Efficacy, feasibility and tolerability of ketogenic diet for the treatment of poor response to bariatric surgery.

PURPOSE: Poor response to bariatric surgery, namely insufficient weight loss (IWL) or weight regain (WR), is a critical issue in the treatment of obesity. The purpose of our study was to assess the efficacy, feasibility, and tolerability of very low-calorie ketogenic diet (VLCKD) for the management of this condition. METHODS: A real-life prospective study was conducted on twenty-two patients who experienced poor response after bariatric surgery and followed a structured VLCKD. Anthropometric parameters, body composition, muscular strength, biochemical analyses, and nutritional behavior questionnaires were evaluated. RESULTS: A significant weight loss (mean 14.1 ± 4.8%), mostly due to fat mass, was observed during VLCKD with the preservation of muscular strength. The weight loss obtained allowed patients with IWL to reach a body weight significantly lower than that obtained at the post-bariatric surgery nadir and to report the body weight of patients with WR at the nadir observed after surgery. The significantly beneficial changes in nutritional behaviors and metabolic profiles were observed without variations in kidney and liver function, vitamins, and iron status. The nutritional regimen was well tolerated, and no significant side effects were detected. CONCLUSION: Our data demonstrate the efficacy, feasibility, and tolerability of VLCKD in patients with poor response after bariatric surgery.

Soil loss tolerance in the context of the European Green Deal.

Soil erosion by water, and the consequent loss of a non-renewable resource, is a relevant environmental issue which has economic, ecologic, and social repercussions. In the context of the European Green Deal, the increasing awareness of soil Ecosystem Services is leading to give the due relevance to this problem. Notwithstanding the recent soil conservation strategies adopted by the Common Agricultural Policy had positive effects, the concern regarding this topic is drastically increasing for the normalization of extraordinary rainfall events due to climate change. Recent events occurred in Europe demonstrated that landscape protection is often inadequate and interventions to prevent damages due to hydrogeological instability are scarce. The determination of a "tolerable" soil loss TSL is useful to establish a quantitative standard to measure the effectiveness of strategies and techniques to control soil erosion. However, soil conservation strategies/works designed by the mean annual value of the climatic variable, as the rainfall erosivity factor R, are not appropriate for some erosive events which produce intolerable sediment yield values. Therefore, the adoption of an adequate TSL, which could help to ensure the protection of soil functions and a sustainable soil use, should be a primary goal to reach for policy makers. In this paper, a new method to define the tolerable soil loss is proposed. This approach is based on the statistical analysis of the measured annual values of R and leads to the determination of the cover and management factor for which the maximum tolerable soil loss is equal to the annual soil loss of given return period. The analysis demonstrated that to limit soil erosion to the tolerable soil loss, interventions to change land use, reduce field length or apply support practices can be carried out.

Mechanism of lipid bilayer perturbation by bactericidal membrane-active small molecules.

Membrane-active small molecules (MASMs) are small organic molecules designed to reproduce the fundamental physicochemical properties of natural antimicrobial peptides: their cationic charge and amphiphilic character. This class of compounds has a promising broad range of antimicrobial activity and, at the same time, solves some major limitations of the peptides, such as their high production costs and low in vivo stability. Most cationic antimicrobial peptides act by accumulating on the surface of bacterial membranes and causing the formation of defects when a threshold is reached. Due to the drastically different structures of the two classes of molecules, it is not obvious that small-molecule antimicrobials act in the same way as natural peptides, and very few data are available on this aspect. Here we combined spectroscopic studies and molecular dynamics simulations to characterize the mechanism of action of two different MASMs. Our results show that, notwithstanding their simple structure, these molecules act just like antimicrobial peptides. They bind to the membrane surface, below the head-groups, and insert their apolar moieties in the core of the bilayer. Like many natural peptides, they cause the formation of defects when they reach a high coverage of the membrane surface. In addition, they cause membrane aggregation, and this property could contribute to their antimicrobial activity.

Machine learning applied to ambulatory blood pressure monitoring: a new tool to diagnose autonomic failure?

