Insulin resistance and type 2 diabetes: time for a new hypothesis.
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Amyloid↗
Biomedical subjects
R S Stubbs
Publications and source records attributed to R S Stubbs.
Serum proinflammatory cytokine response in patients with advanced liver tumors following selective internal radiation therapy (SIRT) with (90)Yttrium microspheres.
PURPOSE: To determine the changes in serum levels of proinflammatory cytokines within 48 h after selective internal radiation treatment (SIRT) in patients with advanced liver cancers. METHODS AND MATERIALS: Twenty-eight patients with advanced liver cancers who underwent SIRT were recruited into the study. Serum levels of interleukin (IL)-1beta, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-alpha, and interferon-gamma were determined prior to and 3, 6, 12, 24, and 48 h after SIRT. Their changes were correlated to adverse reactions following treatment as assessed by constitutional symptom scores, and routine blood and liver function tests at 24 and 48 h post-SIRT and falls in serum carcinoembryonic antigen (CEA) level 1 month post-SIRT. RESULTS: Serum IL-6 levels were significantly increased at 24 (p < or = 0.05) and 48 h (p < or = 0.01) post-SIRT. In contrast, there was no significant change in the serum levels of other cytokines studied. The increase in serum IL-6 at 24 h post-SIRT was significantly correlated with the changes in serum alanine transferase (p < or = 0.05) and C-reactive protein (p < or = 0.001) levels and total leukocyte counts (p < or = 0.001) at both 24 and 48 h post-SIRT. Changes in serum IL-6 level were also significantly correlated to the rise of serum aspartate transaminase levels at 48 h post-SIRT (p < or = 0.001), but not with the scores of constitutional symptoms or the changes of serum CEA at 1 month post-SIRT. CONCLUSION: Absence of significant changes in most of proinflammatory cytokines studied confirmed that SIRT is a reasonably safe and well-tolerated treatment with minimal side-effect from the point of view of cytokine-related inflammation. The correlation of serum IL-6 changes with several liver enzymes and C-reactive protein but not with clinical symptom scores or serum CEA levels suggests that the rise in IL-6 levels in the first 48 h following SIRT most likely reflect normal liver cell damage rather than tumor cell damage.
Adult↗
Hepatic artery access ports: recognizing and avoiding the problems.
BACKGROUND: Regional approaches to the management of hepatic tumours are appropriate in some clinical situations and include hepatic arterial chemotherapy (HAC) and selective internal radiation therapy (SIRT). Both require access to the hepatic artery, which is conveniently achieved with a subcutaneously placed port. Placement and use of these ports may be associated with a variety of technical problems which can impact adversely on the outcome of the treatment. The present paper outlines the problems related to port usage for regional hepatic therapies, with emphasis on the technical aspects of insertion and interpretation and management of subsequent problems. METHODS: Hepatic artery port placement was attempted in 129 patients for use with either SIRT and/or HAC. Ports were used or flushed at monthly intervals. RESULTS: Successful port insertion was achieved in 127 patients, of whom 87 received HAC alone, seven received SIRT alone, 28 patients received both and in five patients the port was never used. Methylene blue injection was used to identify anomalous arterial anatomy, which was found in 26 of 95 patients (27%), and significant extrahepatic 'access', which was seen in 25 patients (26%) after initial placement. Forty-six instances of technical problems preventing continued use of the port occurred in 43 patients after a median of 4 (0-36) cycles of chemotherapy, including hepatic artery thrombosis (n = 26), catheter blockage (n = 4), duodenal fistula (n = 3), gastrointestinal (GI) bleeding (n = 3), side-effects (n = 3), access problems (n = 3), extravasation (n = 3) and infection (n = 1). CONCLUSION: Methods used to identify, manage and in some instances prevent the occurrence of these problems are discussed.
Adult↗
Dendritic cell-based cancer immunotherapy: potential for treatment of colorectal cancer?
