Treatment with Umbilical Cord Blood Platelet Lysate Gel Improves Healing of Diabetic Foot Ulcer

BACKGROUND

This study was conducted to examine the hypothesis that umbilical cord blood platelet lysate (UCB-PL) gel has a significant impact on the healing rate of DFU. Μethods: In this open-labeled, randomized controlled trial, 110 patients were randomized to treatment with UCB-PL gel (UCB-PL group, n = 52) every three days for one month or dressing with normal saline (control group, n = 58). All participants were followed up for 20 weeks post treatment. Ulcer surface area was assessed with the imitoMeasure application at two, four, and six weeks, and two, four and six months. This study's main outcome was the reduction in ulcer size over the six-month study period.

RESULTS

The mean ulcer area at baseline was 4.1 cm2 in the UCB-PL group and 1.7 cm2 in the control group. At six months post treatment, patients on the UCB-PL treatment displayed a significant reduction in ulcer size compared to baseline 0.12 (0-8.16) in contrast to a more modest change in the control group 1.05 (0-24.7). The ulcer area was decreased at the end of the study in 40 patients (97.6%) in the UCB-PL group and 27 (73%) in the control group (Fisher's p = 0.002).

CONCLUSIONS

The application of UCB-PL gel in DFU resulted in a significant reduction in ulcer size compared to regular saline dressing.

Familial Partial Lipodystrophy: Clinical Features, Genetics and Treatment in a Greek Referral Center

Familial partial lipodystrophy (FPLD) is a rare syndrome in which a patient's phenotype is not merely dependent on the specific genetic mutation, but it is also defined by a combination of other demographic, environmental and genetic factors. In this prospective observational study in a Greek referral center, we enrolled 39 patients who fulfilled the clinical criteria of FPLD. A genetic analysis was conducted, which included sequence and deletion/duplication analyses of the LMNA and PPRARG genes, along with anthropometric and metabolic parameters. The treatment responses of patients who were eligible for treatment with metreleptin were evaluated at 3 and 12 months. In most of the patients, no significant changes were detected at the exon level, and any mutations that led to changes at the protein level were not associated with the lipodystrophic phenotype. On the contrary, various changes were detected at the intron level, especially in introns 7 and 10, whose clinical significance is considered unknown. In addition, treatment with metreleptin in specific FPLD patients significantly improved glycemic and lipidemic control, an effect which was sustained at the 12-month follow-up. More large-scale studies are necessary to clarify the genetic and allelic heterogeneity of the disease, along with other parameters which could predict treatment response.

Prevalence of Small Intestinal Bacterial Overgrowth Syndrome in Patients with Non-Alcoholic Fatty Liver Disease/Non-Alcoholic Steatohepatitis: A Cross-Sectional Study

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is a multifactorial, wide-spectrum liver disorder. Small intestinal bacterial overgrowth (SIBO) is characterized by an increase in the number and/or type of colonic bacteria in the upper gastrointestinal tract. SIBO, through energy salvage and induction of inflammation, may be a pathophysiological factor for NAFLD development and progression.

AIM/METHODS

Consecutive patients with histological, biochemical, or radiological diagnosis of any stage of NAFLD (non-alcoholic fatty liver [NAFL], non-alcoholic steatohepatitis [NASH], cirrhosis) underwent upper gastrointestinal endoscopy. Duodenal fluid (2cc) was aspirated from the 3rd-4th part of duodenum into sterile containers. SIBO was defined as ≥103 aerobic colony-forming units (CFU)/mL of duodenal aspirate and/or the presence of colonic-type bacteria. Patients without any liver disease undergoing gastroscopy due to gastroesophageal reflux disease (GERD) comprised the healthy control (HC) group. Concentrations (pg/mL) of tumor necrosis factor alpha (TNFα), interleukin (IL)-1β, and IL-6 were also measured in the duodenal fluid. The primary endpoint was to evaluate the prevalence of SIBO in NAFLD patients, while the comparison of SIBO prevalence among NAFLD patients and healthy controls was a secondary endpoint.

RESULTS

We enrolled 125 patients (51 NAFL, 27 NASH, 17 cirrhosis, and 30 HC) aged 54 ± 11.9 years and with a weight of 88.3 ± 19.6 kg (NAFLD vs. HC 90.7 ± 19.1 vs. 80.8 ± 19.6 kg, p = 0.02). Overall, SIBO was diagnosed in 23/125 (18.4%) patients, with Gram-negative bacteria being the predominant species (19/23; 82.6%). SIBO prevalence was higher in the NAFLD cohort compared to HC (22/95; 23.2% vs. 1/30; 3.3%, p = 0.014). Patients with NASH had higher SIBO prevalence (6/27; 22.2%) compared to NAFL individuals (8/51; 15.7%), but this difference did not reach statistical significance (p = 0.11). Patients with NASH-associated cirrhosis had a higher SIBO prevalence compared to patients with NAFL (8/17; 47.1% vs. 8/51; 15.7%, p = 0.02), while SIBO prevalence between patients with NASH-associated cirrhosis and NASH was not statistically different (8/17; 47.1% vs. 6/27; 22.2%, p = 0.11). Mean concentration of TNF-α, IL-1β, and IL-6 did not differ among the different groups.

CONCLUSION

The prevalence of SIBO is significantly higher in a cohort of patients with NAFLD compared to healthy controls. Moreover, SIBO is more prevalent in patients with NASH-associated cirrhosis compared to patients with NAFL.

Short-Term Effects of Spirulina Consumption on Glycemic Responses and Blood Pressure in Healthy Young Adults: Results from Two Randomized Clinical Trials

The effects of spirulina consumption added in foods were investigated in two crossover clinical trials (n = 13 different healthy adults). In Trial-1 adults consumed cookies with-and-without spirulina (3.12 g per 100 g final product; 2.5 g spirulina per 50 g available carbohydrates) according to glycemic index (GI) methodology. In Trial-2, adults consumed 4 g, 6 g, and 8 g spirulina as beverage diluted in 50 g D-glucose vs. 50 g plain D-glucose. Capillary blood glucose samples were collected at 0, 15, 30, 45, 60, 90, and 120 min and blood pressure (BP) was measured at beginning and end of each visit in both trials. Trial-1: both cookies with and without spirulina provided medium GI values (59 and 60, respectively, on glucose-scale), but no significant differences were found for BP. Trial-2: both 4 g and 8 g spirulina lowered postprandial glucose at 120 min (95% CI: -1.64 to -16.12 and -1.23 to -15.87, respectively). The results explained 29% of variation. Only 8 g spirulina decreased significantly 90-120 min area under the curve (AUC) for glucose and systolic BP (-4%). No differences were found for fasting glucose. Adding spirulina to cookies did not affect glucose responses and BP. Only 8 g provided significantly lower 90-120 min-AUC for glucose and BP compared to 4 g, 6 g-and-D-glucose, indicating advantages to glycemic control and hypertension.

Hypertriglyceridemia and Other Risk Factors of Chronic Kidney Disease in Type 2 Diabetes: A Hospital-Based Clinic Population in Greece

Aims/Introduction: Several reports indicate an increasing prevalence of chronic kidney disease (CKD) in type 2 diabetes mellitus (T2DM). Hyperglycemia and hypertension are the main risk factors for CKD development and progression. However, despite the achievement of recommended targets for blood glucose and blood pressure (BP), the residual risk of diabetic chronic kidney disease (DCKD) remains relatively high. The aim of this study is to examine dyslipidemia and other major risk factors to provide support for the prevention and treatment of DCKD. Materials and Methods: Participants are from the Redit-2-Diag study that examines 1759 subjects within a period of 6 months. DCKD severity is staged according to KDIGO criteria. Results: An increase in hemoglobin A_1c (1 unit) and systolic blood pressure (1 mm Hg) increases the probability of being classified into a higher CKD stage by 14% and 26%, respectively. Moreover, an increase of triglycerides by 88.5 mg/dL increases the risk of classification to a worse CKD stage by 24%. Conclusions: Elevated triglycerides, systolic blood pressure, and poor glycemic control increase the risk of CKD in T2DM and should be addressed in the treatment strategies.

