Plasma SHBG Levels as an Early Predictor of Response to Bariatric Surgery.

BACKGROUND: Obesity is a growing global health problem, and currently, bariatric surgery (BS) is the best solution in terms of sustained total weight loss (TWL). However, a significant number of patients present weight regain (WR) in time. There is a lack of biomarkers predicting the response to BS and WR during the follow-up. Plasma SHBG levels, which are low in obesity, increase 1 month after BS but there is no data of plasma SHBG levels at long term. We performed the present study aimed at exploring the SHBG role in predicting TWL and WR after BS. METHODS: Prospective study including 62 patients with obesity undergoing BS. Anthropometric and biochemical variables, including SHBG were analyzed at baseline, 1, 6, 12, and 24 months; TWL ≥ 25% was considered as good BS response. RESULTS: Weight loss nadir was achieved at 12 months post-BS where maximum SHBG increase was reached. Greater than or equal to 25% TWL patients presented significantly higher SHBG increases at the first and sixth months of follow-up with respect to baseline (100% and 150% respectively, p = 0.025), than < 25% TWL patients (40% and 50% respectively, p = 0.03). Also, these presented 6.6% WR after 24 months. The first month SHBG increase predicted BS response at 24 months (OR = 2.71; 95%CI = [1.11-6.60]; p = 0.028) and TWL in the 12th month (r = 0.330, p = 0.012) and the WR in the 24th (r = - 0.301, p = 0.028). CONCLUSIONS: Our results showed for the first time that increase in plasma SHBG levels within the first month after BS is a good predictor of TWL and WR response after 2 years.

Retinal sensitivity and gaze fixation evaluated by microperimetry in subjects with type 2 diabetes: two independent parameters that explore different neuronal circuits.

BACKGROUND AND AIMS: Retinal sensitivity (RS) and gaze fixation (GF) assessed by retinal microperimetry are useful and complementary tools for identifying mild cognitive impairment (MCI) in patients with type 2 diabetes (T2D). The hypothesis is that RS and GF examine different neural circuits: RS depends only on the visual pathway while GF reflects white matter complex connectivity networks. The aim of the study is to shed light to this issue by examining the relationship of these two parameters with visual evoked potentials (VEP), the current gold standard to examine the visual pathway. MATERIALS AND METHODS: Consecutive T2D patients > 65 years were recruited from the outpatient clinic. Retinal microperimetry (MAIA 3rd generation) and visual evoked potentials (VEP) (Nicolet Viking ED). RS (dB), GF (BCEA63%, BCEA95%) (MAIA) and VEP (Latency P100ms, Amplitude75-100 uV) were analyzed. RESULTS: Thirty three patients (45% women, 72.1 ± 4.6 years) were included. VEP parameters significantly correlated with RS but not with GF. CONCLUSIONS: These results confirm that RS but not GF depends on the visual pathway, reinforcing the concept that they are complementary diagnostic tools. Used together can further increase the value of microperimetry as screening test for identifying T2D population with cognitive impairment.

Sleep biosignature of Type 2 diabetes: a case-control study.

AIM: To determine whether or not the sleep disturbances associated with Type 2 diabetes affect the structure of sleep. METHODS: We designed a case-control study in 76 patients with Type 2 diabetes and 76 control subjects without Type 2 diabetes, matched by age, gender, BMI and waist and neck circumferences. A subgroup of 32 patients with Type 2 diabetes was also matched with 64 control subjects without Type 2 diabetes according to apnoea-hypopnoea index score. Examination included an overnight full polysomnography. RESULTS: No differences in the percentage of time spent in either rapid eye movement or non-rapid eye movement sleep were observed between groups; however, patients with Type 2 diabetes had more microarousal events during sleep than control subjects [41.4 (total range 4.0-104.4) vs 20.7 (total range 1.3-94.5) events/h; P < 0.001]. These differences were mainly observed during the non-rapid eye movement sleep [7.4 (total range 0-107.2) vs 0.2 (total range 0-65.2) events/h; P < 0.001]. In addition, sleep variables related to oxygen saturation measures, such as the percentage of time spent with oxygen saturation ≤90%, were significantly greater during the rapid eye movement sleep in patients with Type 2 diabetes [20.3 (total range 0-99.2) vs. 10.5 (total range 0-94.0)%; P = 0.047]. This pattern was maintained in the subgroup of patients matched by apnoea-hypopnaea index. Finally, stepwise regression analyses showed that apnoea-hypopnoea index, the presence of Type 2 diabetes and fasting plasma glucose value were independently associated with the number of microarousals (R2 =0.667). CONCLUSIONS: Type 2 diabetes is associated with an altered sleep structure, with different effects according to rapid eye movement (increase in nocturnal hypoxia) or non-rapid eye movement (increase in sleep fragmentation) sleep.