Human tumours including those of the gastrointestinal tract express a number of specific antigens that can be recognized by T cells, thus providing potential targets for cancer immunotherapy. Dendritic cells (DC) are rare leucocytes that are uniquely potent in their ability to capture, process and present antigens to T cells, and so selectively migrate through tissues to reach lymph nodes and spleen where initiation of immune responses takes place. Studies in murine tumour models have shown clearly that DC are capable of presenting tumour antigens to initiate tumour-specific cytotoxic T cell responses, and DC vaccination can induce anti-tumour activity against both primary tumours and pre-established tumour metastases. These findings together with the ability to culture sufficient numbers of DC from human bone marrow or blood progenitors have prompted the current major interest in their potential use in human tumour vaccination. Vaccine production involves harvesting autologous DC from cultured peripheral blood mononuclear cells in the presence of a cocktail of cytokines, ex vivo exposure of the DC to tumour antigens and return of pulsed DC to the patient to induce tumour immunity. Reports from Phase I/II clinical trials indicate that DC vaccines are safe with little or no side effect, and are capable of initiating antigen-specific T cell responses. Furthermore, defined tumour antigens are not necessarily required, which may make the process more applicable to human cancers, including many gastrointestinal cancers that lack well-characterized tumour-specific antigens. Additional trials of DC vaccination for a variety of human cancers including colorectal cancers are under way, and refinement of vaccine protocols and methods for targeting tumour antigens to DC in vivo are also being explored. There is reason to believe that DC-based vaccination could become an adjunct to current treatments for human cancers including colorectal cancer in the foreseeable future.
Clinical Trials as Topic↗
Improvement in co-morbidities following weight loss from gastric bypass surgery.
BACKGROUND: Clinical observation reveals a close association between morbid obesity and a variety of serious medical conditions. This report describes the changes observed in some of these co-morbid conditions, following weight loss achieved by silastic ring gastric bypass (SRGBP). METHODS: Between 1990 and 1998, 157 severely obese patients aged 15-62 years underwent SRGBP. Initial and follow-up data was recorded prospectively on a computerized database, with minor subsequent additions being achieved by phone call or questionnaire. Particular attention was given to associated co-morbidities and improvement in these that occurred during follow-up. Median pre-operative BMI was 45 (33-97). Patients were followed for a median 2.5 years. At 2 years post-SRGBP, median BMI was 28 (20-52). Weight loss was statistically significant (p<0.0001). RESULTS: Before surgery 42 patients were being treated for hypertension and 34 for asthma. Withdrawal of all medication for these conditions was achieved sometime after surgery in 18 and 17 patients respectively. NIDDM was present in 19 patients before surgery and subsequently resolved completely in 18. Eleven of the 12 patients with recognized obstructive sleep apnea before surgery had resolution of this after surgery. Dyslipidemia was present in the majority of patients before surgery and resolved or improved following surgery in almost all instances. CONCLUSIONS: The findings indicate that reliable and substantial weight loss can be accomplished by gastric bypass surgery with accompanying major reductions in associated co-morbidities. Such benefits suggest that greater attention should be given to this form of treatment for those with severe obesity.
Adolescent↗
Acalculous gallbladder pain: a largely unrecognised entity.
AIM: To study the presentation for and outcome of cholecystectomy in patients with acalculous gallbladder pain. METHODS: Sixty-six consecutive patients with prospective documentation underwent cholecystectomy for putative acalculous gallbladder pain between December 1988 to April 1995. The diagnosis was made on clinical grounds, but in the majority, a CCK oral cholecystogram was performed. Outcomes were assessed by postal questionnaire mailed in October 1995 or by the last recorded follow- up. RESULTS: Fifty-eight females and eight males, with a median age of 37.5 years had experienced abdominal pain, usually with associated nausea, for a median of three years. Preoperative investigations were non-contributory, with the exception of the CCK oral cholecystogram which was regarded as abnormal in all instances. At a median follow-up of 40 months, 48 patients (72.7%) described their symptoms as either totally relieved or much improved by cholecystectomy. CONCLUSION: Though the pathophysiology remains poorly understood, there is clearly a group of patients who suffer from gallbladder pain in the absence of gallstones and who benefit from cholecystectomy.
