United States. METHODS: The 5-year prospective data of patients who underwent LRYGB and LSG at a single center were retrospectively reviewed. The long-term weight loss outcomes between patients who had LRYGB and LSG were compared after adjusting for age, sex, race, diabetes mellitus, and hypertension with the linear mixed-effects or logistic regression model. RESULTS: Most patients were Hispanic (59.2%) and African American (22.7%). The mean% total weight loss (%TWL) values of patients with BMI <45 kg/m2 who underwent LRYGB and LSG were 73% and 62% after 1 year, 69% and 56% after 2 years, and 71% and 54% after 5 years, respectively. In patients with a BMI of 45-50 kg/m2 who underwent LRYGB and LSG, the mean %TWL values were 69% and 56% after 1 year, 75% and 58% after 2 years, and 57% and 45% after 5 years, respectively. Meanwhile, the %TWL values of patients with BMI >50 kg/m2 who had LRYGB and LSG were 53% and 42% after 1 year, 53% and 45% after 2 years, and 49% and 36% after 5 years, respectively. All results were statistically significant (p < 0.0001) and remained valid after adjusting for cofactors. CONCLUSION: Thus, LRYGB had consistent and sustained long-term weight loss outcomes compared with LSG in a predominantly ethnically diverse patient population with different BMI. Our study had several limitations in that it is retrospective in nature and some patients were lost to follow-up during the study period.

Improvement in glycated hemoglobin A1C after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an ethnically diverse population with diabetes.

BACKGROUND: Obesity is a well-known risk factor for the development of type 2 diabetes. The efficacy of bariatric surgery in reducing weight with resulting improvement in type 2 diabetes has been reliably demonstrated. OBJECTIVES: We investigated and compared the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on glycated hemoglobin (HbA1C) levels in a predominantly Hispanic and black population. SETTINGS: Community Hospital in New York, New York, United States. METHODS: This is a retrospective review of a 5-year data from a single center where patients with diabetes who underwent LRYGB or LSG were included. HbA1C levels and body mass index were analyzed preoperatively and then annually postoperatively for up to 5 years. Improvements in HbA1C were compared between the 2 groups after adjusting for age, sex, race, and hypertension with linear mixed-effects or logistic regression models. RESULTS: Of the 676 included patients, 84.8% were females and the mean age was 47 years. HbA1C levels decreased significantly (P < .05) in the entire group at 1 (21%), 2 (20%), 3 (20%), 4 (18%), and 5 (14%) years. Compared with LSG, LRYGB patients displayed greater improvement in HbA1C levels at 1 year (25% versus 17%, P = .001). The differences in the reduction of HbA1C between LRYGB and LSG for the other time intervals were not significant (P > .05), 24% versus 17% (2 yr), 22% versus 16% (3 yr), 22% versus 13% (4 yr), and 17% versus 10% (5 yr). Changes in body mass index were not correlated to changes in HbA1C at various study points. CONCLUSION: Both LRYGB and LSG resulted in significant decreases in HbA1C levels and are correlated with changes in body mass index. LRYGB had the greatest effect at 1 year postoperatively. There was no significant difference in HbA1C reduction for LRYGB and LSG after 1 year postoperatively in this predominantly Hispanic and black cohort.

Giant Mucinous Carcinoma of the Breast.

We report a case of giant mucinous carcinoma of the breast in a 55-year-old female who presented with left breast lump for two years. The patient did not seek any medical attention for two years. On exam, the lump measured 12 x 14 cm. Core needle biopsy showed invasive mucinous adenocarcinoma without ductal component. The patient underwent neo-adjuvant chemotherapy without any response. She underwent left modified radical mastectomy. All lymph nodes were negative. This was followed by adjuvant chemotherapy. Mucinous carcinoma is a rare type of breast cancer that carries a good prognosis compared to other types of breast cancers. In this report, we presented a giant mucinous carcinoma measuring 14 cm.

Small bowel obstruction due to mesenteric abscess caused by Mycobacterium avium complex in an HIV patient: a case report and literature review.

Small bowel obstruction in HIV patients is reportedly caused by inflammatory pseudotumor, Kaposi's sarcoma, cryptococcal lymphadenopathy and intestinal tuberculosis. The incidence of Mycobacterium avium complex (MAC) infection in HIV patients is 3% for CD4 cell count of 100-199 /mm3. MAC causing small bowel obstruction is rarely reported in the literature. We report a rare case of MAC causing mesenteric abscess with small bowel obstruction in a HIV patient with a CD4 cell count of 144 /mm3. Patient was a 35-year-old HIV-positive male on highly active antiretroviral therapy who presented with partial small bowel obstruction secondary to mesenteric abscess. He underwent operative intervention for drainage with cultures growing MAC.