Effects of Spaghetti Differing in Soluble Fiber and Protein Content on Glycemic Responses in Humans: A Randomized Clinical Trial in Healthy Subjects

This randomized, single blind, cross-over study investigated the glycemic responses to three spaghetti No 7 types differing in dietary protein and soluble fiber content. Fourteen clinically and metabolically healthy, fasting individuals (25 ± 1 years; ten women; BMI 23 ± 1 kg/m²) received isoglucidic test meals (50 g available carbohydrate) and 50 g glucose reference, in random order. GI was calculated using the FAO/WHO method. Capillary blood glucose and salivary insulin samples were collected at 0, 15, 30, 45, 60, and 120 min. Subjective appetite ratings (hunger, fullness, and desire to eat) were assessed by visual analogue scales (VAS, 100 mm) at baseline and 120 min. All three spaghetti types (regular, whole wheat, and high soluble fiber–low carbohydrates) provided low GI values (33, 38, and 41, respectively, on glucose scale) and lower peak glucose values compared to glucose or white bread. No differences were observed between spaghetti No 7 types for fasting glucose, fasting and post-test-meal insulin concentrations, blood pressure (systolic and diastolic), and subjective appetite. Conclusions: all spaghetti No 7 types, regardless of soluble fiber and/or protein content, attenuated postprandial glycemic response, which may offer advantages to glycemic control.

Serum Uric Acid and Diabetes: From Pathophysiology to Cardiovascular Disease

Hyperuricemia, has been traditionally related to nephrolithiasis and gout. However, it has also been associated with the development of type 2 diabetes mellitus (T2DM) and cardiometabolic and cardiovascular diseases. Pathophysiologically, elevated serum uric acid (SUA) levels may be associated with abnormal lipid and glucose metabolism. In this narrative review, we consider the associations between hyperuricemia, hyperglycemia, atherosclerosis and thrombosis. Furthermore, we comment on the available evidence linking elevated SUA levels with the incidence and outcomes of coronary heart disease, stroke, peripheral artery disease and non-alcoholic fatty liver in subjects with T2DM. The effects of antidiabetic drugs (e.g. metformin, pioglitazone, sulfonylureas, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors and insulin) on SUA concentrations are also reviewed.

Antidiabetic and Other Therapies Used in Subjects with Diabetes and Chronic Kidney Disease in a Hospital-Based Clinic Population in Greece

(1) Background: Type 2 diabetes mellitus (T2DM) is the main cause of chronic kidney disease (CKD). In Greece, in a population from hospital-based diabetes clinics (n = 1759), the overall prevalence of diabetic chronic kidney disease (DCKD) was 45% including mild, moderate, and severe CKD. The aim of this study was to describe and analyze how T2DM patients with mild-to-severe CKD are managed by diabetologists in Greece and assess the achievement rates in glycemic, blood pressure and low-density lipoprotein-cholesterol (LDL-C) control. (2) Methods: This cross-sectional multicenter study took place from June 2015 to March 2016 and collected data from diabetes centers in public hospitals all over Greece. (3) Results: With regard to the anti-diabetes treatment, most participants were on metformin, DPP-4 (Dipeptidyl Peptidase-4 inhibitors) inhibitors and insulin. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were the most prescribed medications for hypertension. For the management of dyslipidemia, most participants were on statins. For patients with DCKD, the levels of HbA1c, blood pressure and LDL-C were 7.2%, 137.7/76.9 mmHg and 95.9 mg/dL, respectively (mean values). (4) Conclusions: The outcomes of this study suggest that management of DCKD can be further improved and should be enhanced. These results may contribute to the whole health care system in Greece. In addition, the better understanding of therapeutic strategies used by diabetologists treating these patients offers educational benefits to primary care physicians, which can result in an overall more successful and efficient management of subjects with T2DM and DCKD.

Case Report: Metreleptin Treatment in a Patient With a Novel Mutation for Familial Partial Lipodystrophy Type 3, Presenting With Uncontrolled Diabetes and Insulin Resistance

BACKGROUND

Familial partial lipodystrophy type 3 (FPLD3) is a very rare autosomal dominant genetic disorder which is caused by mutations in the peroxisome proliferator activated receptor gamma (PPARG) gene. It is characterized by a partial loss of adipose tissue leading to subnormal leptin secretion and metabolic complications. Metreleptin, a synthetic analogue of human leptin, is an effective treatment for generalized lipodystrophies, but the evidence for efficacy in patients with FPLD3 is scarce.

CASE PRESENTATION

We present a 61-year-old woman, initially misdiagnosed as type 1 diabetes since the age of 29, with severe insulin resistance, who gradually displayed a more generalized form of lipoatrophy and extreme hypertriglyceridemia, hypertension and multiple manifestations of cardiovascular disease. She was found to carry a novel mutation leading to PPARG_Glu157Gly variant. After six months of metreleptin treatment, HbA1c decreased from 10 to 7.9% and fasting plasma triglycerides were dramatically reduced from 2.919 mg/dl to 198 mg/dl.

CONCLUSIONS

This case highlights the importance of early recognition of FPLD syndromes otherwise frequently observed as difficult-to-classify and manages diabetes cases, in order to prevent cardiovascular complications. Metreleptin may be an effective treatment for FPLD3.

Diabetes distress is associated with individualized glycemic control in adults with type 2 diabetes mellitus

PURPOSE

It has been proposed that the negative emotional state of diabetes distress (DD) may exert a detrimental effect on glycemic outcomes of individuals struggling with diabetes-related challenges. Thus far, no study has investigated this association by utilizing individualized treatment targets of patients' glycemic control. Therefore, we sought to identify the potential role of DD in the achievement of individualized glycemic targets (AIGTs) among persons with type 2 diabetes mellitus (T2D).

METHODS

This cross-sectional study included a well-characterized outpatient group of T2D adults cared for in an academic medical center. DD was evaluated with the Diabetes Distress Scale. The AIGTs was defined according to the American Diabetes Association guidelines. Logistic regression analyses were utilized to identify independent correlates of the AIGTs.

RESULTS

A total of 123 individuals (mean [standard deviation] age: 58.0 [6.2] years, 55.3% females) were included in the final analysis. AIGTs was observed in 43.9% of the patients. Experiencing greater DD was associated with a lower likelihood of AIGTs (unadjusted odds ratio [OR]: 0.17, 95% confidence interval [CI]: 0.08-0.34, P value < 0.001), even after accounting for additional individual-level covariates (adjusted OR: 0.18, 95% CI: 0.08-0.42, P value < 0.001). Medication adherence was also a determinant of participants' AIGTs (adjusted OR: 1.91, 95% CI: 1.13-3.23, P value = 0.015).

CONCLUSION

Our findings provide novel evidence that DD likely undermines glycemic status in adult outpatients with T2D, even in the context of individually tailored diabetes care, and this should be taken into account when necessary.

The prevalence of diabetic chronic kidney disease in adult Greek subjects with type 2 diabetes mellitus: A series from hospital-based diabetes clinics

AIMS

To examine the prevalence of diabetic chronic kidney disease (DCKD) and its risk factors in adult Greek subjects with type 2 diabetes mellitus (T2DM) in a population from hospital-based diabetes clinics.