Adult↗
Hydatid disease in New Zealand. What remains and how should we treat it?
AIM: The incidence of hydatid disease in New Zealand has steadily declined since the introduction of control measures in the early 1960s. However, patients continue to present for management of newly recognised, disseminated or recurrent disease. It is desirable that doctors in New Zealand have some knowledge of current patterns of presentation and management of the disease. METHODS: Twenty-five patients with hydatid disease have been seen and managed over a ten-year period by one hepato-biliary surgeon. Their presentation and management is outlined and discussed. Surgery, after pre-treatment with albendazole, was undertaken in 15 patients where eradication seemed possible and desirable and in three others presenting with complications (infection, rupture, fistulation). Albendazole treatment alone was used in six patients (five with uncomplicated recurrent or disseminated disease) and one patient has simply been observed. RESULTS: There were no deaths in 18 patients who underwent surgery and no recurrent disease has been found. Major morbidity was confined to those having surgery for complications. All six patients who received albenzadole alone had a good clinical and radiological response, though they required follow-up. CONCLUSIONS: It is suggested that surgery (with albendazole pre-treatment) should be reserved for those with either curable disease or complications and that all others should be managed, in the first instance, by albendazole alone. Providing treatment is instituted before complications develop it should be associated with minimal morbidity.
Adult↗
Hepatic cryotherapy and subsequent hepatic arterial chemotherapy for colorectal metastases to the liver.
This paper presents an experience of thirty consecutive patients with hepatic colorectal metastases who were treated with hepatic cryotherapy and subsequent hepatic arterial infusion (HAI) chemotherapy using 5 FU. Patients with colorectal metastases confined to the liver but not suitable for resection, and with liver involvement of less than 50% were offered the treatment. Prospective documentation of all patients was undertaken with data being recorded on a computerised database. Patients had a median of 6 (2-15) lesions with sizes ranging from 1-12 cm. There was no 30 day mortality. Postoperative complications developed in 8 patients but were followed by full recovery in all instances. Side effects from chemotherapy occurred in 23% of cycles. Twenty seven patients have died. Median survival from the time of cryotherapy was 18.2 months (7-34), or 23 months (9-44) from diagnosis of liver lesions. Hepatic cryotherapy with subsequent arterial chemotherapy is safe and well tolerated. The results suggest survival of patients with colorectal hepatic metastases can be improved by the use of this modality of treatment.
Antimetabolites, Antineoplastic↗
Peritoneovenous shunting for malignant ascites.
AIM: Malignant ascites may produce a cluster of symptoms including abdominal distension, early satiety, respiratory embarrassment, impaired mobility and lethargy. Successful relief of these symptoms is often difficult to attain. We report on the use of peritoneovenous shunting in a group of patients with troublesome malignant ascites with particular reference to the effectiveness and complications of the procedure. METHODS: Twenty one Denver peritoneovenous shunts were placed in 19 patients with malignant ascites. The patients included 16 females and three males and had a median age of 54 years. All had previously been treated with vigorous diuretic therapy and/or repeated paracentesis. Shunt insertion was carried out under general anaesthetic in a manner similar to that described by others. RESULTS: The procedure was well tolerated by most patients. Median hospital stay was 6 days. One patient died 11 days after her surgery from what was thought to be an unrelated cause. Another patient suffered major problems after shunt insertion from exacerbation of pre-existing pleural effusions. All other complications were minor and self limiting. Two shunts failed to function within the first week. Excellent shunt function with resolution of ascite and of associated symptoms was seen in 16 patients. In five late shunt occlusion occurred with resulting reaccummulation of ascites but in four of these shunt function was able to be restored. Median survival in the 18 patients who survived the procedure was 5.5 months and in 14 of these the shunt was functioning at the time of death with good control of ascites. CONCLUSION: Malignant ascites can result in very troublesome symptoms for patients who may otherwise have some time to live. Peritoneovenous shunting is a well tolerated relatively minor surgical procedure which can achieve excellent control of ascites in the majority of such patients.
