Rocío Aller

Diagnosis and grading of intrapulmonary vascular dilatation in cirrhotic patients with contrast transesophageal echocardiography

BACKGROUND/AIMS The use of transesophageal contrast echocardiography (TOCE) in the diagnosis of intrapulmonary vascular dilatation (IVD) and hepatopulmonary syndrome (HPS) needs to be studied. We tested the specificity of TOCE using traditional criteria and the value of a new method based on TOCE, a grading scale and a selected contrast. METHODS 1) Several solutions were tested and two were selected: 20% mannitol and 0.9% saline. 2) 71 cirrhotic patients and 20 controls were studied. Left atrium opacification with contrast was classified into 6 degrees by TOCE. Mild and significant IVD were considered in relation to results in controls. Patients were studied with saline and mannitol-TOCE. Results were compared to transthoracic contrast echocardiography (TTCE), to gas exchange abnormalities and to Child class. RESULTS The reproducibility of TOCE grading was excellent, (Kappa >0.9). IVD detection using TTCE, mannitol-TOCE and saline-TOCE was 29.5%, 55% (25% mild and 30% significant), and 45% (38% mild and 7% significant), respectively. The best agreement with TTCE (reference method) was obtained with mannitol-TOCE, using significant IVD as the cut point. By this criterion, 18% reached the criteria of HPS using TTCE and 22% using mannitol-TOCE. Patients with IVD by TTCE had non-significant changes in gas exchange determinations. Patients with significant IVD by saline TOCE had lower mean PaO2 levels (67.3+/-14 vs. 79.5+/-11 mm Hg, p<0.05) than patients without IVD. Patients with significant IVD by mannitol TOCE had higher mean AaPO2 (29.3+/-14 vs. 19.7+/-9 mm Hg; p<0.005) and lower mean PaCO2 levels (30.1+/-4.4 vs. 33.4+/-4.8 mm Hg; p<0.05) than patients without IVD. Severity of IVD by TOCE correlated to Child class (r = 0.43; p<0.001). CONCLUSIONS The presence of contrast in the left atrium cannot be a criterion of IVD when TOCE is used. Our semi-quantitative scale has proved to be feasible and reproducible, presenting a good agreement with TTCE, and has shown better correlation with gas exchange abnormalities and Child class. Saline TOCE appears to be more specific in the detection of hypoxemic patients with IVD, but mannitol TOCE adds sensitivity.

Improvement in lipid and haemostasis patterns afterHelicobacter pylori infection eradication in type 1 diabetic patients

Helicobacter pylori has been implicated in the cardiovascular risk of diabetic patients. The aim of our study was to investigate whether the Helicobacter pylori infection plays a role in the lipid and haemostasis patterns of type 1 diabetic patients. Twenty nine patients with type 1 diabetes mellitus and H. pylori infection were enrolled (Chlamydia pneumoniae negative). The H. pylori infection status was assessed by serology and urease breath test. In all patients levels of total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, lipoprotein (a) (Lpa) C reactive protein (CRP), fibrinogen, thrombin/antithrombin III complex (TAT), plasminogen activator inhibitor type 1(PAI-1), tissue plasminogen activator (t-PA) and von Willebrand antigen were measured. All patients were evaluated before and after H. pylori eradicating treatment with amoxicillin, clarithromycin and omeprazole. Twenty two patients were eradicated and seven remained infected. In H. pylori eradicated patients, HDL cholesterol increased (59.7+/-18.9 mg/dl vs 65.2+/-15. 9 mg/dl, P << 0.05), after treatment. After H. pylori eradication, the levels of CRP and TAT decreased (48+/-0.7 ng/l vs 3.3+/-0.4 ng/l;P << 0.05), (27.7+/-44.7 microg/ml vs 2.1+/-1.4 microg/ml, P << 0.05), respectively. The decrease in TAT was higher in the group of H. pylori (+) patients with higher levels of TAT (TAT >> 20 ng/ml, 92.8+/-41.6 ng/ml vs 1.9+/-2.0 ng/ml, P << 0.005; TAT 4Eth 20 ng/ml; 10.1+/-5.2 ng/ml vs 2.2+/-0.6 ng/ml, P << 0.05). These changes did not occur in patients without H. pylori eradication. Eradication of H. pylori infection in type 1 diabetic patients modifies some parameters of lipid and haemostasis patterns, (increase of HDL-cholesterol, reduction of Lpa and decrease of CRP and TAT) and so contributes to improvement of cardiovascular risk factors in these patients.

