New-onset Diabetes Mellitus after EUS-guided Drainage with LAMS: A Pilot Study

BACKGROUND AND AIMS

Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM). The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen-apposing metal stents (LAMS).

METHODS

We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for at least 12 months after stent removal. These patients were compared with age- and sex-matched asymptomatic WON controls without interventional treatment and healthy controls to assess the one-year occurrence of DM. Diabetes was defined according to the American Diabetes Association criteria.

RESULTS

Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; median age, 60 years), 13 patients (26%) had pre-existing DM and were excluded. Ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in asymptomatic WON controls (18.9%, p=0.581) and healthy controls (2%, p = 0.002). In the symptomatic WON group, NOD patients compared to non-DM patients were older (63.5 vs. 56 years old, p=0.042), had more frequent necrosis > 50% of the pancreatic parenchyma (p=0.002) and had a body-tail location of WON (p<0.001). On multivariate analysis, the number of direct endoscopic necrosectomy (DEN) sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients had poor glycemic control and required more DEN sessions to achieve WON resolution than patients with prior DM (p=0.017).

CONCLUSIONS

In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up. Patients with extensive pancreatic necrosis were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence.

Activated Hepatic Stellate Cells (Ito Cells) - Marker of Advanced Fibrosis in Chronic Viral Hepatitis C: A Pilot Study

BACKGROUND AND AIMS

The aim of this study is to determine whether activated hepatic stellate cells (HSCs) may represent a prognostic marker of progressive liver fibrosis in chronic viral hepatitis C (VHC) before antiviral therapy. The possible correlation between HSCs immunohistochemical features, histopathological aspects and clinical data before therapy were also studied.

METHODS

This retrospective pilot study was conducted on 27 liver biopsies from VHC patients before antiviral therapy. HSCs's immunohistochemical analysis used the antibodies alpha-smooth muscle actin (α-SMA), glial fibrillary acidic protein (GFAP) and vinculin. We correlated immunopositive HSCs with HCV load, liver stiffness (LS), fibrosis stage and necro-inflammatory degree before treatment. Also, we assessed the association between liver fibrosis after therapy, the sustained virological response at 12 weeks after therapy (SVR 12) and the type of therapy.

RESULTS

HSCs were increased in VHC patients compared to controls, mainly in the intermediate and periportal lobular regions. α-SMA and vinculin HSCs correlated positively with fibrosis stage (p=0.044), (p=0.028). Furthermore, α-SMA and vinculin HSCs were associated with LS (p=0.027), (p=0.002) and viral load (p=0.021), (p=0.006), but not with necro-inflammation degree. GFAP HSCs inversely correlated with fibrosis stage (r= -0.475), LS (r= -0.422) and HCV load (r= -0.517), but positively with necro-inflammation degree (p=0.038). Liver fibrosis post therapy correlated positively with SVR12 (p<0.001) and the type of therapy (p=0.006) and SVR12 correlated positively with treatment's type (p=0.002).

CONCLUSIONS

Activated HSCs may represent a marker of increased liver fibrosis in VHC. Different immunohistochemical markers can detect various HSCs subpopulations involved in the evolution of VHC and liver fibrosis.

Computed tomographic findings in dogs with suspected aspiration pneumonia: 38 cases (2014‐2019)

OBJECTIVES

To describe computed tomographic (CT) findings in dogs diagnosed with aspiration pneumonia and to assess for any correlation with patient outcome.

MATERIALS AND METHODS

Retrospective analysis of 38 cases with a presumptive diagnosis of aspiration pneumonia at two UK referral centres. Medical records were reviewed for signalment, history, physical examination and clinicopathologic data. CT examinations of the thorax were reviewed by the European College of Veterinary Diagnostic Imaging board-certified radiologist for all dogs to describe the characteristics and distribution of the pulmonary lesions.

RESULTS

The most common CT findings were lung lobe consolidation associated with air bronchograms (100%) followed by ground-glass attenuation (89.4%), bronchial wall thickening (36.8%), bronchiolectasis (31.5%) and bronchiectasis (15.7%). Large-breed dogs were overrepresented. Duration of hospitalisation ranged between 0 and 8 days (mean 3 days). Overall, 89.4% of dogs survived the aspiration event and were discharged from the hospital. The four dogs that did not survive to discharge had five or more lobes affected on CT.

CLINICAL SIGNIFICANCE

CT findings in dogs with aspiration pneumonia are described. CT is a useful imaging modality to diagnose aspiration pneumonia.

Risk factors for new-onset diabetes mellitus following acute pancreatitis: a prospective study

OBJECTIVE

Acute pancreatitis (AP) is increasingly recognized as a major cause of diabetes, however, the frequency and risk factors associated with new-onset diabetes are not well established. We aimed to assess the frequency and risk factors associated with new-onset diabetes, the time of diabetes occurrence, and the difference between early and late-onset diabetes following an AP episode.

