Insulin resistance in patients on valproic acid: relation to adiponectin.

OBJECTIVES: To investigate the presence of insulin resistance in obese children with idiopathic epilepsy on valproic acid (VPA) monotherapy in comparison to obese otherwise healthy subjects. Secondary outcome was to explore the relation between adiponectin and insulin resistance among those patients. MATERIALS AND METHODS: Fifty obese children with generalized idiopathic epilepsy on VPA monotherapy and a control group of 49 obese clinically healthy age and sex-matched children with simple obesity were recruited in the study. Anthropometric assessment, fasting plasma insulin (FI), fasting glucose (FG) and fasting adiponectin levels were measured. Fasting glucose insulin ratio (FGIR) and homoeostasis model assessment for insulin resistance (HOMA-IR) were calculated for both patients and control subjects. Measurement of serum VPA trough level was also performed in patients. RESULTS: Patients had significantly higher fasting blood glucose, fasting insulin, lower FGIR and higher HOMA-IR values, compared to controls. Mean adiponectin level was significantly lower in patients compared to controls. The duration of treatment with valproic acid negatively correlated with adiponectin (r = -0.285, P = 0.045), but did not correlate with fasting glucose, insulin, FGIR or HOMA-IR. Total daily VPA dose significantly correlated with fasting insulin (r = 0.495, P < 0.001), FGIR (r = -0.525, P < 0.001) and HOMA-IR (r = 0.404, P = 0.004). CONCLUSION: This study ascertains the relationship between dose and duration of VPA therapy, insulin resistance and the adipocytokine axis. We are reporting the novel proposal that obese VPA-treated children are more insulin resistant and have lower adiponectin levels than obese and otherwise healthy children.

Impact of anthropometric measures and serum leptin on severity of gastroesophageal reflux disease.

The aim of this prospective study was to evaluate the impact of obesity, determined by different anthropometric measures, on clinical and endoscopic severity of GERD and the relation between serum leptin and clinical and endoscopic severity of GERD in Egyptian patients. The study was carried out at Ain Shams University Hospitals and Theodor Bilharz Research Institute, Cairo, Egypt. A total of 60 patients with clinically and endoscopically evident gastroesophageal reflux disease (GERD) were enrolled in this study as well as 20 healthy subjects matched for age and gender serving as the control group. Patients were divided according to their body mass index (BMI) into two groups: group 1 (n = 30): overweight and obese (BMI ≥ 25 and/or waist-to-height ratio [WHtR] ≥ 0.5) and group 2 (n = 30): normal weight (BMI ≥ 18 to < 25 and/or WHtR ≥ 0.4 to < 0.5). Upper gastrointestinal endoscopy, anthropometric measures, and symptom severity score questionnaire were done for all patients. Serum leptin hormone was assessed for patients and control groups.The evidence revealed statistically significant difference between the two groups in terms of different anthropometric measures (P < 0.00) except the height (P < 0.9), abdominal fat depot equations (P < 0.00), endoscopic findings according to Los Angeles classification (P < 0.001), symptom severity score (P < 0.00), and serum leptin hormone (43.96 ± 23.50 in group 1 vs. 7.5133 ± 8.18294 in group 2 and 6.98 ± 5.90 in the control group) (P = 0.00). Obesity in general and central (abdominal) obesity specifically has significant impact on clinical and endoscopic severity of GERD. Increased leptin hormone level is associated with clinical and endoscopic severity of GERD. Future trial on larger number of patients is emphasized.

Endovascular therapy for patients with renal angiomyolipoma presenting with retroperitoneal haemorrhage.

We report our experience treating four patients with acutely bleeding angiomyolipoma (AML) of sizes between 4 and 12 cm who were managed with endovascular embolisation with a mean follow-up of 10 months. In our case series, we demonstrate that endovascular embolisation in the acute setting for bleeding AMLs is a viable treatment option. AML should be in the differential diagnosis of acutely bleeding renal masses, even when there is no fat assessed by computed tomography (CT) imaging in the renal mass.

Direct trans-cervical endolymphatic thoracic duct stent-graft for plastic bronchitis.