Disturbed Synthesis of Insulinlike Growth Factor I and Its Binding Proteins May Influence Renal Function Changes in Liver Cirrhosis

Insulinlike growth factor-1 (IGF-1) is an anabolic hormone synthesized by the liver upon stimulation by growth hormone (GH). IGF-1 exerts important effects on renal hemodynamics and renal sodium handling. The bioactivity of this hormone is influenced by its binding proteins (BP) of which IGF-BP3 favors retention in the capillary lumen while IGF-BP1 facilitates the transport to the target tissues. IGF-BP1 modulates the actions of IGF-1 on target cells including renal tubules. Although a number of reports have dealt with disturbances of the IGF-1/IGF-BP system in cirrhosis, no studies have yet addressed the relationship between alterations in this system and renal function changes in cirrhosis. In the present study we have included 20 patients with cirrhosis and 10 healthy subjects (control group). As compared with the controls, patients showed lower circulating levels of IGF-1 and IGF-BP3, higher IGF-BP1 levels, and a tendency to higher insulinemia and GH values. The index IGF-1 × IGF-BP1/IGF-BP3 (IGF-1–IGF-BP index, reflecting the accessibility of circulating IGF-1 to target cells) was higher in patients with ascites. IGF-1 directly correlated with renal blood flow (P < 0.05), with IGF-BP3 (P < 0.001) and inversely with the Pughs score (P < 0.02). A negative correlation was found between IGF-1–IGF-BP index and fractional sodium excretion (P < 0.01) and between IGF-BP1 and urinary sodium excretion (P < 0.02). Our findings support the hypothesis that the disturbance of the IGF-1/IGF-BP axis may be related to the degree of renal vasodilation and renal sodium retention in cirrhotic patients.

Effect of the treatment of Helicobacter pylori infection on gastric emptying and its influence on the glycaemic control in type 1 diabetes mellitus.

Helicobacter pylori (Hp) infection plays a role in gastric emptying (GE) in type 1 diabetic patients and may have implications for glycaemic control. The aim of our study was to investigate this relationship. Gastric emptying was studied in 13 patients with type 1 diabetes and Hp infection. The Hp infection status was assessed by serology and urease breath test (UBT). In addition upper gastrointestinal endoscopy with gastric mucosal biopsy was performed to look for gastritis. A radionuclide-labeled solid meal was used to study GE before and after eradication therapy (amoxicillin, clarithromycin and omeprazole) for Hp infection. All patients were evaluated for autonomic and peripheral neuropathy and were asked for symptoms of gastrointestinal motor dysfunction. Blood glucose levels were determined before the meal and at 30,60,90 and 120 min after the start of the meal. Home blood glucose self-monitoring and HbA(1c) were performed to document glycaemic control during the study. Three months after treatment, five patients were free of Hp infection and were without gastritis (group I: no Hp infection, no gastritis); eight of the patients continued to have gastritis after treatment (group II) and of these eight patients, six had gastritis without Hp infection and two had gastritis plus persistent Hp infection. These last two patients were re-treated with eradication therapy. Patients with gastritis were re-evaluated 6 months after initial treatment; at which time four were now free of gastritis and were added to group I (n=9) while four continual to have gastritis although without Hp infection (group II, n=4). In group I, GE half-time showed an increase (30.6+/-10.3 min vs. 60.2+/-15.4 min; P<0.05) while no change (28.8+/-9.5 vs. 26.9+/-8.7 min; n.s.) was observed in group II. GE half-time was not altered by autonomic and peripheral neuropathy or blood glucose during solid meal test. HbA(1c) did not change significantly after treatment in either groups but the blood glucose levels were more stable in group I compared to group II. A delay in GE was observed with disappearance of gastritis associated to H. pylori infection after eradication treatment in patients with type 1 diabetes. This change in GE could help to stabilise the blood glucose levels in these patients treated with insulin before each meal.

The rs9939609 Gene Variant in FTO Modified the Metabolic Response of Weight Loss After a 3-Month Intervention With a Hypocaloric Diet

Background Common polymorphisms in the fat mass and obesity associated gene (FTO) have been linked to obesity in some populations. Nevertheless, the role of FTO variants on body weight response after dietary intervention remains equivocal. Objective We decided to analyze the effects of the rs9939609 FTO gene polymorphism on body weight changes and metabolic parameters after 3 months of a hypocaloric diet. Design Before and after 3 months on a low-fat hypocaloric diet, a white population of 106 subjects with obesity was analyzed. Results Of the study subjects, 35 (33%) had the genotype TT and 71 (67%) had the next genotypes; TA (46 study subjects, 43.4%) or AA (25 study subjects, 23.6%). After dietary treatment and in TT group, weight, waist circumference, total cholesterol, LDL-cholesterol, insulin, and homeostasis model assessment decreases were less than subjects carrying the A allele [−3.1 (3.6) vs −2.4 (4.1) kg: P < 0.05], waist circumference [−5.4 (6.4) vs −2.6 (4.8) cm; P < 0.05], total cholesterol [−12.3 (35.3) vs −6.4 (4.7) mg/dL; P < 0.05], LDL-cholesterol [−22.3 (30.5) vs −10.7 (30.5) mg/dL; P < 0.05], insulin [−1.89 (5.5) vs +0.94 (8.2) mUI/L; P < 0.05], and homeostasis model assessment [−0.46 (1.11) vs −0.01 (2.4); P < 0.05]. Conclusions Our study confirmed a higher weight loss in A carriers of FTO rs9939609 polymorphism than in TT genotype study subjects.

