Impact of gut–brain interaction in emerging neurological disorders

The central nervous system(CNS)is a reservoir of immune privilege.Specialized immune glial cells are responsible for maintenance and defense against foreign invaders.The blood–brain barrier(BBB)prevents detrimental pathogens and potentially overreactive immune cells from entering the periphery.When the double-edged neuroinflammatory response is overloaded,it no longer has the protective function of promoting neuroregeneration.Notably,microbiota and its derivatives may emerge as pathogen-associated molecular patterns of brain pathology,causing microbiome–gut–brain axis dysregulation from the bottom-up.When dysbiosis of the gastrointestinal flora leads to subsequent alterations in BBB permeability,peripheral immune cells are recruited to the brain.This results in amplification of neuroinflammatory circuits in the brain,which eventually leads to specific neurological disorders.Aggressive treatment strategies for gastrointestinal disorders may protect against specific immune responses to gastrointestinal disorders,which can lead to potential protective effects in the CNS.Accordingly,this study investigated the mutual effects of microbiota and the gut–brain axis,which may provide targeting strategies for future disease treatment.

Premedication with pronase or N-acetylcysteine improves visibility during gastroendoscopy: An endoscopist-blinded, prospective, randomized study

AIM： To assess the efficacy of premedicaton with pronase or N-acetylcysteine （NAC） at 20 min before upper gastrointestinal （UGI） endoscopy and to determine whether pronase or NAC pretreatment influences the reliability of the rapid urease test. METHODS： A total of 146 patients were prospectively and randomly assigned into the study groups according to different premedications before endoscopy. One endoscopist assessed mucosal visibility （MV） with scores ranged from 1 to 4 at four sites in the stomach. The sum of the MV scores from these four locations was defined as the total mucosal visibility （TMV） score. Identification of Hpylori was performed using CLO test, histology, and serology. RESULTS： The Group with pronase premedication had a significantly lower TMV score than did the groups with gascon and gascon water （P 〈 0.001 and P 〈 0.01, respectively）. The group with NAC had a significantly lower TMV score than the group with gascon （P 〈 0.01） and a trend of a lower MV score than the group with gascon water （P = 0.06）. The THV score did not significantly differ between the group with pronase and the group with NAC （P = 0.39 and P = 0.14, respectively）. The sensitivity and specifidty of the CLO test were 92.5% and 93.9%, respectively, in groups premedicated with pronase and NAC together.CONCLUSION： Premedication with pronase or NAC at 20 min before UGI endoscopy improves the mucosal visibility of the stomach. Neither pronase nor NAC produces any obvious interference with the CLO test for the identification of H pylori infection.

Recent advances in bariatric/metabolic surgery:appraisal of clinical evidence

Obesity and associated type 2 diabetes mellitus（T2DM） are becoming a serious medical issue worldwide.Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients.Increasing data indicates bariatric surgery as metabolic surgery is an effective and novel therapy for not well controlled obese T2 DM patients.The review of recent developments in bariatric/metabolic surgery covers 4major fields.1） Improvement of safety：recent advances in laparoscopic/metabolic surgery has made this minimal invasive surgery more than ten times safer than a decade ago.The safety profile of laparoscopic/metabolic surgery is compatible with that of laparoscopic cholecystectomy now.2） New bariatric/metabolic surgery：laparoscopic sleeve gastrectomy（LSG） is becoming the leading bariatric surgery because of its simplicity and efficacy.Other new procedures,such as gastric plication,banded plication,single anastomosis（mini） gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for bariatric/metabolic surgery.3）Mechanism of bariatric/metabolic surgery：Restriction is the most important mechanism for bariatric surgery.Weight regain after bariatric surgery is usually associated with loss of restriction.Recent studies demonstrated that gut hormone,microbiota and bile acid changes after bariatric surgery may play an important role in durable weight loss as well as in T2 DM remission.However,weight loss is still the cornerstone of T2 DM remission after metabolic surgery.4） Patient selection：patients who may benefit most from bariatric surgery was found to be patients with insulin resistance.For Asian T2 DM patients,the indication of metabolic surgery has been set to those with not well2controlled（Hb A1 c.7.5%） disease and with their BMI.27.5 Kg/m.A novel diabetes surgical score,ABCD score,is a simple system for predicting the success of surgical therapy for T2 DM.

