Impact of small intestinal bacterial overgrowth on systemic inflammation, circulatory and renal function, and liver fibrosis in patients with cirrhosis and ascites.

Background: Small intestinal bacterial overgrowth (SIBO) occurs frequently in patients with cirrhosis, particularly in those with ascites, and promotes the translocation of gut-derived bacterial products into the portal and systemic circulation. We investigated the effects of SIBO on systemic inflammatory activity, circulatory and renal function, and the degree of liver fibrosis in patients with cirrhosis and ascites. Methods: Eighty patients with cirrhosis and ascites were prospectively enrolled. SIBO was determined by lactulose breath test. Serum levels of lipopolysaccharide-binding protein (LBP), tumor necrosis factor-α, and interleukin-6, mean arterial pressure (MAP), cardiac output (CO) by echocardiography, systemic vascular resistance (SVR) as MAP/CO ratio, plasma renin activity (PRA), plasma aldosterone, radioisotope-assessed glomerular filtration rate (GFR), and liver stiffness by shear wave elastography were evaluated. Results: SIBO was detected in 58 patients (72.5%). Compared to patients without SIBO, those diagnosed with SIBO had significantly higher LBP levels (P<0.001), significantly lower MAP (P<0.001) and SVR (P<0.001), and significantly higher CO (P=0.002) and PRA (P<0.001). Patients with SIBO had significantly lower GFR (P=0.02) and higher liver stiffness (P=0.04) compared to those without SIBO. The presence of SIBO was independently associated with LBP (P=0.007) and PRA (P=0.01). Among patients with SIBO, peak breath hydrogen concentration was significantly correlated with serum LBP (P<0.001), MAP (P<0.001), CO (P=0.008), SVR (P=0.001), PRA (P=0.005), plasma aldosterone (P<0.001), GFR (P<0.001), and liver stiffness (P=0.004). Conclusion: SIBO in patients with cirrhosis and ascites may predispose to greater systemic inflammation, circulatory and renal dysfunction, and more advanced liver fibrosis.

Elderly patients with non-cardiac admissions and elevated high-sensitivity troponin: the prognostic value of renal function.

BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events. However, most studies on the role of elevated hs-cTn in elderly populations have investigated the prognostic value of hs-cTn in patients with a specific diagnosis or have assessed the relationship between hs-cTn and comorbidities. AIM: To investigate the in-hospital prognosis of consecutive elderly patients admitted to the Internal Medicine Department with acute non-cardiac events and increased hs-cTnI levels. METHODS: In this retrospective study, we selected patients who were aged ≥ 65 years and admitted to the Internal Medicine Department of our hospital between January 2019 and December 2019 for non-cardiac reasons. Eligible patients were those who had hs-cTnI concentrations ≥ 100 ng/L. We investigated the independent predictors of in-hospital mortality by multivariable logistic regression analysis. RESULTS: One hundred and forty-six patients (59% female) were selected with an age range from 65 to 100 (mean ± SD: 85.4 ± 7.61) years. The median hs-cTnI value was 284.2 ng/L. For 72 (49%) patients the diagnosis of hospitalization was an infectious disease. The overall in-hospital mortality was 32% (47 patients). Individuals who died did not have higher hs-cTnI levels compared with those who were discharged alive (median: 314.8 vs 282.5 ng/L; P = 0.565). There was no difference in mortality in patients with infectious vs non-infectious disease (29% vs 35%). Multivariable analysis showed that age (OR 1.062 per 1 year increase, 95%CI: 1.000-1.127; P = 0.048) and creatinine levels (OR 2.065 per 1 mg/dL increase, 95%CI: 1.383-3.085; P < 0.001) were the only independent predictors of death. Mortality was 49% in patients with eGFR < 30 mL/min/1.73 m2. CONCLUSION: Myocardial injury is a malignant condition in elderly patients admitted to the hospital for non-cardiac reasons. The presence of severe renal impairment is a marker of extremely high in-hospital mortality.

Low-birth-weight, but not catch-up growth, correlates with insulin resistance and resistin level in SGA infants at 12 months.

