Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study.

BACKGROUND: Patients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT). METHODS: This study included 254 patients undergoing pancreatic surgery for oncologic indications. A13C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring 13CO2 in breath samples after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups. RESULTS: In 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11. In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function. CONCLUSIONS: The vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.

Prediction of exocrine and endocrine insufficiency after pancreaticoduodenectomy using volumetry.

Objectives: The aim of this study is to evaluate the use of pancreatic volumetric assessment to predict exocrine and endocrine insufficiency after pancreaticoduodenectomy.Methods: Thirty-seven patients who underwent pancreaticoduodenectomy were included in the study. Endocrine function was assessed in all patients without a history of diabetes using an oral glucose tolerance test. A 13C-labeled mixed triglyceride (MTG) breath test evaluated exocrine function before and after resection. Volumetric measurements were performed on CT or MRI.Results: The volumetric measurements could not predict pre- or postoperative diabetes. Moreover, the resected volume was significantly lower in patients who developed diabetes after resection. Comparing patients with a normal and disturbed postoperative MTG, postoperative volumes and parenchymal thickness were significantly different. The parenchymal thickness on postoperative imaging is withheld as a predictive factor (OR = .85 [95% CI .71-1.01], p = .049). The best cutoff value to predict exocrine insufficiency is a parenchymal thickness of less than 11.4 mm (AUC = .76, p = .025, sensitivity = 88.9%, specificity = 70.0%).Conclusions: Pancreatic remnant volumetry and parenchymal thickness measurement after pancreaticoduodenectomy are correlated with exocrine insufficiency, but with limited predictive value. None of the preoperative measurements are withheld to predict postoperative exocrine function. Pre- and postoperative volumetry appear to have no use in predicting postoperative diabetes.

Cytomegalovirus pleuropericarditis after orthotopic liver transplantation.

Cytomegalovirus (CMV) reactivation is a common complication after liver transplantation. In patients with CMV infection, indicated by a positive CMV DNA titer, the presence of any clinical symptom is termed CMV disease. The most common organ affected in CMV disease is the gastrointestinal tract, causing esophagitis, gastritis, enteritis or colitis. CMV infection of the pleura and pericard has been reported in immunocompromised patients, but is rarely seen following liver transplantation.We report a case of a 59-year-old male who developed CMV pleuropericarditis after liver transplantation. Initial ganciclovir treatment did not improve the patient's symptoms and therapy was switched to Foscarnet which ultimately resulted in resolution of infection. However, a few weeks after Foscarnet cessation, the patient again developed bilateral pleural effusion. Ultimate biochemical and clinical response was achieved with IV ganciclovir treatment. The patient was discharged from the hospital with oral Valganciclovir for 3 weeks and has since remained relapse free for >1 year.

Estimation of the future remnant liver function is a better tool to predict post-hepatectomy liver failure than platelet-based liver scores.

INTRODUCTION: Recently, there has been increasing interest in the preoperative prediction and prevention of post-hepatectomy liver failure (PHLF). This is a particular concern in colorectal liver metastases (CRLM), when surgery follows potentially hepatotoxic chemotherapy. Platelet-based liver scores (PBLS) such as APRI and FIB-4 are predictive of chemotherapy-associated liver injury (CALI) and PHLF. Estimation of the future liver remnant function (eFLRF) by combining 99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBSBSA) with future liver remnant volume ratio (FLRV%), is predictive of PHLF and related mortality. We hypothesized that a HBSBSA based formula was a better predictor for PHLF than PBLS in chemotherapy-pretreated CRLM. METHODS: Between 2012 and 2016, 140 patients underwent liver resection for CRLM following systemic therapy. HBSBSA, FLRV%, eFLRF and PBLS were calculated and compared for their value in predicting PHLF. RESULTS: eFLRF and FLRV% had a better predictive value for PHLF than HBSBSA alone and APRI and FIB-4 (AUC = 0.800, 0.843 versus 0.652, 0.635 and 0.658 respectively). In a subgroup analysis (Oxaliplatin all, Oxaliplatin ≥ 6 cycles, Irinotecan all and Irinotecan ≥ 6 cycles), eFLRF was the only factor predictive for PHLF in all subgroups (all: p ≤ 0.05). Prediction of HBSBSA for chemotherapy associated steato-hepatitis (CASH) reached almost significance (p = 0.06). FIB-4 was predictive for sinusoidal obstruction syndrome (SOS) (p = 0.011). Only weak correlation was found between HBSBSA and PBLS. CONCLUSION: eFLRF is a better predictor of PHLF than PBLS or HBSBSA alone. PBLS seem to measure other aspects of liver function or damage than HBSBSA.