BACKGROUND: Autonomic failure (AF) complicates Parkinson's disease (PD) in one-third of cases, resulting in complex blood pressure (BP) abnormalities. While autonomic testing represents the diagnostic gold standard for AF, accessibility to this examination remains limited to a few tertiary referral centers. OBJECTIVE: The present study sought to investigate the accuracy of a machine learning algorithm applied to 24-h ambulatory BP monitoring (ABPM) as a tool to facilitate the diagnosis of AF in patients with PD. METHODS: Consecutive PD patients naïve to vasoactive medications underwent 24 h-ABPM and autonomic testing. The diagnostic accuracy of a Linear Discriminant Analysis (LDA) model exploiting ABPM parameters was compared to autonomic testing (as per a modified version of the Composite Autonomic Symptom Score not including the sudomotor score) in the diagnosis of AF. RESULTS: The study population consisted of n = 80 PD patients (33% female) with a mean age of 64 ± 10 years old and disease duration of 6.2 ± 4 years. The prevalence of AF at the autonomic testing was 36%. The LDA model showed 91.3% accuracy (98.0% specificity, 79.3% sensitivity) in predicting AF, significantly higher than any of the ABPM variables considered individually (hypotensive episodes = 82%; reverse dipping = 79%; awakening hypotension = 74%). CONCLUSION: LDA model based on 24-h ABPM parameters can effectively predict AF, allowing greater accessibility to an accurate and easy to administer test for AF. Potential applications range from systematic AF screening to monitoring and treating blood pressure dysregulation caused by PD and other neurodegenerative disorders.

Improved imaging using Mn He-α x rays at OMEGA EP.

In this paper, we report on a crystal based x-ray imaging system fielded at the OMEGA EP laser facility. This new system has a pointing accuracy of +/100 µm, a temporal resolution down to 100 ps (depending on backlighter characteristics), variable magnification, and a spatial resolution of 21.9 µm at the object plane at a magnification of 15×. The system is designed to use a crystal along the crystal plane that satisfies the Bragg condition for the x ray of interest. The thin crystal is then bent into a spherical geometry and attached to a glass backing substrate to hold it in the diagnostic, and the x rays are imaged onto a charge coupled device. We report on data acquired with the new Los Alamos National Laboratory supplied spherical quartz crystal to image the Mn He-α 6.15 keV line emission.

Screening indexes for cardiovascular autonomic failure in Parkinson's disease.

Autonomic failure (AF) is a common source of orthostatic hypotension (OH) in Parkinson's disease (PD). The diagnosis of AF is difficult on clinical grounds alone. We used autonomic testing and 24-h BP monitoring (ABPM) in 122 PD patients to evaluate the diagnostic accuracy of AF by (1) the reduced heart rate increase to fall in blood pressure (BP) ratio (ΔHR/ΔSBP), (2) reverse dipping (RD), and (3) increased diurnal systolic BP standard deviation (SD-SBP). Among patients with OH, ΔHR/ΔSBP yielded the best accuracy (85%), with excellent sensitivity (92%) and acceptable specificity (67%). RD and, to a lesser extent, SD-SBP had high specificity (93% and 73%, respectively) but low sensitivity, resulting in overall moderate accuracy (66% and 55%, respectively). In patients with OH, the addition of ABPM indexes to ΔHR/ΔSBP did not result in a significant improvement of accuracy. In patients without OH, RD and SD-SBP may be useful showing an accuracy of 72% and 81%, respectively, with high negative predictive value when both RD and increased SD-SBP are absent. The integration of bedside (∆HR/∆SBP) and ABPM-derived indexes can assist the clinician in screening PD patients for AF and guide referral to autonomic testing.

Experimental measurement of two copropagating shocks interacting with an unstable interface.

In this work, we present results from experiments capable of producing and measuring the propagation of multiple successive, copropagating shocks across an unstable planar interface, where the shocks are independently driven and separately controllable, enabling the study of this important phenomenon. Copropagating shocks play a significant role in a wide range of systems involving stratified media subject to a shock, and exhibit different physical characteristics compared to counterpropagating shocks. Existing techniques, however, preclude copropagating shocks, so experiments to date have been limited to the study of counterpropagating shocks. We address this previous limitation and open a physical parameter space for study using a new hohlraum platform on the National Ignition Facility. Initial experimental results are presented together with comparisons from numerical simulations.

Dual-release hydrocortisone vs conventional glucocorticoids in adrenal insufficiency.