OBJECTIVE: To investigate the insulin resistance status in SGA infants at 12 months and its relationship with auxological and metabolic parameters. METHODS: One group of 45 SGA and one of 50 appropriate for gestational age infants were followed from birth to the end of the first year of life. At 12 months, skinfold thickness, waist circumference, and blood levels of glucose, insulin, adiponectin, leptin, resistin, visfatin, retinol-binding protein 4, IGFs, lipids profile were determined, and the HOMA-IR index was calculated. RESULTS: The SGAs had increased insulin (5.2 ± 2.7 versus 2.9 ± 2.4 µIU/ml, p = 0.012) and HOMA-IR (1.09 ± 0.9 versus 0.59 ± 0.55, p = 0.016). In multiple regression, insulin resistance indices were independently correlated with low-birth-weight (ß = -2.92, p = 0.015 for insulin, ß = -2.98, p = 0.011 for HOMA-IR) but not with catch-up growth in either height or weight or any other metabolic parameter. Resistin was higher in the SGAs (5.1 ± 2.1 versus 3.9 ± 2.1 ng/ml, p = 0.03) and independently correlated with low-birth-weight but not insulin resistance. Resistin was negatively correlated with total cholesterol (R = -0.33, p = 0.007) and positively with lipoprotein(a) (R = 0.49, p = 0.001). CONCLUSION: Low-birth-weight, but not catch-up growth or adiposity tissue hormones, was correlated with insulin resistance at 12 months in non-obese SGA infants. The higher resistin in SGA infants and its correlation with total cholesterol and lipoprotein(a) need further clarification.

Outcomes of one-side versus two-sides recipient vessels for bilateral breast reconstructions with bilateral DIEP flaps.

BACKGROUND: This study was to compare the use of one-side versus two-sides recipient vessels in either bilateral breast reconstructions or unilateral breast reconstruction with contralateral augmentation using bilateral DIEP flaps. PATIENTS AND METHODS: A retrospective review including all cases of bilateral breast reconstructions and unilateral reconstruction with contralateral augmentation with DIEP flaps was performed. Patient's demographics, surgical variables, and outcome were collected. Two distinct cohorts based on the recipient vessel techniques, one-side versus two-sides, were compared. RESULTS: A total of 25 patients with 50 split-DIEP flaps were included, with one-side recipient vessels used in 19 patients and two-sides recipient vessels in 6 patients. Ischemia time was significantly reduced in one-side recipient group compared to two-sides recipient vessels group (62.4 ± 21.3 vs. 105.9 ± 32.5, P < 0.001). There was no statistic difference in venous congestion, partial flap loss, or fat necrosis in both groups. CONCLUSIONS: Using one-side recipient vessels for bilateral breast reconstructions with unilateral breast reconstruction with contralateral augmentation using differentially split DIEP flaps presents a high success rate, acceptable ischemia time, and minimal complications for small to medium volume breast reconstructions. Utilizing this method can reduce the ischemia time and spare one side internal mammary vessels. J. Surg. Oncol. 2016;114:5-10. © 2016 Wiley Periodicals, Inc.

The Folded Ulnar Forearm Flap for Nasal Reconstruction.

BACKGROUND: Many strategies exist to reconstruct composite nasal defects, but free flaps are necessary for extensive defects. The workhorse radial forearm flap is hair-bearing and donor-site cosmesis is unfavorable. The ulnar forearm flap is overlooked despite important aesthetic benefits. The authors describe their experience with the ulnar forearm flap, with a novel folding technique in staged nasal reconstruction. METHODS: Between December of 2010 and April of 2015, 10 nasal reconstructions in five men and five women were performed. Average patient age was 47.6 years (range, 31 to 76 years). The ulnar forearm flap was designed as a narrow contiguous flap along the ulnar vascular axis. Inset began with the nasal floor; the flap was then tubularized twice to create nasal passages before it was folded on itself for coverage. Caudal edges were sewn together to create alae and a columella. Follow-up time, complications, number of operations, and reconstructive duration were documented. RESULTS: Average follow-up was 25.2 months (range, 18 to 44 months). Patients had satisfactory aesthetic and functional outcomes after 6.4 operations (range, five to eight) over 11.1 months (range, 8 to 18 months). Partial necrosis of the alar lining in one case was salvaged with the covering flap. Two cases of chondritis were managed with conservative débridement and antibiotics. One case of severe chondritis necessitated removal and de novo reconstruction. CONCLUSIONS: The ulnar forearm flap is safe and reliable in nasal reconstruction, with superior donor-site cosmesis. The tubular folding method creates a vascular envelope amenable to same-stage framework construction. With thoughtful planning and sufficient refinement, excellent aesthetic and functional results are achievable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Forty-five degree cutting septoplasty.