Single-Center Case Series of Donor-Related Malignancies: Rare Cases With Tremendous Impact.

BACKGROUND: Donor-related malignancy is a rare complication of organ transplantation. METHODS: In this case series, we discuss three cases of donor-related cancers in kidney transplant recipients who were registered in our center between 1979 and 2015. They account for an incidence of 0.29% of donor-related malignancies of a total of 1015 transplanted kidney grafts (deceased and living donors). The three cases that we describe presented in different ways and with different severity, although the response to the initiated treatment was comparable. RESULTS: All three patients not only survived their cancer episode but also had a complete oncological remission and underwent successful second kidney transplantation, accounting for a 100% survival rate in our small cohort. CONCLUSIONS: Despite the very low incidence of this complication, transplant clinicians must be aware of the occurrence of donor-related malignancies when selecting a donor and should be able to diagnose and treat a case of donor-related cancer.

Gafchromic EBT2 film dosimetry in reflection mode with a novel plan-based calibration method.

PURPOSE: A dosimetric system formed by Gafchromic EBT2 radiochromic film and Epson Expression 10000XL flatbed scanner was commissioned for dosimetry. In this paper, several open questions concerning the commissioning of radiochromic films for dosimetry were addressed: (a) is it possible to employ this dosimetric system in reflection mode; (b) if so, can the methods used in transmission mode also be used in reflection mode; (c) is it possible to obtain accurate absolute dose measurements with Gafchromic EBT2 films; (d) which calibration method should be followed; (e) which calibration models should be used; and (f) does three-color channel dosimetry offer a significant improvement over single channel dosimetry. The purpose of this paper is to help clarify these questions. METHODS: In this study, films were scanned in reflection mode, the effect of surrounding film was evaluated and the feasibility of EBT2 film dosimetry in reflection mode was studied. EBT2's response homogeneity has been reported to lead to excessive dose uncertainties. To overcome this problem, a new plan-based calibration method was implemented. Plan-based calibration can use every pixel and each of the three color channels of the scanned film to obtain the parameters of the calibration model. A model selection analysis was conducted to select lateral correction and sensitometric curve models. The commonly used calibration with fragments was compared with red-channel plan-based calibration and with three-channel plan-based calibration. RESULTS: No effect of surrounding film was found in this study. The film response inhomogeneity in EBT2 films was found to be important not only due to differences in the fog but also due to differences in sensitivity. The best results for lateral corrections were obtained using absolute corrections independent of the dose. With respect to the sensitometric curves, an empirical polynomial fit of order 4 was found to obtain results equivalent to a gamma-distributed single hit model based on physical assumptions. Three-channel dosimetry was found to be substantially superior to red-channel dosimetry. CONCLUSIONS: Reflection mode with Gafchromic EBT2 radiochromic film was found to be a viable alternative to transmission mode. The same methods that are used in transmission mode can be followed in reflection mode. A novel plan-based method was developed for calibration and multichannel dosimetry. This novel method offers increased robustness against film response inhomogeneities and reduces considerably the time required for calibration.

Acute colonic pseudo-obstruction in vascular patients (Ogilvie syndrome).