Adolescent↗
Silastic ring gastric bypass: results in 64 patients.
BACKGROUND: The silastic ring gastric bypass (SRGB) was introduced by Fobi in 1989, in an effort to combine the advantages of the Roux-en-Y gastric bypass with those of the vertical banded gastroplasty, while avoiding the disadvantages of each. METHODS: The results of our first 64 patients who underwent SRGB with a 5.5 cm ring have been reviewed with particular attention to weight loss, short- and medium-term morbidity and patient satisfaction. Most patients have had regular follow-up, and those not seen during the last 6 months were sent a postal questionnaire. RESULTS: The patients included 52 females and 12 males, ranging in age from 23 to 59 years (median age=39 years) at the time of surgery. Median preoperative weight, body mass index (BMI) and % excess weight were 126 kg (range 89-253 kg), 44 kg/m2 (range 36-78 kg/m2) and 113 (range 76-209) respectively. There were no serious postoperative complications and no deaths. Median hospital stay was 7 days (range 5-14 days). Eight patients (13%) are known to have had a staple-line dihiscence. Eighteen patients (28%) have had major difficulties with eating, and in nine (14%) of these the silastic ring has been removed with resolution of the eating problems, but some gain in weight. In the 54 patients with follow-up data at 2 years, median weight was 78 kg (range 55-137 kg), median BMI was 27 kg/m2 (range 20-43 kg/m2) and mean +/- SD % excess weight loss was 69+/-16. After 2 years of follow-up, eight of 54 patients (15%) were unhappy with the results of the procedure. CONCLUSION: SRGB is an effective, safe and well-tolerated procedure for achieving weight loss in the morbidly obese. The principal drawbacks relate to staple-line problems and eating difficulties related to the silastic ring. A 5.5 cm ring is probably too small to be ideal.
Adult↗
Silastic ring gastric bypass: a comparison of two ring sizes: a preliminary report.
BACKGROUND: The silastic ring (vertical) gastric bypass (SRGB) was introduced by Fobi in 1989, in an effort to combine the advantages of the Roux-en-Y gastric bypass with those of the VBG, while avoiding disadvantages of each. We remain unsure of the ideal ring size. METHODS: Sixty-four patients having SRGB between June 1990 and September 1994 had a 5.5 cm ring placed and 24 patients operated between October 1994 and September 1995 had a 6.0 cm ring placed. Weight loss and quality of eating data is compared 12 months after surgery. RESULTS: Median preoperative per cent excess weight was 113 (range 76-209) in the 5.5 cm group and 106 (range 79-196) in the 6.0 cm group. Weight loss was equivalent at 12 months, with median percent excess weight of 33 (range 8-109) and 27 (range 6-81) in the two groups respectively. Quality of eating data appears better in those with the larger ring size. Nine patients with a 5.5 cm ring have subsequently had their ring removed to improve their quality of eating and a further six may require this in the future. One patient with a 6.0 cm ring has had the ring removed and two others may require this be done. CONCLUSION: An SRGB with a 6.0 cm ring achieves equivalent weight loss to one with a 5.5 cm ring, but with better quality of eating, and less prospect of requiring ring removal. However, there remains a small proportion of patients in whom a 6.0 cm ring is poorly tolerated. For this reason a 6.5 cm ring should be tested.
Adult↗
Percutaneous biopsy of operable liver lesions: is it necessary or advisable?