PATIENTS AND METHODS

This prospective study included adult patients with AP admitted to a tertiary referral center, followed-up for one year to assess the occurrence of postpancreatitis diabetes. Diabetes was defined in accordance with World Health Organization criteria and the severity of AP was assessed based on the 2012 revised Atlanta classification.

RESULTS

Of 329 patients with AP, 29 (8.8%) were diagnosed with diabetes secondary to AP. Of these, 21 (6.37%) had early-onset diabetes (within one month after the acute episode) whereas 8 (2.42%) had late-onset diabetes (more than one month after the AP episode). Obesity and acute necrosis were more frequent in patients with new-onset diabetes compared to those without (55.2% vs. 33.4%, p=0.040 and 31% vs. 7.7%, p<0.01), and remained statistically significant in multivariate analysis. No statistically significant differences were found between these groups regarding sex, age, etiology and severity of AP. The patients with early-onset diabetes were older than those with late-onset (61 vs. 45 years old), in univariate and multivariate analysis (p=0.018 and p=0.038, OR=0.87).

CONCLUSIONS

Less than 10% of patients with AP developed diabetes within 1 year, particularly obese patients and those with acute pancreatic necrosis of more than 50%. Patients aged over 61 years old developed diabetes in the first month after the acute episode of AP.

Treatment with Tocilizumab in Adult Patients with Moderate to Critical COVID‐19 Pneumonia: A Single‐Center Retrospective Study

Objectives

This study aimed to assess if tocilizumab (TCZ) timing is associated with improved survival.

Material and methods

Data obtained from adult patients with moderate/severe/critical COVID-19 and treated with TCZ, who were admitted to the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania (April 2020-April 2021), were retrospectively analyzed. The database included demographics, clinical data, computed tomography scan results, the kinetics of IL-6, laboratory variables, and the outcome until discharge.

Results

A total of 221 patients received dexamethasone, antivirals, anticoagulants, and 1-2 doses of TCZ, 8 mg/kg. In 2021, more patients received high-flow oxigen/non-invasive ventilation compared to those hospitalized in 2020, but demographics, in-hospital mortality, and laboratory data did not differ significantly. In-hospital mortality was associated with age, disease severity, lung damage, intensive care unit (ICU) admission, cardiovascular comorbidities, and IL-6>100 pg/mL at TCZ administration. In multivariate analysis the risk of death was significantly higher in patients with a persistent inflammatory state, adjusted odds ratio (aOR) 16.6 (95% CI 3.07-108.96); lung damage>40%, aOR 11.68 (95% CI 2.05-224.98); and cardiovascular comorbidities>2, aOR 3.65 (95% CI 1.06-12.53). TCZ initiation at ≤3 days after admission showed improved survival, odds ratio (OR)=0.39 (95% CI 0.16-0.9). Severe infections were found in 11 (4.9%) patients.

Conclusion

Early initiation of TCZ seems beneficial and safe in patients with moderate to critical COVID-19 pneumonia.

Antibody and viral RNA kinetics in SARS-CoV2 infected patients admitted to a Romanian University Hospital of Infectious Diseases

OBJECTIVES

To assess the antibody and viral kinetics in asymptomatic/mild confirmed SARS-CoV-2 infections compared to more severe patients.

MATERIAL AND METHODS

Retrospective analysis of data obtained from adult patients with a confirmed SARS-CoV2 infection having at least one SARS-CoV-2 pair of specific IgM/IgG tests, admitted in The University Hospital of Infectious Diseases Cluj-Napoca, Romania (28 February to 31 August 2020). The database also included: demographic, clinical, chest X-ray and/or CT scan results, RT-PCR SARS-CoV-2, and dexamethasone treatment. A total of 469 patients were evaluated as "asymptomatic/mild" and "moderate/severe/critical" cases.

RESULTS

The median time since confirmation to SARS-CoV-2 PCR negativity was 15 days [95% CI: 13-18] in asymptomatic/mild cases and 17 days [95% CI: 16-21] in moderate/severe ones. The median time to seroconversion for both IgM and IgG was 13 days [95% CI: 13-14] in asymptomatic/mild cases and 11 days [95% CI: 10-13] in moderate/severe ones. For both antibody types, the highest reactivity was significantly associated with more severe presentation (IgM: OR = 10.30, IgG: OR = 7.97).

CONCLUSION

Asymptomatic/mild COVID-19 cases had a faster RT-PCR negativity rate compared to moderate/severe/critical patients. IgG and IgM dynamics were almost simultaneous, more robust for IgG in more severe cases, and at one month after confirmation, almost all patients had detectable antibody titers.