Utilidad de la tomografía computarizada de doble energía con un programa específico para la identificación de litiasis renales de ácido úrico / Usefulness of dual-energy computed tomography with and without dedicated software in identifying uric acid kidney stones

Objetivo. Valorar de manera prospectiva e in vivo la identificación de litiasis renales de ácido úrico con tomografía computarizada (TC) de doble energía (TCDE) con y sin software específico. Material y métodos. Se estudiaron 65 litiasis de 63 pacientes analizadas ex vivo con espectrofotometría y que habían sido estudiadas con una TCDE. Se valoró el rendimiento diagnóstico en identificar litiasis de ácido úrico con TCDE mediante el análisis de las densidades radiológicas de las litiasis utilizando el software específico, o sin utilizarlo (midiéndolo manualmente), y mediante el análisis de las ratios de densidad de las litiasis en ambas energías con o sin el software específico. Resultados. Las seis litiasis de ácido úrico incluidas fueron correctamente identificadas mediante la valoración de la ratio de densidades con un punto de corte de 1,21, tanto con el software específico como sin él, con un rendimiento diagnóstico perfecto, sin presencia de falsos positivos ni negativos. El estudio de densidades de las litiasis obtuvo valores de las curvas COR en clasificación de litiasis de ácido úrico de 0,92 para medición con la aplicación informática y de 0,89 para las mediciones manuales y una precisión diagnóstica del 84% (42/50) con el software y del 83,1% (54/65) para las mediciones manuales para un punto de corte de 538 UH. Conclusiones. El estudio de litiasis con TCDE permite identificar correctamente las litiasis de ácido úrico mediante el cálculo de la ratio de densidades en ambas energías. Los resultados obtenidos con y sin software específico son similares (AU)

Objective. To prospectively evaluate the usefulness of dual-energy computed tomography (DECT) with and without dedicated software in identifying uric acid kidney stones in vivo. Material and methods. We studied 65 kidney stones in 63 patients. All stones were analyzed in vivo by DECT and ex vivo by spectrophotometry. We evaluated the diagnostic performance in identifying uric acid stones with DECT by analyzing the radiologic densities with dedicated software and without using it (through manual measurements) as well as by analyzing the attenuation ratios of the stones in both energies with and without the dedicated software. Results. The six uric acid stones included were correctly identified by evaluating the attenuation ratios with a cutoff of 1.21, both with the dedicated software and without it, yielding perfect diagnostic performance without false positives or false negatives. The study of the attenuations of the stones obtained the following values on the receiver operating characteristic curves in the classification of the uric acid stones: 0.92 for the measurements done with the software and 0.89 for the manual measurements; a cutoff of 538 HU yielded 84% (42/50) diagnostic accuracy for the software and 83.1% (54/65) for the manual measurements. Conclusions. DECT enabled the uric acid stones to be identified correctly through the calculation of the ratio of the attenuations in the two energies. The results obtained with the dedicated software were similar to those obtained manually (AU)

Usefulness of dual-energy computed tomography with and without dedicated software in identifying uric acid kidney stones.

OBJECTIVE: To prospectively evaluate the usefulness of dual-energy computed tomography (DECT) with and without dedicated software in identifying uric acid kidney stones in vivo. MATERIAL AND METHODS: We studied 65 kidney stones in 63 patients. All stones were analyzed in vivo by DECT and ex vivo by spectrophotometry. We evaluated the diagnostic performance in identifying uric acid stones with DECT by analyzing the radiologic densities with dedicated software and without using it (through manual measurements) as well as by analyzing the attenuation ratios of the stones in both energies with and without the dedicated software. RESULTS: The six uric acid stones included were correctly identified by evaluating the attenuation ratios with a cutoff of 1.21, both with the dedicated software and without it, yielding perfect diagnostic performance without false positives or false negatives. The study of the attenuations of the stones obtained the following values on the receiver operating characteristic curves in the classification of the uric acid stones: 0.92 for the measurements done with the software and 0.89 for the manual measurements; a cutoff of 538 HU yielded 84% (42/50) diagnostic accuracy for the software and 83.1% (54/65) for the manual measurements. CONCLUSIONS: DECT enabled the uric acid stones to be identified correctly through the calculation of the ratio of the attenuations in the two energies. The results obtained with the dedicated software were similar to those obtained manually.