BACKGROUND: The crooked nose represents a challenge for rhinoplasty surgeons, and many methods have been proposed for management; however, there is no ideal method for treatment. Accordingly, the 45° cutting septoplasty technique, which involves a 45° cut at the junction of the L-shaped strut and repositioning it to achieve a straight septum is proposed. METHODS: From October 2010 to September 2014, 43 patients underwent the 45° cutting septoplasty technique. There were 28 men and 15 women, with ages ranging from 20 to 58 years (mean, 33 years). Standardized photographs were obtained at every visit. Established photogrammetric parameters were used to describe the degree of correction: Correction rate = (preoperative total deviation - postoperative residual deviation)/preoperative total deviation × 100% was proposed. RESULTS: The mean follow-up period for all patients was 12.3 months. The mean preoperative deviation was 64.3° and the mean postoperative deviation was 2.7°; the overall correction rate was 95.8%. One patient experienced composite implant deviation two weeks postoperatively and underwent revision rhinoplasty. There were no infections, hematomas or postoperative bleeding. CONCLUSION: Based on the clinical observation of all patients during the follow-up period, the 45° cutting septoplasty technique was shown to be effective for the treatment of crooked nose.

HISTORIQUE: Le nez aquilin est un défi pour les chirurgiens en rhinoplastie. De nombreuses méthodes de prise en charge ont été proposées, mais il n'existe pas de solution thérapeutique idéale. La technique de septoplastie par incision à 45° est pratiquée à la jonction de l'étai en L, qui est repositionné pour redresser la cloison nasale. MÉTHODOLOGIE: D'octobre 2010 à septembre 2014, 43 patients ont subi une septoplastie par incision à 45°. Il s'agissait de 28 hommes et de 15 femmes de 20 à 58 ans (moyenne de 33 ans). Les chercheurs ont pris des photos standardisées à chaque visite. Ils ont utilisé les paramètres de photogrammétrie établis pour décrire le degré de correction. Ils ont proposé que le taux de correction = (déviation préopératoire totale ­ déviation résiduelle postopératoire)/déviation préopératoire totale × 100 %. RÉSULTATS: Tous les patients ont été suivis en moyenne 12,3 mois. Ils avaient une déviation préopératoire moyenne de 64,3° et une déviation postopératoire moyenne de 2,7°, pour un taux de correction global de 95,8 %. Un patient a présenté une déviation composite de l'implant deux semaines après l'opération et a subi une rhinoplastie de révision. Il n'y a pas eu d'infections, d'hématomes ni d'hémorragies postopératoires. CONCLUSION: D'après l'observation clinique de tous les patients pendant la période de suivi, la septoplastie par incision à 45° est efficace pour corriger un nez aquilin.

Comparison of Posteromedial Thigh Profunda Artery Perforator Flap and Anterolateral Thigh Perforator Flap for Head and Neck Reconstruction.

BACKGROUND: The anterolateral thigh perforator flap is a common workhorse flap for head and neck reconstruction. The authors present an alternative method using the posteromedial thigh profunda artery perforator flap and compare its characteristics, outcomes, donor-site morbidity, and donor-site cosmesis with those of the anterolateral thigh perforator flap. METHODS: Between May of 2013 and July of 2014, 41 patients undergoing head and neck reconstruction consisting of 18 posteromedial thigh profunda artery perforator flaps and 23 anterolateral thigh perforator flaps were included in this study. Thirty-eight of the patients were men, and the patient age ranged from 32 to 76 years (mean, 54.5 years). RESULTS: The success rate was 100 percent. The mean number of perforators was significantly higher in the profunda artery perforator flap group (2.0 versus 1.5). There was no significant difference in flap elevation time (66.3 minutes versus 60.7 minutes), pedicle length (9.8 cm versus 10 cm), flap area (166.1 cm versus 156.8 cm), flap width (7.7 cm versus 7.7 cm), reexploration rate, recipient-site complication rate, or donor-site complication rate. Based on patient self-assessment, the profunda artery perforator flap group had significantly better donor-site cosmesis than the anterolateral thigh perforator flap group (satisfaction rate, 100 percent versus 70 percent). CONCLUSIONS: The posteromedial thigh profunda artery perforator flap is a good alternative for head and neck reconstruction. It offers flap size, pedicle length, flap elevation time, and success rate comparable to those of the anterolateral thigh perforator flap. It has more perforators and better donor-site cosmesis than the anterolateral thigh perforator flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An economic comparison of surgical and medical therapy in patients with secondary hyperparathyroidism--the German perspective.