Consejo nutricional aislado frente a suplemento y consejo nutricionales en pacientes con infección por el virus de la inmunodeficiencia humana

Fundamento Y Objetivo La intervencion nutricional en pacientes con infeccion por el virus de lainmunodeficiencia humana (VIH) es un aspecto controvertido. El objetivo de nuestro estudiofue comparar la influencia en el estado nutricional de la administracion de un suplemento nutricionalfrente a la educacion nutricional sin suplementacion. Pacientes Y Metodo Se aleatorizo a 70 pacientes, 66 fueron totalmente evaluados. De estos pacientes,35 fueron incluidos en el grupo I (suplementacion con formula) y 35 en el grupo II(consejo nutricional). Los pacientes del grupo I recibieron tres botes de 250 ml de una formulanormocalorica y consejo nutricional; el grupo II solo recibio educacion nutricional. A los pacientesse les realizo una evaluacion nutricional antropometrica y bioquimica y evaluacion inmunologica,asi como una encuesta nutricional de 24 h, antes de la aleatorizacion y a los tresmeses de iniciar el tratamiento. Resultados En los pacientes del grupo I se detecto un aumento significativo del peso (2,75%;p Conclusiones La suplementacion oral en un periodo de tres meses en pacientes con infeccionpor el VIH aumenta su peso, debido al aumento de la masa grasa. La educacion nutricional aisladano tuvo efectos sobre el peso. Background and Objective Nutritional intervention is a controversial area. The aim of the studywas to compare the influence on nutritional status of nutritional supplementation with a standardpolymeric formula as well as nutritional counselling versus isolated nutritional counsellingin a group of HIV-infected patients. Patients and Method There were 70 patients, 66 of whom were fully evaluated for each studyend point after application of prospectively determined evaluability criteria. Of these, 35 wererandomized to group I (standard formula) and 35 were randomized to unsupplemented groupII. Group I patients received standard enteral formula (3 cans/day, 250 ml per can). Patientswere submitted to a prospective serial assessment of their nutrition status (anthropometric andbiochemical status) and the nutritional intake was determined by means of 24-hours writtenfood records. Determinations were performed at baseline and at 3 months. Results Treatment with oral supplements in group I resulted in a significant and sustained increasein weight (2.75%; p Conclusions Oral nutritional supplements for a 3-months period resulted in body weight gain inHIV-infected patients, increasing the fat mass. An isolated nutritional counselling did not resultin such an increase.

Mediterranean diet is associated with liver histology in patients with non alcoholic fatty liver disease

BACKGROUND clinical data on impact of the Mediterranean diet on the the stage of non alcoholic fatty liver disease are limited and these studies have heterogeneous designs. AIM we decide to explore any potential associations between adherence to the Mediterranean diet and histological characteristics of patients with NAFLD. METHODS a sample of 82 patients was analyzed in a cross sectional study. To evaluate the level of adherence to the Mediterranean dietary pattern the 14-Item Mediterranean Diet Assessment Tool was used. RESULTS thirty five patients (42.7%) had a low grade of steatosis (grade 1 of classification) and 47 patients (57.3%) had a high grade of steatosis (grade 2 and 3). Fifty-six patients (68.3%) had liver steatohepatitis and forty-two patients (51.2%) had liver fibrosis. In the logistic regresion analysis, one unit of the 14-Item Mediterranean Diet Assessment Tool was associated with a lower likehood of having steatohepatitis odds ratio 0.43 (CI:95%: 0.29-0.64) and steatosis 0.42 (CI:95%: 0.26- 0.70). Secondly, one unit of HOMA-IR was associated with higher likehood of having steatosis odds ratio 2.01 (CI:95%: 1.08-3.71) and liver fibrosis 1.38 (CI:95%: 1.10-1.80) . CONCLUSIONS greater adherence to the Mediterranean diet was associated with lower likelihood of high grade of steatosis and presence of steatohepatitis.