BACKGROUND: Dual-release hydrocortisone (DR-HC) improves metabolism in patients with adrenal insufficiency. The aims of this study were to compare the cardiovascular and metabolic effects of conventional glucocorticoids (GCs) vs. DR-HC and of high vs. low doses of GCs, after 48 months of observation. METHODS: We selected 27 patients on hydrocortisone (mean dose 17.5 ± 4.2 mg/day) and 20 patients on cortisone acetate (mean dose 37.5 ± 12.1 mg/day) who maintained this treatment (group A) and 53 patients switched to DR-HC (mean dose 22 ± 4.8 mg/day) (group B). At baseline and after 48 months, clinical and metabolic parameters and Framingham Risk Score (FRS) were obtained. RESULTS: After 48 months, patients in group A had a significant increase from baseline in BMI (P < 0.001), waist circumference (P = 0.001), systolic blood pressure (P = 0.001), LDL cholesterol (P = 0.018), HbA1c (P = 0.020) and FRS (P = 0.002). By contrast, patients in group B had a significant decrease in BMI (P = 0.002), waist circumference (P = 0.015), diastolic blood pressure (P = 0.031), total (P = 0.006) and LDL cholesterol (P = 0.005), HbA1c (P < 0.001) and FRS (P = 0.015) compared to baseline. No significant differences between high and low doses of both conventional GCs and DR-HC were observed. CONCLUSIONS: DR-HC is associated with an improvement of metabolic parameters and cardiovascular risk compared to conventional GCs, which are associated with a worsening of these parameters, regardless of the dose used.

Evolution of surface structure in laser-preheated perturbed materials.

We report an experimental and computational study investigating the effects of laser preheat on the hydrodynamic behavior of a material layer. In particular, we find that perturbation of the surface of the layer results in a complex interaction, in which the bulk of the layer develops density, pressure, and temperature structure and in which the surface experiences instability-like behavior, including mode coupling. A uniform one-temperature preheat model is used to reproduce the experimentally observed behavior, and we find that this model can be used to capture the evolution of the layer, while also providing evidence of complexities in the preheat behavior. This result has important consequences for inertially confined fusion plasmas, which can be difficult to diagnose in detail, as well as for laser hydrodynamics experiments, which generally depend on assumptions about initial conditions in order to interpret their results.

Daily peer review of abnormal cervical smears in the assessment of individual practice as an additional method of internal quality control.

OBJECTIVE: An important internal quality control system used in the Cancer Prevention and Research Institute cytopathology laboratory in Florence is the peer review procedure, based on the review of all abnormal cytological smears which routinely emerge. Peer review is an important training opportunity for all cytologists, especially for those with less experience. This article shows the results of the peer review procedure. METHODS: Of the 63 754 Papanicolaou (Pap) smears screened in 2011, 1086 were considered to be abnormal [at least atypical squamous cells of undetermined significance (ASC-US+)] on primary screening (selected by a single cytologist) and were subjected to the peer review procedure. The overall performance of the laboratory's cytologists was evaluated using a multiple rater analysis and the comparison of each cytologist with the final diagnosis. Further, the agreement was assessed by means of Cohen's kappa and weighted kappa statistics. RESULTS: In general, a moderate/substantial level of agreement between the ten cytologists and the final diagnoses was evident. Kappa values for each reader compared with the final diagnosis ranged from 0.54 to 0.69. The overall kappa value was 0.62 [95% confidence interval (CI), 0.58-0.66] and overall weighted kappa value was 0.76 (95% CI, 0.74-0.79). The category-specific agreement showed the lowest values for atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H). CONCLUSION: In summary, peer review represents an important internal quality control in the evaluation and improvement of inter-observer agreement and of the functioning of the laboratory as a whole. Multi-head microscope sessions may improve particularly the reproducibility of borderline diagnoses and, above all, can be an important training contribution for cytologists.

Energetic electrons driven in the polarization direction of an intense laser beam incident normal to a solid target.

Experiments were performed at the LLNL Titan laser to measure the propagation direction of the energetic electrons that were generated during the interaction of the polarized laser beam with solid targets in the case of normal incidence. The energetic electrons propagated through vacuum to spectator metal wires in the polarization direction and in the perpendicular direction, and the K shell spectra from the different wire materials were recorded as functions of the distance from the laser focal spot. It was found that the fluence of the energetic electrons driven into the spectator wires in the polarization direction compared to the perpendicular direction was larger and increased with the distance from the focal spot. This indicates that energetic electrons are preferentially driven in the direction of the intense oscillating electric field of the incident laser beam in agreement with the multiphoton inverse Bremsstrahlung absorption process.

Observation of Single-Mode, Kelvin-Helmholtz Instability in a Supersonic Flow.

We report the first observation, in a supersonic flow, of the evolution of the Kelvin-Helmholtz instability from a single-mode initial condition. To obtain these data, we used a novel experimental system to produce a steady shock wave of unprecedented duration in a laser-driven experiment. The shocked, flowing material creates a shear layer between two plasmas at high energy density. We measured the resulting interface structure using radiography. Hydrodynamic simulations reproduce the large-scale structures very well and the medium-scale structures fairly well, and imply that we observed the expected reduction in growth rate for supersonic shear flow.