METHODS

This is a cross-sectional multicentre study based on data collected from Greek hospital-based diabetes clinics from June 2015 to March 2016. DCKD severity was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines. Multivariate analyses assessed the associations between DCKD and its potential risk factors.

RESULTS

Among the entire population (n = 1759), the overall prevalence of DCKD was 45% including mild, moderate and severe CKD. Older age, male gender, body-mass index, lack of exercise and diabetes duration were significantly associated with DCKD.

CONCLUSIONS

In Greece, DCKD in T2DM is highly prevalent. It is significantly associated with demographic and lifestyle parameters, as well as T2DM complications, suggesting that further efforts to prevent DCKD should be addressed to subjects with specific characteristics.

Competing Effects of Renin Angiotensin System Blockade and Sodium-Glucose Cotransporter-2 Inhibitors on Erythropoietin Secretion in Diabetes

BACKGROUND

Anaemia is a common finding in diabetes, particularly in those patients with albuminuria or renal dysfunction and is associated with impaired erythropoietin (EPO) secretion. This review focuses on mechanisms involved in the regulation of erythropoiesis in diabetic patients in an effort to elucidate the competing effects of the renin angiotensin system (RAS) blockade and sodium-glucose cotransporter-2 (SGLT2) inhibitors on haemoglobin concentration and hematocrit values.

SUMMARY

The RAS shows significant activation in diabetic subjects. Angiotensin II, its active octapeptide, causes renal tubulointerstitial hypoxia, which stimulates hypoxia-inducible factors (HIF) and increases EPO secretion and erythropoiesis. As expected, drugs that inactivate RAS, such as angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARB) are associated with a significant hematocrit-lowering effect and/or anaemia in various clinical conditions, including diabetes. Dual blockade by a combination of ACEi and ARB in diabetic patients achieves a better RAS inhibition, but at the same time a worse drop of haemoglobin concentration. Increased glucose reabsorption by SGLTs in diabetic subjects generates a high-glucose environment in renal tubulointerstitium, which may impair HIF-1, damage renal erythropoietin-producing cells (REPs) and decrease EPO secretion and erythropoiesis. SGLT2 inhibitors, which inhibit glucose reabsorption, may attenuate glucotoxicity in renal tubulointerstitium, allowing REPs to resume their function and increase EPO secretion. Indeed, EPO levels increase within a few weeks after initiation of therapy with all known SGLT2 inhibitors, followed by increased reticulocyte count and a gradual elevation of haemoglobin concentration and hematocrit level, which reach zenith values after 2-3 months. Key Messages: The competing effects of RAS blockade and SGLT2 inhibitors on erythropoiesis may have important clinical implications. The rise of hematocrit values by SGLT2 inhibitors given on top of RAS blockade in recent outcome trials may significantly contribute to the cardiorenal protection attained. The relative contribution of each system to erythropoiesis and outcome remains to be revealed in future studies.

Monitoring of colonoscopy quality indicators in an academic endoscopy facility reveals adherence to international recommendations

Background

We monitor colonoscopy service quality biannually, by measuring sedation administration, colonoscopy completion, adenoma detection and early complications rates (CR). We herein present our audit results for the years 2013 and 2015.

Methods

In our endoscopy facility, five rotating senior gastroenterologists perform colonoscopies, on a daily basis. We measured the quality indicators in three cohorts: A, intention for total colonoscopy cases; B, cohort A excluding bowel obstruction cases; C, colorectal cancer (CRC) screening cases.

Results

In 2015, overall sedation administration rate (SAR) was 93.0% (91.6-94.4%), achieving our target to give conscious sedation to >90% of patients undergoing colonoscopy in all three cohorts. Colonoscopy completion rate (CCR) increased significantly (P<0.0001) from 94.8% (93.4-96.2%) to 98.1% (97.3-98.9%) in cohort B and numerically from 96.6% (94.4-98.8%) to 98.6% (97.4-99.7%) in cohort C, at the same periods. In cohort C, adenoma detection rates (ADR) were similar-27.1% (21.7-32.5%) and 27% (22.7-31.3%)-in the two periods. There were only two serious early complications: one cardiorespiratory event and one perforation in 2013 and 2015, respectively. While significant variability regarding SAR (ranging from 80% to 100%) was detected among the participating endoscopists, all but one of them constantly achieved [judged by the lower confidence interval (CI) of the quality indicator] CCRs higher than the recommended by international guidelines. On the contrary ADR was variable among endoscopists during the studied periods.

Conclusions

Although there is certain variability in endoscopists' performance, the overall colonoscopy quality indicators meet or exceed the internationally recommended standards, in our endoscopy facility.

Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy

BACKGROUND

The usefulness of purgative preparation before small-bowel video capsule endoscopy is controversial. We aimed to examine the effect of purgative preparation on small-bowel video capsule endoscopy outcomes.

METHODS

We performed literature searches in MEDLINE and the Cochrane library for randomized controlled trials evaluating the effect of purgative preparation (polyethylene glycol, sodium phosphate, others) vs. clear-liquid diet/fasting in patients undergoing small-bowel capsule endoscopy. Meta-analysis outcomes included the examination's diagnostic yield, small-bowel mucosal visualization quality, the examination's completion rate, and gastric and small-bowel transit times. The effect size on study outcomes was calculated using a fixed- or random-effect model, as appropriate, and is shown as the risk ratio (RR) with 95 % confidence interval (CI).

RESULTS

We identified 12 eligible trials with 17 sets of data including 1221 subjects. Significant heterogeneity was detected with no evidence of publication bias. As compared with clear-liquid diet, purgative bowel preparation did not increase capsule endoscopy diagnostic yield (RR 1.17 [95 %CI 0.97 to 1.40]; P = 0.11). Neither the small-bowel mucosal visualization quality (RR 1.14 [95 %CI 0.96 to 1.35]; P = 0.15) nor completion rate for the examination (RR 0.99 [95 %CI 0.95 to 1.04]; P = 0.76) significantly improved after purgative preparation. Purgatives also had no effect on video capsule endoscopy gastric and small-bowel transit times.

CONCLUSIONS

Our analysis challenges the usefulness of purgative preparation for improving the diagnostic yield of small-bowel video capsule endoscopy and the quality of small-bowel mucosal visualization.

Dislodged biliary stent causes lower gastrointestinal hemorrhage four years postendoscopic retrograde cholangiopancreatography

Endoscopic biliary stent placement is an efficient method for the decompression of the biliary system in various benign and malignant causes. Dislocation and stent migration is a well-known complication, with most displaced stents passing through the bowel, uneventfully. Rarely, migrated stents can be accounted for potentially life-threatening complications.

Publication dynamics in gastroenterology and hepatology over the last decade in Greece: a SCImago-based study

Background

There is evidence that the financial crisis has deleteriously affected scientific output. We aimed to assess the dynamics of Greek publications in gastroenterology and hepatology over the last ten years.

Methods

Data were collected from SCImago. The average annual growth rate (AAGR) of total and citable documents published in Greece in the field of gastroenterology and hepatology was compared with that of cardiology, surgery, and radiology. In addition, it was compared with the corresponding rates in Belgium, Ireland and Portugal.

Results

The annual number of Greek publications (total and citable documents) remained relatively unchanged in the field of gastroenterology and hepatology from 2006-2011. During the following years, we detected a negative AAGR, with values of -12%, -3.3%, -9.5% and -5.4% for gastroenterology-hepatology, cardiology, surgery and radiology, respectively. During the same period, the AAGR of the citable documents of the respective specialties was -8.6%, -3.7%, -9.8%, and -5.1%. Comparison of the 4 European countries in the field of gastroenterology and hepatology revealed that publications from Portugal rose massively (AAGR +24.6% and +20.6% for total and citable documents, respectively), almost reaching the number of Greek publications in 2015. The number of publications from Belgium and Ireland remained essentially unchanged after 2011, with AAGR values of -0.7%, and -2.1% for total and -1.1% and -1.4% for citable documents, respectively.