Accuracy of Urea Breath Test Performed Immediately After Emergency Endoscopy in Peptic Ulcer Bleeding

AimsThe aim of this work is to investigate the accuracy of the urea breath test (UBT) performed immediately after emergency endoscopy in peptic ulcer bleeding (PUB).MethodsUrea breath test was carried out right after emergency endoscopy in patients with PUB. The accuracy of this early UBT was compared to a delayed one after hospital discharge that was considered the gold standard. Clinical and epidemiological factors were analyzed in order to study their influence on the accuracy of the early UBT.ResultsEarly UBT was collected without any complication and good acceptance from all the 74 patients included. In 53 of the patients (71.6%), a delayed UBT was obtained. Comparing concordance between the two tests we have calculated an accuracy of 83% for the early UBT. Sensibility and specificity were 86.36 and 66%, respectively, with a positive predictive value of 92.68% and negative predictive value of 50% (Kappa index = 0.468; p = 0.0005; CI: 95%). We found no influence of epidemiological factors, clinical presentation, drugs, times to gastroscopy, Forrest classification, endoscopic therapy, hemoglobin, and urea levels over the accuracy of early UBT.ConclusionsUrea breath test carried out right after emergency endoscopy in PUB is an effective, safe, and easy-to-perform procedure. The accuracy of the test is not modified by clinical or epidemiological factors, ulcer stage, or by the type of therapy applied. However, we have found a low negative predictive value for early UBT, so a delayed test is mandatory for all negative cases.

Effect of -55CT Polymorphism of UCP3 on Insulin Resistance and Cardiovascular Risk Factors after a High Protein/Low Carbohydrate versus a Standard Hypocaloric Diet

Background: The C/C genotype of a polymorphism in the uncoupling protein3 (UCP3) promoter (-55C->T) (rs1800849) is associated with an increased body mass index. Objective: The aim of our study was to investigate the effect of polymorphism on the UCP3 promoter (-55C->T) on insulin resistance and cardiovascular risk factors secondary to a high protein/low carbohydrate vs. a standard hypocaloric diets (1,000 kcal/day). Design: A population of 283 obese subjects was analyzed in a randomized trial. A nutritional evaluation was performed at the beginning and at the end of a 9-month period in which subjects received 1 of 2 diets (diet HP: high protein/low carbohydrate vs. diet S: standard diet). Results: Weight improvement was higher in non-T carriers. With both diets and only in wild genotype (diet HP vs. diet S), total cholesterol (-9.7 ± 4.0 vs. -11.1 ± 2.0 mg/dl; p > 0.05) and low density lipoprotein (LDL) cholesterol (-8.3 ± 3.0 vs. -5.5 ± 2.7 mg/dl; p > 0.05) decreased. The improvement in these parameters was similar in subjects with diet HP than HS. With diet HP and only in wild genotype, glucose (-5.2 ± 2.2 mg/dl; p < 0.05), triglycerides (-15.5 ± 3.9 mg/dl; p < 0.05), insulin levels (-3.9 ± 3.1 UI/l; p < 0.05) and homeostasis model assessment (HOMA-R; -0.6 ± 0.1 units; p < 0.05) decreased. Conclusion: Carriers of T allele have a different response than non-carrier subjects, with a lack of decrease of LDL cholesterol, glucose, insulin levels and HOMA-R. The weight loss was lower in T carriers. HP diet showed a better metabolic response than S diet in 55CC homozygous.

Role of the rs6923761 Gene Variant in Glucagon-Like Peptide 1 Receptor Gene on Cardiovascular Risk Factors and Weight Loss after Biliopancreatic Diversion Surgery

Background: Studies of the glucagon-like peptide 1 (GLP-1) receptor (GLP-1R) have been directed at identifying polymorphisms in the GLP-1R gene that may be a contributing factor in the pathogenesis of obesity. Objective: We decided to investigate the role of the rs6923761 GLP-1R polymorphism on outcomes after biliopancreatic diversion. Design: A sample of 137 morbidly obese patients was operated. Weight, blood pressure, basal glucose and lipid profile were measured at the basal visit and at each following visit (basal, 3, 9, 12 and 18 months). Results: Body mass index, weight and waist circumference were lower in non-A allele carriers than A allele carriers 12 and 18 months after surgery. The initial weight percent loss at 12 months (45.6 vs. 39.8%; p < 0.05) or 18 months (49.6 vs. 41.3%; p < 0.05) was higher in patients with GG genotype than A allele carriers. Conclusion: Our study showed a higher weight loss 12 and 18 months after bariatric surgery in GG variant than A allele carriers. The biochemical parameters and cardiovascular comorbidity rates improved similarly in both genotypes.