Terapia focal en cáncer de próstata. Alternativas de tratamiento / Focal therapy for prostate cancer. Alternative treatment

Contexto: Los tratamientos radicales o de seguimiento activo son alternativas en el manejo del cáncer de próstata localizado, ambos no exentos de riesgos y efectos secundarios. El objetivo de este trabajo es analizar las diferentes posibilidades de la terapia focal en sus diferentes opciones para tratar el cáncer de próstata localizado. Adquisición de evidencia: Realizamos una revisión en Medline de las diferentes posibilidades de tratamiento focal desde el punto de vista técnico, desarrolladas en la actualidad con atención a los estudios prospectivos aleatorizados, así como las formas de seguimiento y evolución de resultados. Síntesis de evidencia: Diferentes técnicas en este momento están disponibles para realizar terapia focal, básicamente aquellas mínimamente invasivas -terapia vascular fotodinámica (TVF), crioterapia, braquiterapia, ultrasonido focalizado de alta intensidad (HIFU), láser intersticial- que permiten acceso directo y dirigido a la glándula. Los resultados preliminares de los estudios actuales demuestran una buena aceptabilidad de las técnicas con escasos efectos secundarios y buenos resultados oncológicos. La biopsia junto con la resonancia magnética nuclear (RMN) son las guías de seguimiento en estos pacientes, siendo el papel del antígeno prostático específico (PSA) menos definido. Conclusiones: La terapia focal es en la actualidad una alternativa con técnicas disponibles para una buena ejecución. Los datos actuales apuntan a una escasa morbilidad y buenos resultados oncológicos que hacen de la terapia focal una posible alternativa de tratamiento en los tumores localizados, a la espera de los resultados de más estudios aleatorizados

Context: The great controversy surrounding the treatment of localized prostate cancer is related with its possibilities of radical treatment or active surveillance. The objective of this paper is to analyze the rationale selection among current focal therapy modalities regarding tumor and patient selection. Evidence acquisition: Current articles about advantages and disadvantages on the treatment of localized prostate cancer as well as information about focal therapy regarding tumor selection, characteristics and indications cited in MEDLINE search were reviewed. Summary of evidence: Focal therapy standardized criteria must be: low risk tumors, PSA < 10-15, Gleason score ≤ 6, and unilateral presentation all supported by image-guided biopsy and nuclear magnetic resonance (NMR). There are doubts about the suitability of focal therapy in cases of bilateralism or in those with Gleason score 3 + 4 or PSA > 15. Conclusions: Focal therapy is an alternative for localized prostate cancer treatment. However, some aspects of their diagnosis and selection criteria should be defined by prospective studies which should provide knowledge about the indication for focal therapy

Focal therapy for prostate cancer. Alternative treatment.

CONTEXT: The great controversy surrounding the treatment of localized prostate cancer is related with its possibilities of radical treatment or active surveillance. The objective of this paper is to analyze the rationale selection among current focal therapy modalities regarding tumor and patient selection. EVIDENCE ACQUISITION: Current articles about advantages and disadvantages on the treatment of localized prostate cancer as well as information about focal therapy regarding tumour selection, characteristics and indications cited in MEDLINE search were reviewed. SUMMARY OF EVIDENCE: Focal therapy standardized criteria must be: low risk tumors, PSA<10-15, Gleason score ≤ 6, and unilateral presentation all supported by image-guided biopsy and nuclear magnetic resonance (NMR). There are doubts about the suitability of focal therapy in cases of bilateralism or in those with Gleason score 3+4 or PSA>15. CONCLUSIONS: Focal therapy is an alternative for localized prostate cancer treatment. However, some aspects of their diagnosis and selection criteria should be defined by prospective studies which should provide knowledge about the indication for focal therapy.