Conclusion

The publication output in the field of gastroenterology and hepatology decreased significantly after the outbreak of the financial crisis in Greece, not only in relation to other medical specialties, but also compared to the output of other European countries with or without fiscal austerity measures.

Meta-analysis shows similar re-bleeding rates among Western and Eastern populations after index video capsule endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (VCE) is the first-line diagnostic procedure for investigating obscure gastrointestinal bleeding (OGIB). Different re-bleeding rates following index VCE have been reported among Western and Eastern studies.

METHODS

We conducted a comprehensive literature search to identify studies examining re-bleeding rates after VCE for OGIB. Meta-analysis assessed the pooled proportion of re-bleeding events after VCE for OGIB according to study's origin (Western vs. Eastern) and according to the length of follow-up (≥24 months vs. <24 months). We also calculated the re-bleeding odds ratios (OR; 95% CI) after positive vs. negative index VCE, overt vs. occult initial presentation of bleeding and after interventional treatment for positive index cases, according to the study's origin.

RESULTS

We included 46 (30 Western and 16 Eastern) studies with 5796 patients. Significant heterogeneity was detected among meta-analyzed studies. Overall, the pooled re-bleeding rate was similar between Western (29%; 95% CI: 23-34) and Eastern (21%; 95% CI: 15-27) populations, irrespective of the length of follow-up. The odds of re-bleeding was significantly higher after positive as compared to negative index VCE in Eastern studies (OR: 1.77; 95% CI: 1.07-2.94). Application of specific treatment after positive index VCE was associated with lower re-bleeding odds in both Western (OR: 0.37; 95% CI: 0.16-0.87) and Eastern (OR: 0.39; 95% CI: 0.21-0.72) populations.

CONCLUSIONS

Patients undergoing VCE for OGIB have similar re-bleeding rates in the East and the West, regardless of the length of follow-up. However, increased re-bleeding odds after positive index VCE is observed in Eastern studies.

Embolia cutis medicamentosa: an unusual adverse reaction to terlipressin

Terlipressin is a synthetic long-acting analog of vasopressin widely used to control variceal bleeding by lowering portal venous pressure. We report an unusual adverse reaction to terlipressin in a 78-year-old patient with esophageal variceal bleeding who developed skin necrosis soon after treatment initiation. Skin biopsy revealed embolia cutis medicamentosa.

Activation of NLRP3 Inflammasome in Inflammatory Bowel Disease: Differences Between Crohn's Disease and Ulcerative Colitis

BACKGROUND

NLRP3 inflammasome is a multimolecular cytosol complex that, when activated, contributes to the cleavage of pro-interleukin (IL)-1β to IL-1β.

AIMS

To investigate NLRP3 inflammasome activation in inflammatory bowel disease.

METHODS

Peripheral blood mononuclear cells from Crohn's disease (CD), ulcerative colitis (UC) patients and controls were stimulated with LPS in the absence or presence of MSU. After incubation, concentrations of IL-1β, IL-6, and TNFα were measured in cell supernatants and concentration of pro-IL-1β was measured in cell lysates. NLRP3 activation was defined as more than 30% increase in IL-1β production after MSU addition. In separate experiments, PBMCs were lysed for RNA isolation transcripts of IL-1β, TNFα, NLRP3, and CASP1 were measured by RT-PCR. DNA was isolated from CD patients for ATG16L1 gene genotyping.

RESULTS

NLRP3 inflammasome was activated in 60% of CD patients compared to 28.6% of controls (p = 0.042); no significant difference was detected between UC and controls. Among UC patients, NLRP3 activation was associated (p = 0.008) with long-standing disease (>1.5 years). IL-1β levels were significantly higher in CD patents in comparison with controls (p = 0.032). No difference was detected in the levels of IL-6, TNFα, pro-IL-1β and in the numbers IL-1β, TNFα, NLRP3, and CASP1 transcripts among groups. IL-1β production was similar between carriers of wild-type and of SNP alleles of the rs2241880.

CONCLUSIONS

NLRP3 inflammasome is activated in CD patients and in UC patients with long-standing disease.

An unusual cause of acute lower gastrointestinal bleeding: lung adenocarcinoma metastasis to the descending colon

Lung adenocarcinoma with symptomatic GI metastasis occurs seldom in everyday clinical practice. However, as diagnostic modalities, therapeutic interventions, and supportive care for cancer evolve, it is likely that the clinician might encounter a number of similar cases in the future, and therefore, he should be aware of this rare entity.

New endoscopes and add-on devices to improve colonoscopy performance

Colonoscopy is the gold standard for colorectal cancer prevention; however, it is still an imperfect modality. Precancerous lesions can be lost during screening examinations, thus increasing the risk of interval cancer. A variety of factors either patient-, or endoscopist dependent or even the procedure itself may contribute to loss of lesions. Sophisticated modalities including advanced technology endoscopes and add-on devices have been developed in an effort to eliminate colonoscopy's drawbacks and maximize its ability to detect potentially culprit polyps. Novel colonoscopes aim to widen the field of view. They incorporate more than one cameras enabling simultaneous image transmission. In that way the field of view can expand up to 330°. On the other hand a plethora of add-on devices attachable on the standard colonoscope promise to detect lesions in the proximal aspect of colonic folds either by offering a retrograde view of the lumen or by straightening the haustral folds during withdrawal. In this minireview we discuss how these recent advances affect colonoscopy performance by improving its quality indicators (cecal intubation rate, adenoma detection rate) and other metrics (polyp detection rate, adenomas per colonoscopy, polyp/adenoma miss rate) associated with examination's outcomes.

Lower adenoma miss rate with FUSE vs. conventional colonoscopy with proximal retroflexion: a randomized back-to-back trial

Background and study aims Full-spectrum colonoscopy (FSC) promises to increase adenoma detection by providing a wider field of view. The aim of this study was to compare adenoma miss rates of FSC with those of conventional colonoscopy complemented by right-colon re-examination using scope retroflexion (CC/R). Patients and methods At two tertiary endoscopy facilities, patients who were scheduled for colonoscopy for the assessment of symptoms or for colorectal cancer screening/surveillance were randomized (1:1) to undergo same-day, back-to-back colonoscopies (FSC or CC/R first), performed by one of five endoscopists who had documented adenoma detection rates > 35 %. Per-protocol data were analyzed. Results We randomized 220 patients. There were five FSC technical failures (three air pump and two left screen); therefore, 107 and 108 cases were analyzed in the FSC and CC/R index procedure arms, respectively. Withdrawal times were similar for FSC and CC/R (7.7 minutes vs. 7.6 minutes). Overall, we detected 3 cancers and 153 adenomas (FSC = 92; CC/R = 61); 81 were detected in the proximal colon, 3 of which were detected by retroflexed examination. By per-lesion analysis, FSC showed a significantly lower adenoma miss rate compared with CC/R overall (10.9 % [95 % confidence interval (CI) 3.8 to 18.1] vs. 33.7 % [95 %CI 23.4 to 44.1]) and in the proximal colon (13.9 % [95 %CI 2.6 to 25.2] vs. 42.2 % [95 %CI 27.8 to 56.7]). The advanced adenoma miss rate was lower with FSC overall (4.3 % [95 %CI - 4.0 to 12.7] vs. 25.9 % [95 %CI 9.4 to 42.5]). There were no adverse events. Conclusions FSC outperformed conventional colonoscopy with right-colon scope retroflexion in the detection of missed adenomas, both overall and in the proximal colon, even when performed by experienced endoscopists.Trial registered at ClinicalTrials.gov (NCT02117674).