AIM: The necessity and desirability of performing percutaneous biopsy of potentially resectable liver tumours is called into question. METHODS: Two cases are reported in which percutaneous biopsy of resectable liver tumours was performed unnecessarily and resulted in needle track seeding. RESULTS: In both instances patients who underwent potentially curative liver resection were rendered incurable because of biopsy track recurrence. CONCLUSION: The common practice of performing percutaneous ultrasound or CT guided biopsy of potentially resectable lesions in the liver is generally neither necessary nor desirable.
Adenocarcinoma↗
Computed tomographic portography in preoperative imaging of hepatic neoplasm.
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Adult↗
Instillation of scolicidal agents into hepatic hydatid cysts: can it any longer be justified?
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Adult↗
Inhibition of the stimulated canine exocrine pancreas by amino acids and fat.
To investigate the possible exocrine pancreatic inhibitory actions of amino acids and fat, pancreatic fistula outputs and plasma concentrations of glucagon, somatostatin, and pancreatic polypeptide were measured for response to intravenous (IV) and intraduodenal nutrient administration in six dogs submaximally stimulated with cholecystokinin. Intravenous amino acids caused abrupt and significant 45% to 73% reductions in stimulated pancreatic protein, bicarbonate, and volume outputs. There were no significant associated changes in plasma hormone concentrations and no similar immediate pancreatic inhibition with IV mannitol, thus suggesting a possible direct inhibitory effect of amino acids. Intraduodenal amino acids and IV fat evoked no significant pancreatic output suppression. Intraduodenal fat rapidly caused a significant 40% to 62% reductions in stimulated outputs that were associated with an 81% rise in plasma pancreatic polypeptide concentration, suggesting a gut-mediated inhibition. We conclude that IV amino acids and intraduodenal fat both inhibited stimulated pancreatic secretion but probably by different mechanisms.
Amino Acids↗
Papillary cystadenocarcinoma of the appendiceal stump with mucocele and peritoneal metastases.
A 54-year-old Polynesian male developed a mucocele of the appendiceal stump 25 years after appendicectomy. Scattered peritoneal deposits up to 0.4 cm in diameter were also identified at laparotomy, and these were confined to the right iliac fossa. The cyst was excised with a right hemicolectomy and histology showed a mucus-producing papillary cystadenocarcinoma arising in the unburied appendiceal stump. There was invasion of the cyst wall and the peritoneal nodules contained metastatic tumour acini. The patient is well 12 months after surgery. This is a case of a rare tumour arising uniquely in an appendiceal stump and producing a mucocele. The term mucocele is discussed and recommendations made for its usage in pathological diagnosis.
Appendectomy↗
Choledochal cyst: case reports and current concepts.
Choledochal cyst is an unusual but serious condition which most commonly affects Oriental people. Recent experience of three patients with this condition in whom diagnosis was made by ultrasound examination is reported. Cholangiography (ERCP or PTC) was performed in two of the cases to define the anatomy. All three cases were successfully managed by cyst excision and biliary reconstruction by Roux-en-Y hepaticojejunostomy. The rationale for and importance of cyst excision are discussed.
Adolescent↗
Single dose mezlocillin versus three dose cefuroxime plus metronidazole for the prophylaxis of wound infection after large bowel surgery.
A prospective, randomized, controlled trial was conducted in 116 consecutive patients undergoing colorectal surgery to compare single dose prophylaxis with mezlocillin to cefuroxime plus metronidazole in three doses. Patients were randomized to receive either a single dose of iv mezlocillin (5.0 g) or three doses of iv cefuroxime plus metronidazole at 8-hourly intervals. The first dose was given on the operating table. The overall wound infection rate in the mezlocillin treated patients (n = 54) was 30% and in the patients treated with cefuroxime plus metronidazole (n = 56) 25%. This difference is not statistically significant. When trivial wound infections were disregarded the wound infection rates were 11% and 16% respectively, which again was not statistically significant.
Adult↗