Transposition of iliac vessels in implantation of right living donor kidneys.

BACKGROUND: The rate of right laparoscopic living-donor nephrectomy (RLLDN) is low among kidney transplantations due to the short renal vein and presumed higher risk of thrombosis. Our objective was to describe a surgical technique to compensate for the shorter veins of these grafts. METHODS: Between January 2004 and July 2010, we prospectively collected data from all transplantations using RLLDN-harvested kidneys at our center. Recipient iliac vein transposition was performed in all patients. We reviewed the indications, surgical techniques, and postoperative courses. RESULTS: The 43 included cases showed a 2.1 +/- 0.6 cm, average length of the right renal vein as measured on abdominal computed tomography (CT). The mean extraction and implantation times were 109 +/- 33 and 124 +/- 31 minutes, respectively; the mean warm ischemia time was 151 +/- 29 seconds. Two recipients required postsurgical blood transfusions. In 97.6% of cases, there was immediate urine flow. Postoperative echo-Doppler revealed good arterial and venous flows in all patients. No venous thromboses were detected. The recipients' average hospital stay was 8 +/- 5 days. With a mean follow-up of 57 months, 86% of recipients maintain a glomerular filtration rate (GFR) >50 mL/min and creatinine levels <1.5 mg/dL. CONCLUSIONS: Transposition of the recipient iliac vein during implantation is a good technical solution to compensate for the short length of the right renal vein. The use of iliac vein transposition allowed us to perform safe implants of RLLDN-harvested kidneys with good short-term and long-term results.

Sangrado diferido después de nefrectomía parcial. Manejo mediante embolización selectiva / Delayed Bleeding after Partial Nephrectomy. Management with Selective Embolization

Introducción: El sangrado después de una nefrectomía parcial es una complicación con posibles consecuencias graves. Puede ser inmediato o diferido y su incidencia es baja. La causa más frecuente del sangrado diferido es el pseudoaneurisma arterial. La embolización supraselectiva vascular es una opción terapéutica posible que ha demostrado buenos resultados. Objetivo: Evaluar la evolución y el tratamiento del sangrado diferido en nuestra serie de pacientes con nefrectomías parciales. Material y métodos: Realizamos un estudio retrospectivo de nuestra base de datos de nefrectomías parciales. Identificamos los pacientes que presentaron sangrado diferido (después del alta). Se revisó la historia clínica, analizando datos sobre la presentación, el diagnóstico, el tratamiento y la evolución de los pacientes. Resultados: De nuestra serie de nefrectomías parciales tres pacientes presentaron sangrado diferido (1,3%). La clínica se inició después de 17 a 25 días de la cirugía por la aparición de hematuria o dolor lumbar. El diagnóstico se realizó mediante ecografía, TAC abdominal y angiografía renal. En todos los pacientes se diagnosticó un pseudoaneurisma arterial complicado, siendo sometidos a cateterismo arterial renal con embolización selectiva del mismo. La evolución fue correcta en todos los pacientes con control inmediato del sangrado. Documentamos un seguimiento posterior favorable de 61 a 92 meses. Conclusiones: La embolización selectiva vascular es el tratamiento de elección del pseudoaneurisma renal sintomático después de nefrectomía parcial en el paciente hemodinámicamente estable (AU)

Introduction: Bleeding after partial nephrectomy can be immediate or delayed and may have severe consequences. The incidence of this complication is low. The most frequent cause of delayed bleeding is arterial pseudoaneurysm. Superselective embolization is a feasible therapeutic option that has shown good results. Objective: To evaluate treatment and outcomes of delayed bleeding in our series of patients with partial nephrectomy. Material and methods: We performed a retrospective study of our database of partial nephrectomies. Patients who developed delayed bleeding (after discharge) were identified. Clinical histories were reviewed and data on presentation, diagnosis, treatment and outcomes were analyzed. Results: Among our series of patients undergoing partial nephrectomy, three developed delayed bleeding (1.3%). Symptom onset occurred 17 to 25 days after surgery and consisted of hematuria or lumbar pain. Diagnosis was provided through ultrasound, abdominal computed tomography and renal angiography. In all three patients, a complicated pseudoaneurysm was diagnosed and all patients underwent renal artery catheterization with selective renal artery embolization. In all patients, immediate control of bleeding was achieved. Outcome after a follow-up of 61 to 92 months was favorable. Conclusions: Selective vascular embolization is the treatment of choice of renal pseudoaneurysm after partial nephrectomy in hemodynamically stable patients (AU)

[Delayed bleeding after partial nephrectomy. Management with selective embolization]. / Sangrado diferido después de nefrectomía parcial. Manejo mediante embolización selectiva.