Acute Pancreatitis with Splenic Infarction as Early Postoperative Complication following Laparoscopic Sleeve Gastrectomy.

Obesity is becoming a global health burden along with its comorbidities. It imposes tremendous financial burden and health costs worldwide. Surgery has emerged as the definitive treatment option for morbidly obese patients with comorbidities. Laparoscopic sleeve gastrectomy is performed now more than ever making it imperative for physicians and surgeons to recognize both the common and the uncommon risks and complications associated with it. In this report we describe a rare early life-threatening postoperative complication following laparoscopic sleeve gastrectomy. From our extensive review of literature, there is no existing report of acute pancreatitis with splenic infarction postsleeve gastrectomy to this date.

Tracheostomy Exchange Resulting in Rare Combination of Pneumomediastinum, Pneumothorax, Massive Pneumoperitoneum, and Subcutaneous Emphysema.

Tracheostomy tube change is a relatively common and simple procedure once a tract is formed between the skin and the trachea. Regular tracheostomy tube changes decrease the risk of postoperative pulmonary infection and granulation tissue formation. However, serious complications, such as loss of airway, subcutaneous emphysema, and mediastinitis, can occur if the tube exchange is performed inappropriately. We present a rare association of subcutaneous emphysema, tension pneumothorax, pneumomediastinum, and pneumoperitoneum following a tracheostomy tube exchange in a 56-year-old patient who had his tracheotomy placed a month ago. The patient was successfully managed conservatively by chest tube and supportive care.

Small bowel lymphangioma causing ileo-ileal intussusception in adults.

INTRODUCTION: Lymphangioma is a rare benign tumor found in gastrointestinal tract. Most lymphangiomas can occur at any age and but mostly are found in children and infants. They are mainly due to malformation of the lymphatic system. They occur mainly in the head, neck and oral cavity, but less commonly develop in the abdominal cavity. Colonoscopy and endoscopic ultrasonography are frequently used to diagnose lymphangiomas of the small bowel. Ileo-ileal intussusception due to small bowel lymphangiomas has been rarely reported. PRESENTATION OF CASE: We report a case of 24 year old female who presented to the hospital with sudden onset of right sided upper and lower abominal pain with nausea and vomiting, elevated WBC count of 15.1 µL. After careful examination and CT scan of Abdomen patient was found to have an ileo-ileal intussusception secondary to small bowel lymphangioma. In a rare clinical presented case, we performed a diagnostic laparoscopy (Fig. 1), exploratory laparotomy, small bowel resection, and stable primary anastomosis. Post-operative patient did well and was discharged on 4th post-operative day without complications. DISCUSSION: Lymphangiomas are rare benign tumors which have soft tissue consistency and often congenital malformation of the lymphatic system. Ileo-ileal intussusception in an adults can be a life threatening condition which requires prompt diagnosis and urgent intervention due to the risk of developing ischemic bowel. Prompt diagnosis and urgent intervention can lead to favourable. CONCLUSION: We present this rare case of ileo-ileal intussusception secondary to small bowel lymphangioma with literature review.

A rare case of listeriosis, acute cholecystitis and multiple myeloma.

Listeria monocytogenes (LM) is an aerobic, motile, intracellular gram-positive bacterium. Most invasive systemic infections caused by LM are commonly seen in patients at both extremes of age, during pregnancy or in immunocompromised hosts. Common clinical manifestations of LM infection in immunocompromised adults are bacteremia, infections of central nervous system, such as meningitis, and self-limiting febrile gastroenteritis. Focal infections of listeria are rare, especially cholecystitis, with only few cases reported in the last 33 years. A 62-year-old man presented with multiple myeloma, cholecystitis and LM bacteremia. Due to prompt surgical treatment and antibiotics (amoxicillin plus clavulanic acid and gentamycin), this high-risk patient recovered without any complications.

A giant phyllodes tumor causing ulceration and severe breast disfigurement: case report and review of giant phyllodes.

Phyllodes tumors are rare fibroepithelial tumors that account for <1% of the breast tumors in women. These tumors are often benign unilateral lesions of the female breast (70%). Less common are malignant phyllodes, which have the potential for hematogenous spread. Phyllodes tumors can be seen in all age groups, and the median age of presentation is 45 years. Surgery is the main form of treatment. Wide excisions with margins of 1cm are suggested. While smaller and moderate size phyllodes may typically be seen, gigantic ones are very rare. These may be seen in neglected tumors. By definition, a giant phyllodes tumor is one larger than 10 cm in diameter. We report a gigantic phyllodes tumor that grew over 7 years period causing significant ulceration and disfigurement and review features of these tumors and management.