Plastic bronchitis is a poorly understood and uncommon diagnosis, arising from multiple etiologies. Traditional treatment consists of steroids and vasodilators, with thoracic duct embolization emerging as a new procedural therapy. Herein, abnormal lymphatic vessels were noted on lymphangiography in an adult patient with debilitating plastic bronchitis, but anterograde lymphatic access was not feasible due to the patient's morbid obesity and non-visualization of retroperitoneal lymphatics. After trans-venous thoracic duct access could not be established, direct trans-cervical thoracic duct access was performed. A thoracic duct stent-graft was placed, excluding the abnormal bronchial lymphatics and maintaining physiologic anterograde flow through the central lymphatics. At three-month follow-up, the patient's condition had resolved.

Two-year outcomes of balloon-occluded retrograde transvenous obliteration of gastric varices in liver transplant recipients: A multi-institutional study.

PURPOSE: To assess the 2-year effectiveness and safety of balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices (GVs) in liver transplant recipients. MATERIALS AND METHODS: Eleven liver transplant recipients underwent consecutive BRTO for GVs at four institutions. Patients included eight (73%) men and three (27%) women with mean age of 56 years±12 (SD) (range: 26-67 years). Underlying cause of liver transplantation was hepatitis C virus (HCV)-related cirrhosis in five (45%), alcohol- and HCV-related cirrhosis in three (27%), primary biliary cirrhosis in two (18%), and alcoholic cirrhosis in one (9%). Five (45%) patients underwent BRTO for actively bleeding GVs, three (17%) for high-risk GVs, and three (17%) for augmentation of portal venous flow through obliteration of gastrorenal shunts. Mean time between liver transplantation and BRTO was 78 months (range: 0.1-276 months). Technical success, GVs obliterative rates, and immediate complications were recorded. Post-BRTO hemorrhagic, transplant, and overall survival rates were evaluated at 6, 12, and 24 months. RESULTS: All (100%) procedures were technically successful. Complete GVs obliteration was achieved in ten patients (91%). Two major complications (18%) occurred in the immediate post-procedure period. One patient developed complete portal vein thrombosis, and another patient developed consumptive coagulopathy, ultimately leading to death. No post-BRTO hemorrhagic recurrences were seen at 6, 12, or 24 months. One patient (9%) had delayed upper gastrointestinal bleeding at 34 months after the procedure which was managed conservatively. Transplant and overall survival rates were 91% at 6, 12, and 24 months. CONCLUSION: BRTO has high technical success and complete GVs obliterative rates in liver transplant recipients with few complications and high graft survival rates.

Thrombocytopenia in Patients with Gastric Varices and the Effect of Balloon-occluded Retrograde Transvenous Obliteration on the Platelet Count.

OBJECTIVES: Gastric varices primarily occur in cirrhotic patients with portal hypertension and splenomegaly and thus are probably associated with thrombocytopenia. However, the prevalence and severity of thrombocytopenia are unknown in this clinical setting. Moreover, one-third of patients after balloon-occluded retrograde transvenous obliteration (BRTO) have aggravated splenomegaly, which potentially may cause worsening thrombocytopenia. The aim of the study is to determine the prevalence and degree of thrombocytopenia in patients with gastric varices associated with gastrorenal shunts undergoing BRTO, to determine the prognostic factors of survival after BRTO (platelet count included), and to assess the effect of BRTO on platelet count over a 1-year period. MATERIALS AND METHODS: This is a retrospective review of 35 patients who underwent BRTO (March 2008-August 2011). Pre- and post-BRTO platelet counts were noted. Potential predictors of bleeding and survival (age, gender, liver disease etiology, platelet count, model for end stage liver disease [MELD]-score, presence of ascites or hepatocellular carcinoma) were analyzed (multivariate analysis). A total of 91% (n = 32/35) of patients had thrombocytopenia (<150,000 platelet/cm(3)) pre-BRTO. Platelet counts at within 48-h, within 2 weeks and at 30-60 days intervals (up to 6 months) after BRTO were compared with the baseline pre-BRTO values. RESULTS: 35 Patients with adequate platelet follow-up were found. A total of 92% and 17% of patients had a platelet count of <150,000/cm(3) and <50,000/cm(3), respectively. There was a trend for transient worsening of thrombocytopenia immediately (<48 h) after BRTO, however, this was not statistically significant. Platelet count was not a predictor of post-BRTO rebleeding or patient survival. However, MELD-score, albumin, international normalized ratio (INR), and etiology were predictors of rebleeding. CONCLUSION: Thrombocytopenia is very common (>90% of patients) in patients undergoing BRTO. However, BRTO (with occlusion of the gastrorenal shunt) has little effect on the platelet count. Long-term outcomes of BRTO for bleeding gastric varices using sodium tetradecyl sulfate in the USA are impressive with a 4-year variceal rebleed rate and transplant-free survival rate of 9% and 76%, respectively. Platelet count is not a predictor of higher rebleeding or patient survival after BRTO.