Oculo-facio-cardio-dental (OFCD) syndrome: the first Italian case of BCOR and co-occurring OTC gene deletion.

Oculo-facio-cardio-dental (OFCD) syndrome is a rare genetic disorder affecting ocular, facial, dental and cardiac systems. The syndrome is an X-linked dominant trait and it might be lethal in males. This syndrome is usually caused by mutations in the BCL6 interacting co-repressor gene (BCOR). We described a female child with mild phenotype of oculo-facio-cardio-dental syndrome. Array-comparative genomic hybridization (a-CGH) analysis revealed a de novo heterozygous deletion in the Xp11.4 region of approximately 2.3 Mb, involving BCOR and ornithine carbamoyl-transferase (OTC) genes. The deletion observed was subsequently confirmed by real time PCR. In this study we report a first case with co-occurrence of BCOR and OTC genes completely deleted in OFCD syndrome.

Orthostatic hypotension in a cohort of hypertensive patients referring to a hypertension clinic.

The prevalence of orthostatic hypotension (OH) in hypertensive patients ranges from 3 to 26%. Drugs are a common cause of non-neurogenic OH. In the present study, we retrospectively evaluated the medical records of 9242 patients with essential hypertension referred to our Hypertension Unit. We analysed data on supine and standing blood pressure values, age, sex, severity of hypertension and therapeutic associations of drugs, commonly used in the treatment of hypertension. OH was present in 957 patients (10.4%). Drug combinations including α-blockers, centrally acting drugs, non-dihydropyridine calcium-channel blockers and diuretics were associated with OH. These pharmacological associations must be administered with caution, especially in hypertensive patients at high risk of OH (elderly or with severe and uncontrolled hypertension). Angiotensin-receptor blocker (ARB) seems to be not related with OH and may have a potential protective effect on the development of OH.

Measurement of high-energy (10-60 keV) x-ray spectral line widths with eV accuracy.

A high resolution crystal spectrometer utilizing a crystal in transmission geometry has been developed and experimentally optimized to measure the widths of emission lines in the 10-60 keV energy range with eV accuracy. The spectrometer achieves high spectral resolution by utilizing crystal planes with small lattice spacings (down to 2d = 0.099 nm), a large crystal bending radius and Rowland circle diameter (965 mm), and an image plate detector with high spatial resolution (60 µm in the case of the Fuji TR image plate). High resolution W L-shell and K-shell laboratory test spectra in the 10-60 keV range and Ho K-shell spectra near 47 keV recorded at the LLNL Titan laser facility are presented. The Ho K-shell spectra are the highest resolution hard x-ray spectra recorded from a solid target irradiated by a high-intensity laser.

The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review.

BACKGROUND: Due to the failure of the "old Mason loop," the mini-gastric bypass (MGB) has been viewed with skepticism. During the past 12 years, a growing number of authors from around the world have continued to report excellent short- and long-term results with MGB. METHODS: One university center, three regional hospitals, and two private hospitals participated in this study. From July 2006 to December 2012, 475 men (48.8 %) and 499 women (51.2 %) underwent 974 laparoscopic MGBs. The mean age of these patients was 39.4, and their preoperative body mass index was 48 ± 4.58 kg/m(2). Type 2 diabetes mellitus (T2DM) affected 224 (22.9 %) of the 974 patients, whereas 291 of the 974 patients (29.8 %) presented with hypertension. The preoperative gastrointestinal status was explored in all the patients through esophagogastroduodenoscopia. The major end points of the study were definitions of both MGB safety and efficacy in the long term as well as the endoscopic changes in symptomatic patients eventually produced by surgery. RESULTS: The rate of conversion to open surgery was 1.2 % (12/974), and the mortality rate was 0.2 % (2/974). The perioperative morbidity rate was 5.5 % (54/974), with 20 (2 %) of the 974 patients requiring an early surgical revision. The mean hospital length of stay was 4.0 ± 1.7 days. At this writing, 818 patients are being followed up. Late complications have affected 74 (9 %) of the 818 patients. The majority of these complications (66/74, 89.1 %) have occurred within 1 year after surgery. Bile reflux gastritis was symptomatic, with endoscopic findings reported for 8 (0.9 %) and acid peptic ulcers for 14 (1.7 %) of the 818 patients. A late revision surgery was required for 7 (0.8 %) of the 818 patients. No patient required revision surgery due to biliary gastritis. At 60 months, the percentage of excess weight loss was 77 ± 5.1 %, the T2DM remission was 84.4 %, and the resolution of hypertension was 87.5 %. CONCLUSIONS: Despite initial skepticism, this study, together with many other large-scale, long-term similar studies from around the world (e.g., Taiwan, United States, France, Spain, India, Lebanon) demonstrated the MGB to be a short, simple, low-risk, effective, and durable bariatric procedure.