BACKGROUND: Treatment options for secondary hyperparathyroidism were significantly amended with the introduction of cinacalcet and paricalcitol. Limitations of resources in public health systems demand detailed analyses of accruing costs. The aim of this study was to compare the costs of these new treatment modalities to surgery. METHODS: Patients who underwent initial parathyroidectomy (n = 91) and patients treated with cinacalcet or paricalcitol (n = 100) at an ambulatory dialysis center between 01/2003 and 12/2006 were analyzed. The revenues of both therapies for the funding agencies were calculated by a cost-cost analysis. The real arising costs of the supplier were analyzed and compared to the revenues. RESULTS: Treatment costs for cinacalcet (60 mg/day/year) were 5828.40€ and 4485.20€ for paricalcitol (15 µg/week/year). Revenues for inpatient surgical treatment according to the German DRG system were 3755.38€/case. Additionally, costs for postoperative ambulatory therapies were 545.05€ for the first year and 384.97€ for the following. CONCLUSION: Due to linearly increases, expenses of medical treatment with cinacalcet for more than 9 months or paricalcitol for more than 12 months exceeded the costs of surgical therapy. The indication of these new medical therapies should be restricted to patients as an interim solution ahead of surgery or in patients considered unfit for surgery.

Promoter methylation status of hMLH1, MGMT, and CDKN2A/p16 in colorectal adenomas.

AIM: To investigate aberrant DNA methylation of CpG islands and subsequent low- or high-level DNA microsatellite instability (MSI) which is assumed to drive colon carcinogenesis. METHODS: DNA of healthy individuals, adenoma (tubular or villous/tubulovillous) patients, and colorectal carcinoma patients who underwent colonoscopy was used for assessing the prevalence of aberrant DNA methylation of human DNA mismatch repair gene mutator L homologue 1 (hMLH1), Cyclin-dependent kinase inhibitor 2A (CDKN2A/p16), and O-6-methylguanine DNA methyltransferase (MGMT), as well as their relation to MSI. RESULTS: The frequency of promoter methylation for each locus increased in the sequence healthy tissue/adenoma/carcinoma. MGMT showed the highest frequency in each group. MGMT and CDKN2A/p16 presented a statistically significant increase in promoter methylation between the less and more tumorigenic forms of colorectal adenomas (tubular vs tubullovillous and villous adenomas). All patients with tubulovillous/villous adenomas, as well as all colorectal cancer patients, showed promoter methylation in at least one of the examined loci. These findings suggest a potentially crucial role for methylation in the polyp/adenoma to cancer progression in colorectal carcinogenesis. MSI and methylation seem to be interdependent, as simultaneous hMLH1, CDKN2A/p16, and MGMT promoter methylation was present in 8/9 colorectal cancer patients showing the MSI phenotype. CONCLUSION: Methylation analysis of hMLH1, CDKN2A/p16, and MGMT revealed specific methylation profiles for tubular adenomas, tubulovillous/villous adenomas, and colorectal cancers, supporting the use of these alterations in assessment of colorectal tumorigenesis.

Progressive multifocal leukoencephalopathy developing in advanced pulmonal sarcoidosis.

Coincidence of pulmonal sarcoidosis and progressive multifocal leukoencephalopathy (PML) rarely occurs. So far an entire course has been recorded in only very few cases. We demonstrate the case of a 49-year-old male developing an infratentorial localized PML in the setting of advanced pulmonal sarcoidosis. PML was not included in the diagnostic considerations in the first instance. Regarding the diagnosis of pulmonal sarcoidosis proved by lung biopsy, the neurological impairment was first thought to be due to a neurosarcoidosis. But magnetic resonance tomography (MRI) clearly showed a demyelination process in the cerebellum. Because of the inconsistency of the radiological findings with a neurosarcoidosis the diagnosis of an acute disseminated encephalomyelitis (ADEM) was favoured. Therefore, the patient was initially treated with corticosteroids. Because of increasing deterioration further diagnostic testings were performed. In the cerebrospinal fluid (CSF) as well as in the paraffin-embedded tissue of a stereotactical brain biopsy JCV-DNA was successfully demonstrated by PCR. Cidofovir was administered. The progression of the disease could not be influenced. The patient died 5 months after the first neurological symptoms. This report stresses the diagnostic difficulties considering patients with sarcoidosis and neurological symptoms.