Immature rat myeloid dendritic cells generated in low-dose granulocyte macrophage-colony stimulating factor prolong donor-specific rat cardiac allograft survival.

BACKGROUND: Because the differential polarization of T cells in response to antigen presentation is dependent on the maturational state of dendritic cells (DCs), we hypothesized that the adoptive transfer of immature myeloid DCs (iMDCs) would prolong graft survival. METHODS: To evaluate this hypothesis, we studied the effects of transfer of iMDCs and mature myeloid DCs (mMDCs) on rat cardiac allograft survival. RESULTS: Whereas iMDCs that do not express costimulatory molecules induce allogeneic T-cell hyporesponsiveness in coculture studies, mMDCs that express high levels of major histocompatibility complex class II costimulatory and maturation molecules induce a robust allostimulatory T-cell response. Adoptive transfer of Wistar Furth iMDCs, unlike mMDCs, 7 days before cardiac transplantation significantly prolonged graft survival. It was important that adoptive transfer of iMDCs combined with 0.5 mL antilymphocyte serum (ALS) transient immunosuppression on day -7 led to donor-specific permanent graft survival in 50% of recipients. In contrast, adoptive transfer of mMDCs combined with ALS led to graft survival similar to that in recipients treated with ALS alone. Stimulation of CD4 T cells isolated from the spleen of unresponsive allograft recipients with donor antigen resulted in donor-specific hyporesponsiveness and production of interleukin (IL)-10 and transforming growth factor-beta but not IL-4 and interferon-gamma. The tolerant T-cell unresponsiveness was reversed by the addition of IL-2. CONCLUSION: Our data confirming the immunoregulatory effect of immature DCs indicate that induction of transplant tolerance by iMDCs is partly dependent on in vivo generation of regulatory T cells. This finding suggests that immunization with immature donor DCs has therapeutic potential for the induction of transplant tolerance and treatment of autoimmune diseases.

Role of CD41CD251 regulatory T cells from naive host thymus in the induction of acquired transplant tolerance by immunization with allo-major histocompatibility complex peptide.

BACKGROUND: Immunization with allo-major histocompatibility complex peptide induces operational tolerance, whereas thymectomy abrogates this effect. We hypothesized that recent thymic emigrants with regulatory function are important in the induction of acquired transplant tolerance in this system. METHODS: In this study, we examined the possibility of restoring transplant tolerance to thymectomized (TMX) ACI recipients with concomitant adoptive transfer of syngeneic T cells indirectly primed with a single immunodominant Wistar Furth allo-major histocompatibility complex class I peptide (peptide 5, residues 93-109) and unmodified thymocytes or CD4+CD25+ thymic T cells. RESULTS: Co-transfer of in vivo allopeptide-primed T cells and naive syngeneic thymic T cells on day -7 restored permanent acceptance of cardiac allografts to 70% of transiently antilymphocyte serum-immunosuppressed TMX recipients. Similarly, the adoptive transfer of allopeptide-primed T cells led to 100% donor-specific permanent graft acceptance among transiently antilymphocyte serum-immunosuppressed TMX recipients with renal subcapsular syngeneic thymic grafts. To demonstrate the role of regulatory T cells among new thymic emigrants in the induction of tolerance, we showed that the co-transfer of CD4+CD25+ but not CD4+CD25- thymic T cells with allopeptide-primed syngeneic T cells restored tolerance to TMX recipients. It seems that the induction of transplant tolerance in this system is dependent on the presence of CD4+CD25+ regulatory T cells among the recent thymic emigrants. CONCLUSIONS: This study suggests that CD4+CD25+ regulatory T cells specific for the induction of transplant tolerance are similar in origin, phenotype, and function to those involved in the maintenance of self-tolerance and the prevention of autoimmunity.

Peritransplant streptavidin recipient treatment prolongs rat cardiac allograft survival.

BACKGROUND: Because streptavidin shows high localization in inflamed tissues, it might also interfere with the proliferation of cells involved in allograft rejection. METHODS AND RESULTS: Treatment of naïve ACI recipients with 20 mg/kg streptavidin i.p. alone significantly prolonged Lewis cardiac allografts from a mean survival time of 9.8+/-0.7 days in controls to 19.8+/-6.5 days, with one recipient accepting the graft permanently (>250 days). Peritransplant streptavidin treatment combined with 0.5 ml of antilymphocyte serum (ALS) transient immunosuppression led to permanent graft survival (>250 days) in 6 of 10 recipients. Second-set skin grafts performed 60 days after the primary cardiac allograft were prolonged to 45 days, whereas the third party Wistar-Furth (WF) skin grafts were rejected in 15 days without the rejection of the primary Lewis cardiac allografts. Pathology of transplanted cardiac allografts at 100 days showed no mononuclear cell infiltration or chronic allograft vasculopathy. Streptavidin given for 5 days at 20 mg/kg caused a moderate initial weight loss but had no effect on hematologic, biochemical, and histologic parameters in the treated recipients. CONCLUSION: This study demonstrates that peritransplant recipient treatment with streptavidin combined with peritransplant ALS induces prolonged cardiac and second-set skin allograft survival. We conclude that recipient peritransplant streptavidin treatment may provide a new strategy for the induction of transplant tolerance.