Two patients with acute colonic pseudo-obstruction are presented. Acute colonic pseudo-obstruction, first described by Ogilvie in 1948, is characterised by signs of colonic obstruction, but without mechanical obstruction to the intestinal flow. The current hypothesis states that it is caused by an imbalance between sacral parasympathetic excitatory nerves and sympathetic inhibitory nerves, thus inducing functional obstruction. It mostly develops in hospitalised patients with a variety of medical and surgical conditions. Two such patients with extensive co-morbidities, developed progressive colon dilatation with signs of acute peritonitis, and were operated on urgently. In both patients, right hemicolectomy and postoperative medical treatment resulted in complete recovery.

Succesful [Successful] endovascular repair of an abdominal mycotic aneurysm. A case report.

A 73-year-old man was admitted to the emergency department presenting with cramping pain in the left iliac fossa that had persisted for ten days, with diarrhoea and dysuria. A recent onset of high fever had urged him to the hospital. A routine blood sample showed a leukocytosis of 11.9 x 10(3)/mm(3) and an elevated CRP of 16 mg/dl. Haemocultures and a urine sample were taken. A colonoscopy and ultrasound showed no abnormalities. The urine culture contained salmonella enteritidis. On day 5 a CT scan of the abdomen was performed. This showed a saccular aneurysm of the abdominal aorta, approximately 2 cm in length, with clear signs of a contained rupture. An urgent EVAR procedure was performed. An Excluder bifurcation-endoprosthesis was placed under antibiotic coverage. Control CT scan showed a thrombosis of the aneurysm and a type II endoleakage. The endoleakage spontaneously resolved within 3 months. The patient was kept on antibiotics (levofloxacine) for 4 months. We suggest that the use of an endoprosthesis could be a good and safe alternative for the repair of infrarenal mycotic aorta aneurysm.

Pseudo-pulmonary embolism as a sign of acute heparin-induced thrombocytopenia in hemodialysis patients: safety of resuming heparin after disappearance of HIT antibodies.

Heparin-induced thrombocytopenia (HIT) is a syndrome caused by platelet-activating antibodies that recognize complexes of platelet factor 4 (PF4) and heparin. Thrombocytopenia is the most common clinical feature of HIT. HIT can be considered as a hypercoagulable state, with a high risk of thrombosis. Another feature of HIT is an acute systemic reaction that characteristically begins 5-30 min after receiving an intravenous bolus of unfractionated heparin, such as is commonly given for hemodialysis (HD). Here we present 4 patients who developed acute HIT at or near the start of their chronic HD. All patients were anticoagulated with the low-molecular-weight heparin, nadroparin, for HD. Three of our patients underwent surgery approximately 1-2 weeks before developing HIT. All patients presented with an acute systemic reaction during HD. All patients were treated and further dialyzed with lepirudin. Under this treatment we observed a quick recovery of the platelet count, and patients remained symptom-free. Antibodies against the PF4-heparin complex were detected with a combination of a 'quick test' and an enzyme-linked immunosorbent assay test. The likelihood of having HIT previous to the detection of antibodies was estimated with the pre-test probability score criteria. The tests for PF4-heparin antibodies remained positive for an average of 165 days. Three patients underwent a rechallenge with nadroparin after disappearance of the HIT antibodies in their serum. All 3 remained symptomless when they were further hemodialyzed on nadroparin. Our observations indicate that nadroparin can be successfully reintroduced for HD anticoagulation once the patient's HIT antibodies have disappeared.

Investigation of gastrointestinal transport by magnetic marker localization.

The method of magnetic marker monitoring MMM with a biomagnetic measurement system allows the tracking of the transport of solid drug forms with high spatiotemporal resolution. This technique enables to display the path and the disintegration of the magnetic marked pharmaceutical dosage form via the decrease of its magnetic moment. The method was used to assess exogenous factor on the esophageal transport of orally administered solid drug forms in five healthy volunteers. In a drug delivery study we have applied the MMM to monitor the path of a tablet during the gastrointestinal passage and to visualize the disintegration in the small intestine by the magnetic moment of the tablet. The signal to noise ratio of the measurement data was improved by ICA filtering.

Testosterone regulates alpha-synuclein mRNA in the avian song system.

