Physician adherence to societal guidelines following colonoscopy with polypectomy.

BACKGROUND: Colorectal cancer is a significant cause of mortality and morbidity in western countries. Polypectomy reduces the incidence and mortality of colorectal cancer. Following polypectomy, recommendations regarding the frequency and duration of surveillance rely mostly on features of the resected polyps and are summarized in various gastroenterological societal guidelines. In this study, we aimed to delineate the accuracy of current post-polypectomy surveillance recommendations and to check whether active intervention would lead to an improvement in accuracy and consistency with societal guidelines. METHODS: We prospectively collected polypectomy reports over a 3-month period in 2 tertiary medical centers. We then performed an intervention that included: 1) presentation of results from 1st phase; 2) re-affirming the guidelines in a departmental meeting; 3) addition of a dedicated reporting form for post-polypectomy surveillance recommendations in the patients' electronic medical file. Finally, we conducted a second prospective collection of post-polypectomy recommendations, over a second 3-month period. RESULTS: Prior to the intervention, 76% of the colonoscopies with polypectomy had a recommendation for surveillance, compared to 85% after the intervention (P=0.003). Prior to the intervention, 65% of patients received a recommendation consistent with societal guidelines, compared with 78% after the intervention (P=0.001). CONCLUSION: Intervention, including re-affirmation of the current guidelines and creation of a dedicated reporting platform, significantly increases the number of follow-up recommendations after polypectomy and their consistency with societal guidelines.

Increasing prevalence of type 2 diabetes mellitus and impact of ethnicity in north Sudan.

BACKGROUND: Diabetes mellitus constitutes a global health threat, with increasing burden of disease in low and middle-income countries witnessing ongoing epidemiological transition including Sudan. AIMS: To study the prevalence of type 2 diabetes mellitus (T2DM) and prediabetes and determine the relationship to gender, age, waist circumference, body mass index, residence and ethnicity among the adult population in north Sudan. METHODS: A cross-sectional, population-based study in Northern State and River Nile State using random multi-stage cluster sampling targeting 5376 participants from 14 localities divided into 60 urban and 40 rural clusters. In each cluster, 60 households were studied. Blood glucose level and anthropometric measurements were recorded and a questionnaire containing demographic data was obtained from each participant. RESULTS: The prevalence of T2DM among participants was 18.7% and prediabetes was 12.9%. Among people living with T2DM, 694(71.0%) were known cases of T2DM, whereas 284(29.0%) were newly diagnosed cases. The significant associated risk factors for T2DM included urban residence (AOR 1.23, 95%CI 1.09-1.41), age above 60 years (AOR 4.77, 95%CI 4.04-5.63), obese BMI (AOR 1.26, 95%CI 1.03-1.55) and central obesity (AOR 1.39, 95%CI 1.14-1.68). Compared to indigenous population, individuals of Egyptian descents (AOR 1.28, 95%CI 1.04-1.57) and mixed origin (AOR 1.24, 95%CI 1.04-1.48) had increased risk of T2DM. CONCLUSION: The prevalence of T2DM and prediabetes in north Sudan have increased significantly since 1996 with variations between ethnicities which showed to be an independent risk factor for T2DM. Health authorities are recommended to set plans to meet the health needs of these communities.

ARA290 Improves Insulin Release and Glucose Tolerance in Type 2 Diabetic Goto-Kakizaki Rats.

Effects of ARA290 on glucose homeostasis were studied in type 2 diabetic Goto-Kakizaki (GK) rats. In GK rats receiving ARA290 daily for up to 4 wks, plasma glucose concentrations were lower after 3 and 4 wks, and hemoglobin A1c (Hb A1c) was reduced by ~20% without changes in whole body and hepatic insulin sensitivity. Glucose-stimulated insulin secretion was increased in islets from ARA290-treated rats. Additionally, in response to glucose, carbachol and KCl, islet cytoplasmic free Ca2+ concentrations, [Ca2+]i, were higher and the frequency of [Ca2+]i oscillations enhanced compared with placebo. ARA290 also improved stimulus-secretion coupling for glucose in GK rat islets, as shown by an improved glucose oxidation rate, ATP production and acutely enhanced glucose-stimulated insulin secretion. ARA290 also exerted an effect distal to the ATP-sensitive potassium (KATP) channel on the insulin exocytotic pathway, since the insulin response was improved following islet depolarization by KCl when KATP channels were kept open by diazoxide. Finally, inhibition of protein kinase A completely abolished effects of ARA290 on insulin secretion. In conclusion, ARA290 improved glucose tolerance without affecting hematocrit in diabetic GK rats. This effect appears to be due to improved γ-cell glucose metabolism and [Ca2+]i handling, and thereby enhanced glucose-induced insulin release.