Long-term effects of video capsule endoscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) accounts for approximately 5% of all gastrointestinal (GI) hemorrhages. It usually arises from a small bowel lesion beyond the reach of conventional endoscopy including esophagogastroduodenoscopy and colonoscopy. Video capsule endoscopy (VCE) revolutionized the evaluation of OGIB patients since it allows reliable and noninvasive visualization of the small bowel mucosal surface. Since 2001, VCE has evolved into an efficient technology integrated in clinical practice. It is the cornerstone in the algorithm of OGIB investigation given its high diagnostic yield, which compares favorably to that of double-balloon enteroscopy (DBE). In terms of outcomes, a positive index VCE examination usually correlates to a high re-bleeding rate, while a negative one provides adequate evidence of low re-bleeding risk, suggesting a wait and watch approach in this subset of patients. Additionally, a variety of factors has been acknowledged as significant predictors of re-bleeding episodes. While research data regarding immediate endoscopic findings have matured, data concerning the clinical utility of VCE in patients with OGIB on the long-term remain sparse. This manuscript reviews the current literature, aiming to highlight the role of VCE in the long-term management of OGIB.

A nationwide survey of training satisfaction and employment prospects among Greek gastroenterology fellows during the economic recession

BACKGROUND

This study assessed Greek gastroenterology fellows' satisfaction regarding training, working conditions, quality of life and future employment perspectives.

METHODS

Greek gastroenterology fellows completed an anonymous multiple-choice electronic questionnaire designed to rate their satisfaction using a five-step Likert scale in two major domains: 1) fellowship program (training, working conditions, research activity, acquisition of endoscopic competencies, quality of life); and 2) professional expectations. Pareto analysis was used to determine the factors that had the most negative effect on fellows' satisfaction.

RESULTS

In 2016, over a two-month period, 121 invitations were distributed and 70 (58%) fellows responded. Overall, responders reported a low level of satisfaction with their training programs: the mean total satisfaction score was 42.94±11.55 (range 15-75). Pareto analysis revealed that the main factors negatively affecting satisfaction were financial remuneration, routine or menial work, and uncertainty about professional future (98.6%, 94.3% and 92.9% unfavorable answers, respectively). Of the total participants, 53% felt tired or very tired and 44.3% of them reported high levels of stress following a normal working day. Although the majority of the fellows did not regret choosing gastroenterology fellowship training, 34.4% of them would choose a different training environment, if possible.

CONCLUSION

Our study revealed that Greek gastroenterology fellows are dissatisfied with their training programs and with their professional perspectives. It also detected the issues that contribute most to this unfavorable outcome.

Functional dyspepsia susceptibility is related to CD14, GNB3, MIF, and TRPV1 gene polymorphisms in the Greek population

BACKGROUND

Functional dyspepsia (FD) susceptibility might be influenced by polymorphisms of genes related to inflammation (CD14, macrophage migration inhibitory factor [MIF]), motor (GNB3), and sensory dysfunction (GNB3, TRPV1). We examined the association between CD14 rs2569190, GNB3 rs5443, MIF rs222747, and TRPV1 rs755622 gene polymorphisms with FD (Rome III criteria) in the Greek population.

METHODS

We genotyped 174 dyspeptics (115 with epigastric pain syndrome; 41% Helicobacter pylori positive) and 181 controls using polymerase chain reaction-based methods and we measured disease symptoms' burden with a modified Gastrointestinal Symptoms Related Scale.

KEY RESULTS

Homozygous for the TT genotype and the T allele of the CD14 gene were significantly associated (OR [95% CI]) with FD (2.65 [1.42-4.94] and 1.67 [1.23-2.26], respectively). The CT, TT genotypes, and T allele frequencies of GNB3 showed also significant association with FD (2.18 [1.35-3.54], 3.46 [1.30-9.23], and 2.18 [1.48-3.19]). While heterozygous GC MIF genotype was more common in dyspeptics (1.67 [1.07-2.60]), homozygous CC genotype and the C allele of TRPV1 gene were more prevalent in controls (0.47 [0.25-0.87] and 0.69 [0.51-0.92], respectively). None of the gene polymorphism was related either to dyspepsia clinical syndrome type or to the H. pylori infection. Among dyspeptics, CD14 TT genotype was related to lower epigastric pain burden score (p<.011); CD14 CT genotype was related to higher epigastric burning and nausea burden scores (p<.04) while belching score was lower (p=.027) in MIF CG dyspeptics.

CONCLUSION & INFERENCES

Functional dyspepsia susceptibility is related to CD14, GNB3, MIF, and TRPV1 gene polymorphisms, while CD14 and MIF gene variants are also associated with dyspepsia symptoms burden.

The association between smoking and psychopathology adjusted for body mass index and gender

OBJECTIVE

This study examined the correlation between smoking habits and psychopathology status, as well as the impact of confounders such as body mass index and gender.

METHOD

A total of 134 non-smokers and 152 smokers were enrolled in this study. We measured psychopathology features using Symptom Checklist 90-Revised. We ran logistic regression models testing the smoking-psychopathology association, controlling for body mass index and gender.

RESULTS

Smoking was positively correlated with depression, interpersonal sensitivity, hostility, somatization, paranoid ideation and psychoticism (P<0.05). Adjusting for body mass index and gender, the results remained largely unchanged, with a slight independent effect of body mass index.

CONCLUSIONS

Our data suggest that smoking is a stronger predictor of psychopathology than body mass index and gender.

Intermediate Postchallenge Hyperglycemia in Overweight and Obese Subjects: A New Marker of Impaired Glucose Regulation?

The objective of this study was to compare subjects with intermediate postchallenge hyperglycemia (INPH) to those with normal glycemic status, impaired fasting glucose (IFG), and/or impaired glucose tolerance (IGT), as well as type 2 diabetes mellitus. Furthermore, the authors evaluated the impact of INPH on target organ damage. In total, 487 overweight and obese adults (BMI ≥27 kg/m2), 252 men and 235 women, mean age 52.9 ±10.2 years, were studied. All participants underwent a clinical and laboratory evaluation, as well as an oral glucose tolerance test (OGTT). They were also investigated by echocardiography, carotid ultrasonography, and pulse wave analysis. Overall, 302 (62%) subjects had normal glycemic status, 64 (13.1%) had IFG and/or IGT, 95 (19.5%) had type 2 diabetes mellitus, and 26 (5.4%) had INPH. Individuals with INPH had an increased index of insulin resistance (higher homeostasis model assessment-insulinogenic index [HOMA-IR], p<0.0001), impaired insulin secretion (lower insulinogenic index, p<0.0001), and higher glycosylated hemoglobin (HbA1c) levels (p<0.0001) in comparison with the normoglycemic subjects, but not to those with IFG and/or IGT or diabetes (p = 0.6). No difference was observed concerning the risk factors studied, left ventricular mass and vascular remodeling, among subjects with INPH, IFG and/or IGT, and diabetes. However, individuals with INPH had a higher proportion of echolucent carotid artery plaques in comparison with the normoglycemic subjects (p = 0.04) and those with IFG and/or IGT (p = 0.01). Intermediate postchallenge hyperglycemia seems to represent a new category of glucose metabolism disturbances with increased atherogenic impact. Therefore, evaluating intermediate glucose levels in an OGTT could contribute to better identify overweight individuals at risk of developing diabetes mellitus and cardiovascular events.