Alpha-synuclein is a small, highly conserved protein in vertebrates that has been linked to several neurodegenerative diseases. The avian song control system is one of the model systems in which the protein was independently discovered. Alpha-synuclein is dynamically regulated in the song system during song learning, a process in which sex steroids play a central role. We compared alpha-synuclein mRNA expression in the brains of 12 adult male chipping sparrows (Spizella passerina) treated with either testosterone or blank s.c. implants. We saw pronounced upregulation of alpha-synuclein mRNA in, as well as an increase in the volume of, the song control nucleus area X in response to exogenous testosterone. To our knowledge this is the first report of steroid regulation of synuclein gene expression in any model system.

Androgenic regulation of steroid hormone receptor mRNAs in the brain of whiptail lizards.

Sex and species differences in androgenic regulation of steroid hormone receptor mRNAs were examined in the diencephalon of two species of whiptail lizards: Cnemidophorus inornatus is a sexual species and the direct evolutionary ancestor to Cnemidophorus uniparens, an all-female parthenogenetic species. Lizards were gonadectomized and treated with different doses of either aromatizable testosterone or nonaromatizable dihydrotestosterone. The relative abundances of androgen-, oestrogen-, and progesterone-receptor mRNAs were compared in various nuclei following in situ hybridization with homologous riboprobes. A diversity of patterns in androgenic regulation was observed, with effects differing according to brain region, the steroid-receptor mRNA being considered and, in some cases, between androgens. In the ancestral sexual species, intact males had lower androgen-receptor mRNA abundances than castrated, blank-implanted males in the medial preoptic area. Testosterone significantly decreased androgen-receptor mRNA abundance in the medial preoptic area of castrated males. Males had higher androgen-receptor mRNA levels in the preoptic area than females generally and neither the sexual or parthenogenetic females showed a decrease in androgen-receptor mRNA with androgen treatment. Both testosterone and dihydrotestosterone increased oestrogen-receptor mRNA abundance in the ventromedial hypothalamus of C. inornatus, but no sex differences in this effect were observed. Gonadectomy decreased, whereas androgen treatment increased, progesterone-receptor mRNA abundance in the ventromedial hypothalamus. There was a sex difference in this response to androgen in the sexual species, with males having greater amounts than females in this brain area. The parthenogenetic species exhibited a similar pattern to females of the sexual species, but the levels were higher overall, possibly because Cnemidophorus uniparens is triploid. The periventricular preoptic area showed a different pattern, with testosterone treatment increasing progesterone-receptor mRNA abundance in both sexes of the sexual species and in the parthenogenetic species, while dihydrotestosterone did not. The diversity of patterns in androgen effects indicates that gonadal sex, aromatization of androgen, and perhaps gene dosage all influence the expression of steroid-receptor mRNAs in the lizard brain.

Breeding conditions induce rapid and sequential growth in adult avian song control circuits: a model of seasonal plasticity in the brain.

In adult songbirds, seasonal changes in photoperiod and circulating testosterone (T) stimulate structural changes within the neural song control circuitry. The mechanisms that control this natural plasticity are poorly understood. To determine how quickly and in what sequence the song nuclei respond to changing daylength and circulating T, we captured 18 adult male white-crowned sparrows and kept them on short days for 12 weeks. We killed five of these birds and exposed the rest to long days (LD) and elevated T. We killed these birds either 7 or 20 d after LD + T exposure. We measured song nuclei volumes and cellular attributes, the mass of the vocal production organ (the syrinx), and song behavior. The neostriatal song control nucleus HVC (also known as "high vocal center"), added 50,000 neurons and increased in size within 7 d of exposure to LD + T. Efferent targets of HVC, the robust nucleus of the archistriatum (RA), and area X of the parolfactory lobe grew more slowly and were not significantly larger until day 20 of the study. The tracheosyringeal portion of the hypoglossal nucleus (nXIIts), which receives projections from RA and normally grows in response to seasonal cues, did not grow over the time course of this study. Syringeal mass increased within 7 d of LD + T treatment. The anatomical changes in the brain were accompanied by behavioral changes in song production. On day 7 when the song circuitry was incompletely developed, male sparrows sang less stereotyped songs than males at day 20 with more completely developed song circuits. These results suggest that the song circuitry responds rapidly and sequentially to breeding-typical conditions (long days and elevated T), and that song stereotypy increases as nuclei within this circuitry grow.