Endoscopic removal of partially migrated intragastric bands following surgical gastroplasty: a prospective case series.

BACKGROUND: The intragastric migration of a surgically placed adjustable gastric band is believed to occur slowly, over months to years. Band removal procedures necessitate surgical laparotomy, thus increasing the risk of complications. METHODS: The endoscopic technique for band removal described in this case-series provides a minimally invasive approach. RESULTS: Fifteen patients referred for endoscopic removal of a partially migrated intragastric band. The partially migrated intragastric bands were all successfully removed in a mean of 1.1 endoscopic sessions. No patient required subsequent surgical intervention, and there were no immediate or delayed adverse events including no infections, bleeding, or perforations. CONCLUSIONS: Endoscopic removal of partially migrated intragastric bands appears feasible, effective, safe, and is a minimally invasive alternative to repeat surgery.

Shikonin increases glucose uptake in skeletal muscle cells and improves plasma glucose levels in diabetic Goto-Kakizaki rats.

BACKGROUND: There is considerable interest in identifying compounds that can improve glucose homeostasis. Skeletal muscle, due to its large mass, is the principal organ for glucose disposal in the body and we have investigated here if shikonin, a naphthoquinone derived from the Chinese plant Lithospermum erythrorhizon, increases glucose uptake in skeletal muscle cells. METHODOLOGY/PRINCIPAL FINDINGS: Shikonin increases glucose uptake in L6 skeletal muscle myotubes, but does not phosphorylate Akt, indicating that in skeletal muscle cells its effect is medaited via a pathway distinct from that used for insulin-stimulated uptake. Furthermore we find no evidence for the involvement of AMP-activated protein kinase in shikonin induced glucose uptake. Shikonin increases the intracellular levels of calcium in these cells and this increase is necessary for shikonin-mediated glucose uptake. Furthermore, we found that shikonin stimulated the translocation of GLUT4 from intracellular vesicles to the cell surface in L6 myoblasts. The beneficial effect of shikonin on glucose uptake was investigated in vivo by measuring plasma glucose levels and insulin sensitivity in spontaneously diabetic Goto-Kakizaki rats. Treatment with shikonin (10 mg/kg intraperitoneally) once daily for 4 days significantly decreased plasma glucose levels. In an insulin sensitivity test (s.c. injection of 0.5 U/kg insulin), plasma glucose levels were significantly lower in the shikonin-treated rats. In conclusion, shikonin increases glucose uptake in muscle cells via an insulin-independent pathway dependent on calcium. CONCLUSIONS/SIGNIFICANCE: Shikonin increases glucose uptake in skeletal muscle cells via an insulin-independent pathway dependent on calcium. The beneficial effects of shikonin on glucose metabolism, both in vitro and in vivo, show that the compound possesses properties that make it of considerable interest for developing novel treatment of type 2 diabetes.

Sex-different hepaticglycogen content and glucose output in rats.

BACKGROUND: Genes involved in hepatic metabolism have a sex-different expression in rodents. To test whether male and female rat livers differ regarding lipid and carbohydrate metabolism, whole-genome transcript profiles were generated and these were complemented by measurements of hepatic lipid and glycogen content, fatty acid (FA) oxidation rates and hepatic glucose output (HGO). The latter was determined in perfusates from in situ perfusion of male and female rat livers. These perfusates were also analysed using nuclear magnetic resonance (NMR) spectroscopy to identify putative sex-differences in other liver-derived metabolites. Effects of insulin were monitored by analysis of Akt-phosphorylation, gene expression and HGO after s.c. insulin injections. RESULTS: Out of approximately 3 500 gene products being detected in liver, 11% were significantly higher in females, and 11% were higher in males. Many transcripts for the production of triglycerides (TG), cholesterol and VLDL particles were female-predominant, whereas genes for FA oxidation, gluconeogenesis and glycogen synthesis were male-predominant. Sex-differences in mRNA levels related to metabolism were more pronounced during mild starvation (12 h fasting), as compared to the postabsorptive state (4 h fasting). No sex-differences were observed regarding hepatic TG content, FA oxidation rates or blood levels of ketone bodies or glucose. However, males had higher hepatic glycogen content and higher HGO, as well as higher ratios of insulin to glucagon levels. Based on NMR spectroscopy, liver-derived lactate was also higher in males. HGO was inhibited by insulin in parallel with increased phosphorylation of Akt, without any sex-differences in insulin sensitivity. However, the degree of Thr172-phosphorylated AMP kinase (AMPK) was higher in females, indicating a higher degree of AMPK-dependent actions. CONCLUSIONS: Taken together, males had higher ratios of insulin to glucagon levels, higher levels of glycogen, lower degree of AMPK phosphorylation, higher expression of gluconeogenic genes and higher hepatic glucose output. Possibly these sex-differences reflect a higher ability for the healthy male rat liver to respond to increased energy demands.