Academic hospital staff compliance with a fecal immunochemical test-based colorectal cancer screening program

AIM: To measure the compliance of an Academic Hospital staff with a colorectal cancer (CRC) screening program using fecal immunochemical test (FIT).

METHODS: All employees of “Attikon” University General Hospital aged over 50 years were thoroughly informed by a team of physicians and medical students about the study aims and they were invited to undergo CRC screening using two rounds of FIT (DyoniFOB^® Combo H, DyonMed SA, Athens, Greece). The tests were provided for free and subjects tested positive were subsequently referred for colonoscopy. One year after completing the two rounds, participants were asked to be re-screened by means of the same test.

RESULTS: Among our target population consisted of 211 employees, 59 (27.9%) consented to participate, but only 41 (19.4%) and 24 (11.4%) completed the first and the second FIT round, respectively. Female gender was significantly associated with higher initial participation (P = 0.005) and test completion - first and second round - (P = 0.004 and P = 0.05) rates, respectively. Phy

sician’s (13.5% vs 70.2%, P < 0.0001) participation and test completion rates (7.5% vs 57.6%, P < 0.0001 for the first and 2.3% vs 34%, P < 0.0001 for the second round) were significantly lower compared to those of the administrative/technical staff. Similarly, nurses participated (25.8% vs 70.2%, P = 0.0002) and completed the first test round (19.3% vs 57.6%, P = 0.004) in a significant lower rate than the administrative/technical staff. One test proved false positive. No participant repeated the test one year later.

CONCLUSION: Despite the well-organized, guided and supervised provision of the service, the compliance of the Academic Hospital personnel with a FIT-based CRC screening program was suboptimal, especially among physicians.

The Association Between Obesity and Hostility: The Mediating Role of Plasma Lipids

OBJECTIVE

Recent research indicates an association between obesity and psychopathology status, the nature of which remains unclear. We evaluated the mediating role of biochemical disturbances in this association among a treatment-seeking sample of obese individuals.

METHOD

The study enrolled 143 consecutive overweight and obese individuals (mean age 35±9 y) and 143 normal-weight controls (mean age 34±9 y), matched by age and sex. We measured psychopathology features using the Symptom Checklist 90-Revised (SCL-90-R), a standardized self-evaluation rating scale, and biochemical parameters (plasma cholesterol, triglyceride, and fasting glucose levels) of all participants. Nonlinear regression models were used to estimate the associations among obesity, psychopathology, and biochemical factors.

RESULTS

Obesity was associated positively and significantly (P<0.05) with all of the SCL-90-R subscales, with the exception of anxiety and phobic anxiety, as well as with levels of plasma glucose, cholesterol (P<0.01), and triglycerides (P<0.001). Tests for mediation showed that obesity was significantly associated, for the mediators of plasma cholesterol [parameter estimate=-0.033, P<0.05] and triglycerides (parameter estimate=-0.059, P<0.05), only with hostility (parameter estimate=-0.024, P<0.05 and parameter estimate=-0.041, P<0.05, respectively).

CONCLUSIONS

Our data suggest that biological substrates that are critically related to obesity, such as dyslipidemia, may mediate, at least in part, the association between obesity and hostility.

Endoscopy after bariatric surgery

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

The role of miRNAs and epigenetic mechanisms in primary gastric mucosa-associated lymphoid tissue lymphoma

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is a rare low-grade B-cell non-Hodgkin lymphoma associated with Helicobacter pylori infection and the subsequent chronic inflammation. Significant progress in understanding the pathogenesis of the disease has already been made. However, the exact molecular pathways of lymphomagenesis remain unclear. Furthermore, difficulties regarding accurate diagnosis of gastric MALT lymphoma and its discrimination from gastritis or other lymphoma subtypes arise. Recent studies evaluate the role of miRNAs and epigenetic alterations on MALT lymphoma pathogenesis and prognosis. This review critically summarizes the most important data on the role of miRNAs and epigenetics in MALT lymphomas pathogenesis, prognosis and treatment.

Long-term patient satisfaction of gastrointestinal endoscopic procedures

Background

We prospectively assessed patient satisfaction in a Greek Academic endoscopy facility.

Methods

Consecutive outpatients filled a satisfaction questionnaire right after their endoscopy (D1), 3 days (D3) and 3 months (M3) later. Overall patient satisfaction was measured by their willingness to repeat endoscopy in our facility and to further recommend it. Participant satisfaction regarding pre-procedural, procedural and post-procedural issues was measured using a five-step Likert scale in 19 items with 4 and 5 scores indicating favorable responses. Pareto analysis was used to determine service issues requiring improvement. Late adverse events were recorded at D3 and M3 assessments.

Results

Over six months, 501 patients participated (89.4% and 87.8% response rate at D3 and M3 assessments, respectively). More than 97% of the participants would repeat the procedure in our facility and would recommend our endoscopy service, at all three assessments. Pareto analysis identified waiting time until the appointment and on the day of the examination, discomfort during and after the endoscopy, time to obtain the pathology report and overall management of the patient problems as the issues requiring improvement. No predictor of high satisfaction score has been identified. No serious late adverse events were reported.

Conclusion

Despite the overall high levels of patient satisfaction, management of patient discomfort and organizational issues need improvement.

Improved bowel preparation increases polyp detection and unmasks significant polyp miss rate

AIM: To retrospectively compare previous-day vs split-dose preparation in terms of bowel cleanliness and polyp detection in patients referred for polypectomy.

METHODS: Fifty patients underwent two colonoscopies: one diagnostic in a private clinic and a second for polypectomy in a University Hospital. The latter procedures were performed within 12 wk of the index ones. Examinations were accomplished by two experienced endoscopists, different in each facility. Twenty-seven patients underwent screening/surveillance colonoscopy, while the rest were symptomatic. Previous day bowel preparation was utilized initially and split-dose for polypectomy. Colon cleansing was evaluated using the Aronchick scale. We measured the number of detected polyps, and the polyp miss rates per-polyp.

RESULTS: Excellent/good preparation was reported in 38 cases with previous-day preparation (76%) vs 46 with split-dose (92%), respectively (P = 0.03). One hundred and twenty-six polyps were detected initially and 169 subsequently (P < 0.0001); 88 vs 126 polyps were diminutive (P < 0.0001), 25 vs 29 small (P = 0.048) and 13 vs 14 equal or larger than 10 mm. The miss rates for total, diminutive, small and large polyps were 25.4%, 30.1%, 13.7% and 6.6%, respectively. Multivariate analysis revealed that split-dose preparation was significantly associated (OR, P) with increased number of polyps detected overall (0.869, P < 0.001), in the right (0.418, P = 0.008) and in the left colon (0.452, P = 0.02).

CONCLUSION: Split-dose preparation improved colon cleansing, enhanced polyp detection and unmasked significant polyp miss rates.

Gene polymorphisms associated with functional dyspepsia

Functional dyspepsia (FD) is a constellation of functional upper abdominal complaints with poorly elucidated pathophysiology. However, there is increasing evidence that susceptibility to FD is influenced by hereditary factors. Genetic association studies in FD have examined genotypes related to gastrointestinal motility or sensation, as well as those related to inflammation or immune response. G-protein b3 subunit gene polymorphisms were first reported as being associated with FD. Thereafter, several gene polymorphisms including serotonin transporter promoter, interlukin-17F, migration inhibitory factor, cholecystocynine-1 intron 1, cyclooxygenase-1, catechol-o-methyltransferase, transient receptor potential vanilloid 1 receptor, regulated upon activation normal T cell expressed and secreted, p22PHOX, Toll like receptor 2, SCN10A, CD14 and adrenoreceptors have been investigated in relation to FD; however, the results are contradictory. Several limitations underscore the value of current studies. Among others, inconsistencies in the definitions of FD and controls, subject composition differences regarding FD subtypes, inadequate samples, geographical and ethnical differences, as well as unadjusted environmental factors. Further well-designed studies are necessary to determine how targeted genes polymorphisms, influence the clinical manifestations and potentially the therapeutic response in FD.