Rheolytic Thrombectomy with or without Adjunctive Indwelling Pharmacolysis in Patients Presenting with Acute Pulmonary Embolism Presenting with Right Heart Strain and/or Pulseless Electrical Activity.

Purpose. To evaluate the safety and efficacy of the Possis rheolytic thrombectomy with or without indwelling catheter-directed pharmacolysis for the treatment of massive pulmonary embolus in patients presenting with right heart strain and/or a pulseless electrical activity (PEA). Materials and Methods. Retrospective review of patients undergoing pulmonary pharmacolysis was performed (07/2004-06/2009). Pre- and posttreatment Miller index scoring weres calculated and compared. Patients were evaluated for tPA doses, ICU stay, hospital stay, and survival by Kaplan-Meier analysis. Results. 11 patients with massive PE were found, with 10/11 presenting with a Miller score of >17 (range: 16-27, mean: 23.2). CTPA and/or echocardiographic evidence of right heart strain was found in 10/11 patients. 3 (27%) patients presented with a PEA event. Two (18%) patients had a contraindication to pharmacolysis and were treated with mechanical thrombectomy alone. The intraprocedural mortality was 9% (n = 1/11). Of the 10 patients who survived the initial treatment, 7 patients underwent standard mechanical thrombectomy initially, while 5 received power pulse spray mechanical thrombectomy. Eight of these 10 patients underwent adjunctive indwelling catheter-directed thrombolysis. The mean catheter-directed infusion duration was 18 hours (range of 12-26 hours). The average intraprocedural, infusion, and total doses of tPA were 7 mg, 19.7 mg, and 26.7 mg, respectively. There was a 91% (10/11) technical success rate. The failure was the single mortality. Average reduction in Miller score was 9.5 or 41% (P = 0.009), obstructive index of 6.4 or 47% (P = 0.03), and perfusion index of 2.7 or 28% (P = 0.05). Average ICU and hospital stay were 7.4 days (range 2-27 days) and 21.3 days (range 6-60 days), respectively. Intent to treat survival was 90% at 6, 12, and 18 months. Conclusion. Rheolytic thrombectomy with or without adjunctive catheter-directed thrombolysis provides a safe and effective method for treatment of acute PE in patients who present with right heart strain and/or a PEA event.

Comparison of vasa vasorum after intravascular stent placement with sirolimis drug-eluting and bare metal stents.

The cytostatic drug, sirolimis has shown prevention in neointimal hyperplasia after stent placement. Recent studies have shown persistent inflammation seen with drug-eluting stents (DES) may result in late stent thrombosis. The aim of this study is to compare effects of bare metal stents (BMS) and sirolimis DES on the neointima and vasa vasorum in stented rabbit aortas. Stents were implanted in eight New Zealand rabbits for 9 weeks. Group I rabbits received BMS. Group II rabbits received sirolimis DES. A balloon-mounted BMS or DES was placed in the infrarenal aorta. Following euthanasia, aortas were perfused with barium sulfate and sectioned for histology. After 9 weeks the qualitative intrastent luminal diameter was fairly uniform in both the DES and the BMS. The thickness of neointima was similar in both groups. The number of vasa vasorum in the sirolimis DES increased compared with the BMS (P < 0.05). An increased number of vasa vasorum produced by the DES when compared with the BMS shows a difference in response to local vessel injury in rabbits. This result suggests that vasa vasorum may play a role in the persistent inflammation generated by sirolimis-coated stents.