INTRODUCTION: Bleeding after partial nephrectomy can be immediate or delayed and may have severe consequences. The incidence of this complication is low. The most frequent cause of delayed bleeding is arterial pseudoaneurysm. Superselective embolization is a feasible therapeutic option that has shown good results. OBJECTIVE: To evaluate treatment and outcomes of delayed bleeding in our series of patients with partial nephrectomy. MATERIAL AND METHODS: We performed a retrospective study of our database of partial nephrectomies. Patients who developed delayed bleeding (after discharge) were identified. Clinical histories were reviewed and data on presentation, diagnosis, treatment and outcomes were analyzed. RESULTS: Among our series of patients undergoing partial nephrectomy, three developed delayed bleeding (1.3%). Symptom onset occurred 17 to 25 days after surgery and consisted of hematuria or lumbar pain. Diagnosis was provided through ultrasound, abdominal computed tomography and renal angiography. In all three patients, a complicated pseudoaneurysm was diagnosed and all patients underwent renal artery catheterization with selective renal artery embolization. In all patients, immediate control of bleeding was achieved. Outcome after a follow-up of 61 to 92 months was favorable. CONCLUSIONS: Selective vascular embolization is the treatment of choice of renal pseudoaneurysm after partial nephrectomy in hemodynamically stable patients.

Effect of atorvastatin on lipoprotein (a) and interleukin-10: a randomized placebo-controlled trial.

AIM: This study aimed to determine the effect of atorvastatin therapy on plasma lipoprotein (a) [Lp(a)] and biomarkers of inflammation in hypercholesterolaemic patients free of cardiovascular disease. METHODS: In this three-month randomized double-blind placebo-controlled trial, 63 hypercholesterolaemic patients were randomly treated with either placebo or atorvastatin (10 or 40 mg/day) for 12 weeks. Lp(a) and biomarkers of inflammation (C-reactive protein [CRP], interleukin [IL]-6 and -10, and tumour necrosis factor-alpha receptors [TNF-Rs]) were measured at study entry, and at four and 12 weeks of follow-up. RESULTS: At the end of the study, patients allocated to atorvastatin (10 or 40 mg/day) presented with significantly lower Lp(a) levels than those taking placebo (10 [1-41]mg/dL versus 6 [1-38]mg/dL [P = 0.02] and 21 [1-138]mg/dL versus 15 [1-103]mg/dL [P = 0.04], respectively]. In multivariate analyses, the relative changes in Lp(a) were independently related to baseline Lp(a) levels and CRP changes. No significant changes in CRP, IL-6 and TNF-Rs were observed. In contrast, IL-10 (pg/mL) increased significantly in patients taking atorvastatin (2.14 [0.49-43]pg/mL versus 4.54 [0.51-37.5]pg/mL; P = 0.01), and was even more increased with the 40-mg dose than with 10mg. CONCLUSION: Our results suggest that 12-week atorvastatin is effective in reducing Lp(a) in dyslipidaemic patients free of CVD. Furthermore, this is also the first evidence that the drug increases IL-10 in a dose-dependent manner.

[Viral small bowel intussusception: a rare cause of intestinal obstruction]. / Invaginatia intestinala de etiologie virala: cauza rara de ocluzie la adult.

Representing a rare cause of bowel obstruction, the ileal intussusception is commonly met in the pediatric surgery. Even if in children's cases the symptoms can mimick a multitude of abdominal syndromes, usually in adult cases the symptoms fit the pattern of the intestinal obstruction. This paper presents 2 clinical cases of small bowel intussusception in adult, the particularity of cases being that the pathogenesis couldn't be established first hand; the pathology exam revealed only minor inflammatory responses,including modest reactive lymph nodes in the vicinity of lesions, without further alterations. The etiology of bowel intussusception was finally attributed to viral infection with gastroenteritis, based on clinical and pathological criteria.