Validation of a turbulent Kelvin-Helmholtz shear layer model using a high-energy-density OMEGA laser experiment.

Following the successful demonstration of an OMEGA laser-driven platform for generating and studying nearly two-dimensional unstable plasma shear layers [Hurricane et al., Phys. Plasmas 16, 056305 (2009); Harding et al., Phys. Rev. Lett. 103, 045005 (2009)], this Letter reports on the first quantitative measurement of turbulent mixing in a high-energy-density plasma. As a blast wave moves parallel to an unperturbed interface between a low-density foam and a high-density plastic, baroclinic vorticity is deposited at the interface and a Kelvin-Helmholtz instability-driven turbulent mixing layer is created in the postshock flow due to surface roughness. The spatial scale and density profile of the turbulent layer are diagnosed using x-ray radiography with sufficiently small uncertainty so that the data can be used to ~0.17 µm) in the postshock plasma flow are consistent with an "inertial subrange," within which a Kolmogorov turbulent energy cascade can be active. An illustration of comparing the data set with the predictions of a two-equation turbulence model in the ares radiation hydrodynamics code is also presented.

A new clinical approach: use of blood-derived stem cells (BDSCs) for superficial digital flexor tendon injuries in horses.

AIMS: In this study, we present an innovative therapy using stem cells that were obtained from the peripheral blood of racehorses affected by uninduced superficial digital flexor tendon (SDFT) injuries. MAIN METHODS: Blood-derived stem cells (BDSCs) were generated from the blood samples of three horses in the presence of macrophage colony-stimulating factor (M-CSF). The racehorses received a single autologous BDSC treatment, which resulted in the successful repair of the tendons injuries. KEY FINDINGS: The results demonstrated that the BDSCs injection into the damaged tendon stimulated the regeneration of normal tissue. Furthermore, a relationship may exist between the speed and the quality of new tissue formation and the welfare and management of the treated animals. SIGNIFICANCE: This study demonstrates that stem cell technology offers new tools for tissue repair that in many cases is considered incurable, and provides additional evidence that BDScs injections increase the speed and quality of the regeneration process in different animal tissues.

[Venous thromboembolism prophylaxis after general surgery: where are we now?]. / Profilassi antitrombotica nel paziente chirurgico: a che punto siamo?

Venous thromboembolism (VTE) is a frequent complication in patients undergoing major surgery, with the possibility of long-term disability or fatal outcome. The rationale of the thromboprophylaxis in all patients can be summarized in three points: 1) the VTE is common in some types of surgery; 2) the VTE can be fatal; 3) thromboprophylaxis is highly effective and safe and, besides these clinical benefits, leads to lower total costs of treatment without further diagnostic and a new shelter for treating venous thrombosis. The surgical patients may present at admission one or more risk factors for VTE, The effect of this risk is cumulative, it is important to stratify the risk and to established an adequate prophylactic strategy. Today there is a unanimous consensus that the low molecular weight heparins are both effective and safe in preventing VTE in surgical patients. Unanimously approved guidelines can help surgeons in making decisions regarding VTE prophylaxis.

[Our experience on the treatment of epigastric hernia]. / Nostra esperienza sul trattamento dell'ernia epigastrica.

The epigastric hernia represents a rare surgical affection, sometimes insidious, whose pathogenesis has been discussed for a long time, revealing, in the course of the years, multiple predisposing and responsible factors of its appearance. From our experience and the data reported in the literature, it is clear that a standard surgery does not exist for this pathology, and it is often necessary to perform preliminary uncommon diagnostic exams. Our retrospective study consists in the analysis of the surgical treatments executed, from 2003 to 2006, on 37 patients suffered from epigastric hernia, for everyone of which, on the basis of the clinical features, of the preoperative diagnostic results and of the characteristics of the hernia defect, it has been encouraged a personalized surgical procedure,obtaining therefore, for the same pathology, different treatment protocols (open or laparoscopic procedures, ordinary hospital stay or day-surgery, prosthetic or not surgical repair).