Comprehensive survey on radon mitigation and indoor air quality in energy efficient buildings from Romania

Over the last 10 years applied scientific research has been carried out in Romania to tacked the residential radon issues. The increased interest to reduce the carbon footprint of buildings has lead to the implementation and use of new architectural solutions aimed to save energy in houses and other buildings. As a consequence, the degree of retrofit in existing buildings and energy efficiency of new buildings promoted the need to not only mitigate indoor radon, but improve indoor air quality overall. The present study found that the while the best performance in radon reduction was confirmed to be based on sub-slab depressurization (61% - 95% reduction), centralized and decentralized mechanical supply and exhaust ventilation with heat recovery yielded a good efficiency in overall improvement of indoor air quality (CO₂, VOC, RH, temperature). The outcome of our research, as well as future perspectives, take into account the recommended harmonization of energy efficiency programs with those of public health by finding and applying the best technologies in compliance with energy saving and indoor environmental quality.

Role of Adiponectin and Tumor Necrosis Factor-Alpha in the Pathogenesis and Evolution of Type 1 Diabetes Mellitus in Children and Adolescents

Type 1 diabetes mellitus (T1DM) is a complex condition caused by the destruction of pancreatic beta cells by autoimmune mechanisms. As a result, insulin deficiency and subsequent hyperglycemia occur. The aim of the present study is to investigate the role of adiponectin and tumor necrosis factor alpha (TNF-α) in the development of T1DM. The study is designed as an observational case-control study, involving 52 diabetic patients and 66 controls. Z scores for Body Mass Index (BMI), weight, height, and adiponectin and TNF-α serum levels were assessed in both groups. The T1DM group had significantly higher TNF-α levels and a significantly higher proportion of high-risk patients for inflammation based on TNF-α values as compared to the control group, while both groups had statistically similar adiponectin levels and a similar proportion of high/medium-risk patients based on adiponectin values. TNF-α plays a significant role in the pathogenesis and evolution of T1DM and it may represent an additional marker of disease progression, as well as a potential target of immunotherapeutic strategies. In the present study, no statistically significant differences were recorded in adiponectin levels neither in diabetic patients and controls, nor in high/medium severity risk diabetic patients.

Variable anti-HBs antibody titers in vaccinated birth cohorts - A cross-sectional population-based study

BACKGROUND

After the introduction of hepatitis B (HB) vaccination in 1995 in newborns, two catch-up campaigns targeted unvaccinated 9 year old in 2000-2003 (born 1991-1994) and the 18 year old in 2004-2008 (born 1986-1990), resulting in several birth-cohorts. Our objective was to assess the anti-HBs titers in each birth-cohort.

METHODS

We included all outpatients (78.5%) and hospitalized patients with measured anti-HBs antibody titers in the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania, during April 2014 - December 2018 (without HB history). We compared the anti-HBs titers in all birth-cohorts using the Lexis surfaces (titers by age, time period and cohort patterns). We also evaluated the number of acute HB in the corresponding inpatient birth-cohorts and special groups.

RESULTS

We included 2963 participants, mean age = 31.0 ± 14.2, 64.1% women. The birth-cohort 1995-2006, vaccinated after delivery (n = 424, 3-dose HB vaccine coverage > 90%), had significantly lower protective titers (41.3% >10 mIU/mL) compared to the other birth-cohorts: born after 2007 (also vaccinated at birth, 67.0%, n = 106), 1991-1994 (age 9, 74.3%, n = 847), 1986-1990 (age 18, 71.3%, n = 543). In the unvaccinated cohort (n = 1043, mean age = 45.5 ± 12.4) protective titers were found in 44.8%, probably after self-limited HB infection. Concordant results were found using the proportion of patients with detectable or robust titers, and median or geometric mean titers. Four breakthrough acute HB infections were hospitalized of the corresponding vaccinated cohorts (birth years 1988, 1990, 1995, 1996). Data on a few tested infants (n = 47, not included in the main study) demonstrated good protection, 88.9%.

CONCLUSIONS

Our study demonstrated the long-term evidence of protection of HBV vaccine at two decades following the primary immunization and a booster seems unsupported. Further studies should be done to assess the need of a booster dose within the general population and special groups.

A comparison of hepatitis E and A in a teaching hospital in Northwestern Romania. Acute hepatitis E - a mild disease?

Background and aims

The incidence of locally acquired hepatitis E has increased in recent years across Europe. There are only few data on hepatitis E in Romania. The purpose of our research was to describe and compare hepatitis E and hepatitis A in adult patients.

Methods

We included all consecutive adult patients with hepatitis E and hepatitis A admitted to the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania between January 2017 and August 2019.