Validity of clinical criteria in the management of endoscopic retrograde cholangiopancreatography related duodenal perforations.

OBJECTIVE: To assess the validity of predetermined clinical and radiologic criteria in the management of endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforations (DPs). DESIGN: Prospective case series. SETTING: Tertiary medical facility. PATIENTS: Twenty-two individuals with ERCP-related DPs. INTERVENTIONS: The guidelines advocated operative management for patients with free contrast leak and those with positive peritoneal signs or other indicators suggesting sepsis irrespective of the mechanism or location of injury. MAIN OUTCOME MEASURES: Thirty-day mortality rates, success of nonoperative management, and complications related to nonoperative and operative policies. RESULTS: Diagnosis of DP was accomplished early (within 6 hours of ERCP) in 20 of 22 patients (91%). Three patients with early positive peritoneal signs were treated surgically; 2 of them sustained injury from the endoscope, and the third by papillotomy. All 3 patients had significant findings justifying immediate surgery. Nineteen patients with retroperitoneal DPs due to papillotomy or guidewire insertion were treated nonoperatively. In patients diagnosed early (n = 17), only 1 failure (6%) occurred. In the 2 patients with delayed diagnosis, there was 1 failure, which culminated in death. CONCLUSIONS: Our results might validate the role of clinical criteria for the selective management of ERCP-related DPs. These criteria were found to correlate well with radiologic findings and the mechanism of injury.

Wireless capsule video endoscopy is a superior diagnostic tool in comparison to barium follow-through and computerized tomography in patients with suspected Crohn's disease.

BACKGROUND: The recently introduced wireless M2A capsule video endoscopy (CVE) has been demonstrated to be superior to barium follow-through and enteroscopy in diagnosing patients with occult blood loss and iron-deficiency anaemia. OBJECTIVE: To further investigate CVE in comparison to barium follow-through and entero-computerized tomography (CT) in establishing the diagnosis of patients with suspected Crohn's disease. DESIGN AND SETTING: The study was conducted in one academic hospital. Twenty patients with recurrent abdominal pain and/or weight loss or chronic diarrhoea underwent barium follow-through as their initial examination, followed by CVE (if there was no stricture) and entero-CT. The radiologist that performed the barium follow-through and entero-CT was blinded to the results of the CVE. A blinded reader who was unaware of the study objective diagnosed the results of the CVE. In most cases in which there was a discrepancy between examinations, colonoscopy and ileoscopy were performed. For each patient, the diagnosis and disease extent were recorded. RESULTS: Twenty patients (13 males, 7 females; mean age 31 years, range 20-57) were included in the study. Ninety-five per cent of the patients had abdominal pain, 75% had diarrhoea, and 65% had weight loss. The mean haemoglobin level of the group was 13.1 g% (range 10-15.5). Only 13 patients underwent entero-CT.CVE confirmed the diagnosis of Crohn's disease that was suspected by alternative methods in six of the 20 patients. CVE made the diagnosis of Crohn's disease in six patients that had normal barium follow-through or entero-CT. CVE ruled out a diagnosis of Crohn's disease suspected by other modalities in three patients. CVE extended the involvement of Crohn's disease in three of the patients, and established new diagnoses in two patients. SUMMARY: CVE established new diagnoses, confirmed existing diagnoses, enlarged the extent of the disease, and ruled out the suspicion of Crohn's disease in 70% of the patients. Barium follow-through established diagnoses, measured the extent of the disease, and ruled out the suspicion of Crohn's disease in 37% of the patients. The capsule detected all of the lesions diagnosed by barium follow-through and entero-CT. CVE detected additional lesions that were not detected by other modalities in 47% of cases and ruled out lesions that were detected by other modalities in 16% of cases (P < 0.05). CONCLUSION: CVE is a superior and more sensitive procedure than barium follow-through and entero-CT in establishing the diagnosis and estimating the extent of Crohn's disease.