Seasonal changes in androgen receptor immunoreactivity in the song nucleus HVc of a wild bird.

In seasonally breeding songbirds, song behavior and neural morphology change seasonally. Song control nuclei are larger during the breeding season, as determined by multiple cytological labels. Seasonal changes in song nuclei are regulated by testosterone (T), and several song nuclei contain intracellular androgen receptors (AR). Changes in AR levels may interact with changes in plasma T levels to regulate song nuclei morphology. We measured seasonal changes in AR-immunoreactive cells in the telencephalic song nucleus HVc using the affinity-purified PG21 antibody to rat AR. We caught wild adult male Gambel's white-crowned sparrows (Zonotrichia leucophrys gambelii) during spring breeding in Alaska and during autumn migration in Washington State. To enhance PG21 labeling, animals were treated with T for 90 minutes (as in Smith et al. [1996] J. Histochem. Cytochem. 44:1075-1080). AR+ cells were found in HVc and other song nuclei, hippocampus, nucleus taeniae (homologue to mammalian amygdala), and the hypothalamus. HVc volume was larger in spring (S) than autumn (A), in both the PG21- and Nissl-stained sections (S:A = 1.9 and 1.7, respectively). In spring, but not autumn, PG21 and Nissl measurements were slightly different (PG21:Nissl = 1.07), perhaps because PG21 labeled the most caudal extent of HVc more clearly. In HVc, AR+ cell density and number were greater in spring. The percentage of AR+ cells was also increased in spring. Qualitatively, the staining intensity of individual cells was higher in spring. In time course studies, the T injection enhanced PG21 staining within 15 minutes, suggesting that it increases labeling via AR translocation to and concentration in the cell nucleus.

An experimental examination of learned helplessness in older adolescents and young adults with long-standing asthma.

OBJECTIVE: To examine the effects of experimentally induced learned helplessness in older adolescents and young adults with long-standing asthma. METHODS: Thirty-nine participants (18-24 years of age) with histories of long-standing asthma (AS) and an age-matched healthy cohort (HC) (N = 94) received either contingent or noncontingent feedback on an experimental task. Participants' anagram-solving performance was assessed following the experimental procedure. Participants also completed a measure of depression and pretest-posttest measures of mood, expectancy, and attributions related to experimental task performance. RESULTS: The AS participants demonstrated significantly greater problem-solving deficits following response-noncontingent feedback, compared to the HC group. Further, whereas both AS and HC participants made more internal performance attributions when given response-contingent feedback, only AS participants demonstrated a pattern of increased internal attributions (i.e., self-focus) following response-noncontingent failure. In addition, 21% of AS participants met DSM-IV criteria for major depression, compared to only 5% of the HC group. CONCLUSIONS: Individuals with long-standing asthma may be at increased risk for depression and for learned helplessness deficits, specifically impaired problem solving, in response to environmental noncontingency. Results are discussed in terms of both learned helplessness theory and perseverative self-focus conceptualizations of depression. The implications for both short- and long-term management of pediatric asthma are also discussed.

Illness uncertainty, attributional style, and psychological adjustment in older adolescents and young adults with asthma.

Examined psychological adjustment in a college sample of older adolescents and young adults (n = 49) with histories of childhood asthma. A substantial number of subjects evidenced clinically significant levels of overall distress. In addition, greater perceived asthma uncertainty and increased stable attributions for negative events were significantly associated with poorer psychological adjustment after controlling for demographic and disease variables. Further analyses revealed a moderating influence of uncertainty on attribution-adjustment relationships. These findings provide initial support for a cognitive diathesis-stress view of adjustment in long-standing asthma. Results also support a growing body of evidence suggesting that the focus of efforts to enhance adjustment to asthma need to be expanded beyond childhood and early adolescence.