Results

Hepatitis E incidence increased in 2018–2019 compared to 2017. The average age in hepatitis E (n=48) patients was 50.6 versus 39.1 years in hepatitis A (n=152, not including 262 minors) and two-thirds of the patients in both groups were men. Compared to hepatitis A, patients with hepatitis E presented significantly less modified AST and ALT, bilirubin, prothrombin index and INR levels. We found more comorbidities in hepatitis E patients adjusted for age and gender. Severe forms were found in 5 (3.3%) hepatitis A patients, compared to 12 (25%) of hepatitis E patients, of which 3 died. Ribavirin treatment was considered in 9 patients with acute-on-chronic hepatitis E, immunosuppression, cancers or neurological manifestations, showing good results.

Conclusions

We observed an increased number of hepatitis E cases. Although laboratory results were less modified compared to hepatitis A, we found a higher number of severe hepatitis E cases. Ribavirin treatment seems to be beneficial in patients with preexisting conditions.

Changes observed in erythrocyte cells exposed to an alternating current

Background and aims

Appliance of electric pulses induces red blood cells (RBCs) membrane poration, membrane aminophospholipid perturbation and alteration of the normal flip-flop process, resulting in various shape changes of the RBCs. We studied morphological and water permeability changes of RBCs bombarded with electrons in an alternating current circuit.

Methods

We used three venous blood samples of 100 mL and an alternating current device. The harvested blood was divided into four experimental sets to be used for various exposure times: 0 hours (control RBCs), 0.5h, 3h and 6h (electric-stimulated RBCs).

Following the electric current each of the four sets were further divided into three samples: one for the assessment of the echinocytes/RBCs ratio, another for the electron microscopy study of ultrastructural changes induced by the alternating electrical current and a larger third one for determining water permeability of RCBs by ¹H-NMR spectroscopy and morphological measurements.

Results

There is a small but statistically significant effect of the RBC exposure to alternating electric current on cell diameters. Exposure to electric current is positively and strongly correlated with the percentage of echinocytes in a duration-dependent manner. There is a strong and statistically significant correlation between electric current exposure and permeability to water as measured by ¹H-NMR spectroscopy.

Conclusion

Following interactions between electric current and RBC membrane, certain modifications were observed in the erythrocyte structure. We attribute the increased cell size to a higher permeability to water and a decreased tonicity. This leads to the transformation of the RBCs into echinocytes.

The ubiquitin proteasomal system: a potential target for the management of Alzheimer's disease

The cellular quality control system degrades abnormal or misfolded proteins and consists of three different mechanisms: the ubiquitin proteasomal system (UPS), autophagy and molecular chaperones. Any disturbance in this system causes proteins to accumulate, resulting in neurodegenerative diseases such as amyotrophic lateral sclerosis, Alzheimer's disease (AD), Parkinson's disease, Huntington's disease and prion or polyglutamine diseases. Alzheimer's disease is currently one of the most common age-related neurodegenerative diseases. However, its exact cause and pathogenesis are unknown. Currently approved medications for AD provide symptomatic relief; however, they fail to influence disease progression. Moreover, the components of the cellular quality control system represent an important focus for the development of targeted and potent therapies for managing AD. This review aims to evaluate whether existing evidence supports the hypothesis that UPS impairment causes the early pathogenesis of neurodegenerative disorders. The first part presents basic information about the UPS and its molecular components. The next part explains how the UPS is involved in neurodegenerative disorders. Finally, we emphasize how the UPS influences the management of AD. This review may help in the design of future UPS-related therapies for AD.

X-ray structure of a lectin-bound DNA duplex containing an unnatural phenanthrenyl pair

DNA duplexes containing unnatural base-pair surrogates are attractive biomolecular nanomaterials with potentially beneficial photophysical or electronic properties.

Giant fibrovascular esophageal polyp misdiagnosed as achalasia

A 59 years old woman was admitted in our unit accusing longtime dysphagia and regurgitation. On admission, the patient was wearing a 3 month old definitive feeding gastrostomy tube. The contrast swallow, endoscopy and esophageal manometry established the diagnostic--achalasia. We removed the gastrostomy tube and we performed an open Heller myotomy. The postoperative period was uneventful and the patient was discharged one week later with affirmatively unimpaired deglutition. One month later, the patient was admitted via emergency with a giant fibrous tumor arising from her mouth after an episode of strong coughing and vomiting. The repeated endoscopy showed a giant esophageal polyp that was missed by the previous investigations, originating from pharingoesophageal junction. The esophageal polyp was resected by cervical approach with good postoperative outcome. The polyp's particular extreme dimensions (27 cm) prevented the acute asphyxia by blockage at the laryngeal level, possibly provoked by smaller tumors. As postoperative one month barium swallow showed a normal esophageal aspect, a final question remains--was achalasia real or an erroneous diagnosis was established the second time too?