Insulin action in muscle and adipose tissue in type 2 diabetes: The significance of blood flow

Under normal metabolic conditions insulin stimulates microvascular perfusion (capillary recruitment) of skeletal muscle and subcutaneous adipose tissue and thus increases blood flow mainly after meal ingestion or physical exercise. This helps the delivery of insulin itself but also that of substrates and of other signalling molecules to multiple tissues beds and facilitates glucose disposal and lipid kinetics. This effect is impaired in insulin resistance and type 2 diabetes early in the development of metabolic dysregulation and reflects early-onset endothelial dysfunction. Failure of insulin to increase muscle and adipose tissue blood flow results in decreased glucose handling. In fat depots, a blunted postprandial blood flow response will result in an insufficient suppression of lipolysis and an increased spill over of fatty acids in the circulation, leading to a more pronounced insulin resistant state in skeletal muscle. This defect in blood flow response is apparent even in the prediabetic state, implying that it is a facet of insulin resistance and exists long before overt hyperglycaemia develops. The following review intends to summarize the contribution of blood flow impairment to the development of the atherogenic dysglycemia and dyslipidaemia.

Self-expandable metal stents for achalasia: Thinking out of the box!

Achalasia is a primary motor disorder of the esophagus diagnosed manometrically in the clinical setting of dysphagia to both solids and liquids. Currently established treatment options include pneumatic dilation, laparoscopic Heller myotomy, botulinum toxin injection performed endoscopically, oral agents that relax the lower esophageal sphincter and esophagectomy for refractory, end-stage disease. Despite their effectiveness, a significant proportion of patients eventually relapses and needs retreatment. In this setting, several new techniques are under investigation promising future enrichment of our therapeutic armamentarium for achalasic patients. Among them, peroral endoscopic myotomy and self-expandable metal stents placed across the gastro-esophageal junction represent the most encouraging modalities, as initial studies assessing their efficacy and safety indicate. This review highlights the role of self-expandable metal stents in the management of patients with achalasia. Their possible position in the therapeutic algorithm of achalasia along with established and novel techniques is also assessed. Finally, the need for large prospective randomized trials is underlined in order to elucidate the numerous relevant issues.

Effect of aliskiren on circulating endothelial progenitor cells and vascular function in patients with type 2 diabetes and essential hypertension

BACKGROUND

The aim of this study was to investigate the effects of aliskiren on vascular function and endothelial progenitor cells (EPCs) in patients with type 2 diabetes and essential hypertension.

METHODS

The study enrolled type 2 diabetic patients aged >50 years under stable glycemic control and first diagnosed mild essential hypertension. In phase A (n = 20), patients received aliskiren 150-300 mg daily for 3 months. In phase B (n = 12), hydrochlorothiazide (HCTZ) 12.5-25mg daily substituted for aliskiren for 3 more months. At baseline and at the end of each phase, we assessed (i) brachial blood pressure (BBP); (ii) central aortic systolic pressure (CSP), aortic augmentation index (Aix), and pulse wave velocity (PWV) as markers of arterial stiffness; (iii) brachial artery flow-mediated dilatation (FMD) as a marker of endothelial function; (iv) left ventricular (LV) twisting and untwisting as markers of LV function and (v) EPC numbers in culture of peripheral blood mononuclear cells.

RESULTS

Aliskiren similarly reduced BBP and CSP, increased FMD (P < 0.001) and EPC numbers (P < 0.001), decreased PWV and Aix (P < 0.05), and improved LV twisting and untwisting (P < 0.05). Although substitution of HCTZ sustained BBP at similar levels, CSP and echocardiographic indices nearly returned at baseline levels, and the improvement of FMD, PWV, Aix, and EPC numbers was abolished.

CONCLUSIONS

Aliskiren had a favorable effect on endothelial function and EPCs, reduced arterial stiffness, and improved LV twisting and untwisting. These effects were independent of BBP lowering, as they were not observed after the achievement of similar values of BBP with HCTZ.

Is there a role for colon capsule endoscopy beyond colorectal cancer screening? A literature review

Colon capsule endoscopy is recommended in Europe alternatively to colonoscopy for colorectal cancer screening in average risk individuals. The procedure has also been proposed to complete colon examination in cases of incomplete colonoscopy or when colonoscopy is contraindicated or refused by the patient. As tissue samples cannot be obtained with the current capsule device, colon capsule endoscopy has no place in diagnosing ulcerative colitis or in dysplasia surveillance. Nevertheless, data are accumulating regarding its feasibility to examine ulcerative colitis disease extent and to monitor disease activity and mucosal healing, even though reported results on the capsule's performance in this field vary greatly. In this review we present the currently available evidence for the use of colon capsule endoscopy to complement colonoscopy failure to reach the cecum and its use to evaluate ulcerative colitis disease activity and extent. Moreover, we provide an outlook on issues requiring further investigation before the capsule becomes a mainstream alternative to colonoscopy in such cases.

Effect and mechanisms of action of vinegar on glucose metabolism, lipid profile, and body weight

The aim of this review is to summarize the effects of vinegar on glucose and lipid metabolism. Several studies have demonstrated that vinegar can help reduce hyperglycemia, hyperinsulinemia, hyperlipidemia, and obesity. Other studies, however, have shown no beneficial effect on metabolism. Several mechanisms have been proposed to explain these metabolic effects, including delayed gastric emptying and enteral absorption, suppression of hepatic glucose production, increased glucose utilization, upregulation of flow-mediated vasodilation, facilitation of insulin secretion, reduction in lipogenesis, increase in lipolysis, stimulation of fecal bile acid excretion, increased satiety, and enhanced energy expenditure. Although some evidence supports the use of vinegar as a complementary treatment in patients with glucose and lipid abnormalities, further large-scale long-term trials with impeccable methodology are warranted before definitive health claims can be made.

Association of lean body mass with cardiometabolic risk factors in healthy postmenopausal women

OBJECTIVE

Aim of this study was to investigate the association of total and regional lean body mass (LBM) with cardiometabolic risk factors in healthy obese and nonobese postmenopausal women.

METHODS

A total of 150 postmenopausal women (age 54 ± 7 years, BMI 29.6 ± 5.8 kg/m2) underwent a comprehensive assessment of cardiometabolic risk, including metabolic syndrome (MS). Body composition analysis was performed with Dual-energy X-ray Absorptiometry, and multiple height-adjusted indices of total and regional LBM were evaluated.

RESULTS

After controlling for age, diet, physical activity, and total fat mass, most indices of total, central, and peripheral LBM displayed significant positive correlations with cardiometabolic risk factors. Most associations were no longer significant after controlling for waist circumference, with the only exception of lean mass in the arms, which remained significantly associated with the presence and severity of MS (number of MS abnormalities), independently of central adiposity. A significant additive interaction was found between lean mass in the arms and waist circumference in increasing the prevalence of MS.

CONCLUSIONS

LBM is unfavorably associated with cardiometabolic risk factors in healthy postmenopausal women. Whether LBM, especially in arms, is associated with cardiometabolic health independently of central fat distribution in postmenopausal women, merits further investigation.

Virtual reality simulators for gastrointestinal endoscopy training

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees’ learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-the-art simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.