CD4+CD25+ regulatory T cells mediate acquired transplant tolerance.

The Holy Grail of clinical organ transplantation is the safe induction of allograft tolerance. Transplant tolerance has been successfully induced in animal models. Since T cells play a pivotal role in graft rejection, modulating T cell function has been the primary focus of studies aimed at inducing transplant tolerance. Rodent models of transplant tolerance induction include central deletion and peripheral mechanisms involving activation-induced cell death (AICD), anergy, immune deviation, and production of regulatory T cells. These mechanisms are not mutually exclusive. Although clonal deletion and anergy limit self-reactive T cells in the thymus, these mechanisms alone are not sufficient for controlling self-reactive T cells in the periphery. There is now evidence that the adult animal harbors two functionally distinct populations of CD4(+) T cells; one mediates autoimmune disease and the other dominantly inhibits it. The latter cells express CD4, CD25 and CTLA-4. These thymus-derived T cells have recently been shown to mediate the induction and maintenance of transplant tolerance. These CD4(+)CD25(+) T cells are similar in origin, phenotype, and function to those that maintain natural self-tolerance and T cell homeostasis in the periphery. Against this background, is it possible that alloantigen specific regulatory T cells might be generated and expanded ex vivo before organ transplantation and then infused to induce long-term tolerance, perhaps without the need for chronic immunosuppression?

Breast cancer in women with human immunodeficiency virus infection: pathological, clinical, and prognostic implications.

BACKGROUND: AIDS and breast cancer have become two important public health issues for women. Of interest is the prolonged survival of patients diagnosed with HIV infection as a result of the use of highly active antiretroviral therapy (HAART). With improved survival, we are likely to see more HIV-infected patients with breast cancer. METHODS: This study, which is a review of our experience at Harlem Hospital Center, New York, between 2000 and 2008, compared HIV-positive with HIV-negative breast cancer patients, with attention to tumor size, stage, grade, molecular markers and lymphovascular invasion, treatment, and patient survival. RESULTS: Only 63 of 370 patients with breast carcinoma were tested for HIV, and 6 of the 63 women tested positive for HIV. We, therefore, compared the clinical features and tumor characteristics seen in the 6 HIV-infected women with those of the 57 HIV-seronegative breast cancer patients. We found no differences in presentation, median age, and tumor morphology in the two groups of patients. When the patients in our previous report on 5 HIV-positive breast cancer patients were added to the present group, the overall 5-year survival rate among the 11 HIV-infected patients was 75%. Of note is the finding that HIV infection in premenopausal women was not associated with aggressive breast cancer subtypes with poor survival outcome. CONCLUSIONS: These results demonstrate that histological subgroups and 5-year survival appear similar among HIV-positive breast cancer patients.

Breast cancer in women with HIV/AIDS: report of five cases with a review of the literature.

BACKGROUND: The association of human immunodeficiency virus (HIV) infection with breast carcinoma is unclear. With improved survival of HIV-infected patients due to better understanding and treatment of the disease, there is likely to be an increase in incidence of breast cancer in women with HIV infection. METHODS: The medical records of 305 patients with breast cancer seen between January 1995 and December 2000 at Harlem Hospital Center, New York, where approximately 1,000 HIV-infected patients are treated yearly, were reviewed with attention to age, breast cancer stage at presentation, and patient survival. RESULTS: Breast cancer in the five HIV-infected patients has same median age distribution, disease stage, and pathologic characteristics as in the 300 HIV-indeterminate patients. Four of the five (80%) HIV-infected women compared to 79% in the HIV-indeterminate patients presented with early breast cancer (Stages I and II). Five-year survival in the HIV-infected patients is 80%, which is similar to the observed 70% 5-year crude survival rate in the indeterminate group. CONCLUSIONS: Our results do not support the recent reports suggesting that HIV infection is associated with poorly differentiated, aggressive disease with poor survival outcome. It remains unclear if breast carcinoma is directly linked to HIV infection.