Percutaneous endoscopic gastrostomy tube replacement unexpected serious events

Percutaneous endoscopic gastrostomy tubes are replaced due to clogging, breaking, and dislodgement. There are potential complications associated with these procedures, including intraperitoneal placement of the tube and peritonitis, which can occur even in the presence of a well established stoma site. Herein we present a case series of 3 patients with mature gastrocutaneous tracks, who developed peritonitis following tube replacement. In the absence of a consensus or international guidelines regarding the management of patients requiring percoutaneous endoscopic gastrostomy tube replacement, emphasis should be given on prevention of severe adverse events and on early anticipation of their occurrence. Clinical experience indicates that recognition of high-risk procedures, selection of the appropriate replacement method and confirmation of correct tube placement can improve patients' safety and reduce the complications rate.

Regional fat distribution and cardiometabolic risk in healthy postmenopausal women

BACKGROUND

Regional fat distribution is an important determinant of cardiometabolic risk after menopause. The aim of the present study was to investigate the association between indices of fat distribution obtained by Dual-energy X-ray Absorptiometry (DXA) and representative cardiometabolic risk factors in a cohort of healthy postmenopausal women.

METHODS

In this cross-sectional study, cardiometabolic risk factors were correlated with a variety of central and peripheral fat depots obtained by DXA, in a total of 150 postmenopausal women, free of diabetes and cardiovascular disease (age 54 ± 7 years, BMI 29.6 ± 5.8 kg/m(2), mean ± 1 SD).

RESULTS

After adjusting for age and total adiposity, DXA-derived indices of central and peripheral fat distribution displayed opposite associations (positive versus negative) with the examined cardiometabolic risk factors. In multivariate regression analysis, thoracic fat mass % was an independent predictor of blood pressure, HOMA index and triglycerides, abdominal fat mass % was an independent predictor of high sensitivity C-reactive protein, and abdominal-to-gluteofemoral fat ratio was an independent predictor of high density lipoprotein cholesterol. An index of peripheral fat distribution, gluteofemoral fat mass %, proved to be the most important determinant of metabolic syndrome (Odds Ratio 0.76, 95% confidence intervals 0.67-0.87, p<0.001), independent of total and central adiposity.

CONCLUSION

DXA-derived indices of regional fat distribution such as thoracic, abdominal and gluteofemoral fat, correlate significantly with cardiometabolic risk factors in healthy postmenopausal women, and may serve as clinically useful tools for evaluating cardiometabolic risk after menopause.

Body composition determinants of metabolic phenotypes of obesity in nonobese and obese postmenopausal women

OBJECTIVE

Although obesity is typically associated with increased cardiovascular risk, a subset of obese individuals display a normal metabolic profile ("metabolically healthy obese," MHO) and conversely, a subset of nonobese subjects present with obesity-associated cardiometabolic abnormalities ("metabolically obese nonobese," MONO). The aim of this cross-sectional study was to identify the most important body composition determinants of metabolic phenotypes of obesity in nonobese and obese healthy postmenopausal women.

DESIGN AND METHODS

We studied a total of 150 postmenopausal women (age 54 ± 7 years, mean ± 1 SD). Based on a cardiometabolic risk score, nonobese (body mass index [BMI] ≤ 27) and obese women (BMI > 27) were classified into "metabolically healthy" and "unhealthy" phenotypes. Total and regional body composition was assessed with dual-energy X-ray absorptiometry (DXA).

RESULTS

In both obese and nonobese groups, the "unhealthy" phenotypes were characterized by frequent bodyweight fluctuations, higher biochemical markers of insulin resistance, hepatic steatosis and inflammation, and higher anthropometric and DXA-derived indices of central adiposity, compared with "healthy" phenotypes. Indices of total adiposity, peripheral fat distribution and lean body mass were not significantly different between "healthy" and "unhealthy" phenotypes. Despite having increased fat mass, MHO women exhibited comparable cardiometabolic parameters with healthy nonobese, and better glucose and lipid levels than MONO. Two DXA-derived indices, trunk-to-legs and abdominal-to-gluteofemoral fat ratio were the major independent determinants of the "unhealthy" phenotypes in our cohort.

CONCLUSIONS

The "metabolically obese phenotype" is associated with bodyweight variability, multiple cardiometabolic abnormalities and an excess of central relative to peripheral fat in postmenopausal women. DXA-derived centrality ratios can discriminate effectively between metabolic subtypes of obesity in menopause.

Anemia due to coadministration of renin-angiotensin-system inhibitors and PPARγ agonists in uncomplicated diabetic patients

Therapy with either angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARB) or thiazolidinediones (TZD) is associated with dose-dependent decrements in hematocrit and hemoglobin levels. We aimed to investigate the impact of the coadministration of TZD and ACEI/ARB on hematocrit and hemoglobin values in uncomplicated patients with type 2 diabetes mellitus and normal serum creatinine.Data from patients with type 2 diabetes currently followed, were reviewed and patients treated with ACEI/ARB and/or TZD were identified. For the purpose of this study the following 4 groups of 30 stable non-anemic diabetic patients each matched for age, gender, and BMI were formed. Group ACEI/ARB included patients on ACEI/ARB without TZD, group TZD included patients on TZD and antihypertensive agents other than ACEI/ARB, group ACEI/ARB/TZD consisted of patients on combined therapy with ACEI/ARB and TZD and the control group C included patients never exposed to ACEI/ARB or TZD. Clinical and laboratory data were collected prior to initiation of treatment and after 6 months.Neither hematocrit nor hemoglobin showed any significant change from baseline at the end of the study in group C. In both group ACEI/ARB and group TZD a small, but statistically significant reduction in hematocrit (~ 1% point) and hemoglobin levels (~ 0.3 g/dl) was seen. A greater statistically and clinically important reduction in hematocrit (~ 3% points) and hemoglobin (~ 1 g/dl) levels was observed in group ACEI/ARB/TZD. Furthermore, incident anemia at the end reached 7% in group TZD and 23% in group ACEI/ARB/TZD.Coadministration of RAS inhibitors and PPAR-γ agonists should be considered in the differential diagnosis of hematocrit lowering and anemia in uncomplicated type 2 diabetic patients with normal serum creatinine. Further studies are required to clarify the mechanism(s), the cardiovascular consequences and the cost utility of anemia workup in such patients.

Thyroid hormone excess and glucose intolerance

The elevated plasma glucose levels in hyperthyroidism may be explained by increased rates of endogenous glucose production, due mainly to increased gluconeogenesis. The rates of insulin-stimulated glucose disposal in peripheral tissues in hyperthyroidism have been found, in general, either normal or increased. Skeletal muscle is the most important tissue for the disposal of glucose in response to insulin. In this tissue, insulin increases glucose disposal by stimulating glucose transport, glucose phosphorylation/glycolysis, glycogen synthesis and glucose oxidation. Studies examining insulin-stimulated glucose metabolism in skeletal muscle have suggested that, in the hyperthyroid state, it may be of primary importance to increase the rates of glycolysis and lactate formation relative to glucose oxidation in this tissue in order to provide substrate for gluconeogenesis (increase Cori cycle activity). This effect will be achieved primarily by a decrease in glycogen synthesis and an increase in glycogenolysis. When hyperthyroidism becomes more severe, an increased rate of glucose uptake into muscle may then be necessary since the increased conversion of glycogen to lactate could not be sustained for prolonged periods and might lead to a depletion in glycogen stores. This mechanism would ensure that the level of glucose in plasma is kept normal or slightly increased. Thus, an increased Cori cycle activity may be a necessary mechanism to provide optimal conditions in hyperthyroidism for the control of glucose utilization without increasing the risk of hypoglycemia. In addition to lactate, increased rates of gluconeogenesis in hyperthyroidism can also be sustained by increased plasma concentrations of amino acids (mostly glutamine and alanine) and glycerol, as well as by increased plasma concentrations of free fatty acids.