Gastrointestinal metabolic surgery for the treatment of type 2 diabetes mellitus

Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has emerged as a cost-effective strategy for obese diabetic individuals; it has low complication rates and results in durable weight loss, glycemic control and improvements in the quality of life, obesity-related co-morbidity and overall survival. The finding that glucose homeostasis can be achieved with a weight loss-independent mechanism immediately after bariatric surgery, especially gastric bypass, has led to the paradigm of metabolic surgery. However, the primary focus of metabolic surgery is the alteration of the physio-anatomy of the gastrointestinal tract to achieve glycemic control, metabolic control and cardio-metabolic risk reduction. To date, metabolic surgery is still not well defined, as it is used most frequently for less obese patients with poorly controlled diabetes. The mechanism of glycemic control is still incompletely understood. Published research findings on metabolic surgery are promising, but many aspects still need to be defined. This paper examines the proposed mechanism of diabetes remission, the efficacy of different types of metabolic procedures, the durability of glucose control, and the risks and complications associated with this procedure. We propose a tailored approach for the selection of the ideal metabolic procedure for different groups of patients, considering the indications and prognostic factors for diabetes remission.

Do different bariatric surgical procedures influence plasma levels of matrix metalloproteinase-2,-7,and-9 among patients with type 2 diabetes mellitus?

BACKGROUND Bariatric surgery is an efficient strategy for body weight and type 2 diabetes mellitus(T2 DM) management. Abnormal lipid deposition in visceral organs,especially the pancreas and liver, might cause beta-cell dysfunction and insulin resistance. Extracellular matrix(ECM) remodeling allows adipose expansion, and matrix metalloproteinases(MMPs) play essential roles in ECM construction.MMP-2 and MMP-9 are the substrates of MMP-7. Different studies have reported that MMP-2,-7, and-9 increase in patients with obesity and metabolic syndromes or T2 DM and are considered biomarkers in obesity and hyperglycemia patients.AIMTo prospectively investigate whether MMP-2, MMP-7, and MMP-9 differ after two bariatric surgeries: Gastric bypass(GB) and sleeve gastrectomy(SG).METHODS We performed GB in 23 and SG in 19 obese patients with T2 DM. We measured body weight, waist circumference, body mass index(BMI), and serum concentrations of total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fasting blood sugar(FBS),hemoglobin A1 c(Hb A1 c), C-peptide, homeostasis model assessments of insulin resistance, and MMP-2, MMP-7, and MMP-9 levels at baseline and at 3, 12, and 24 mo post-operation.RESULTS Twenty-three patients aged 44.7 ± 9.7 years underwent GB, and 19 patients aged40.1 ± 9.1 years underwent SG. In the GB group, BMI decreased from 30.3 ± 3.4 to24.4 ± 2.4 kg/m2, Hb A1 c decreased from 9.2% ± 1.5% to 6.7% ± 1.4%, and FBS decreased from 171.6 ± 65.0 mg/d L to 117.7 ± 37.5 mg/d L 2 years post-operation(P < 0.001). However, the MMP-2, MMP-7, and MMP-9 levels pre-and post-GB were similar even 2 years post-operation(P = 0.107, 0.258, and 0.466,respectively). The SG group revealed similar results: BMI decreased from 36.2 ±5.1 to 26.9 ± 4.7 kg/m2, Hb A1 c decreased from 7.9% ± 1.7% to 5.8% ± 0.6%, and FBS decreased from 138.3 ± 55.6 mg/d L to 95.1 ± 3.1 mg/d L(P < 0.001). The serum MMP-2,-7, and-9 levels pre-and post-SG were not different(P = 0.083,0.869, and 0.1, respectively).CONCLUSION Improvements in obesity and T2 DM induced by bariatric surgery might be the result of MMP-2,-7, or-9 independent pathways.

The Association between Surgery Laterality in Orthopedists and the Choices of Prostheses in Total Knee and Hip Replacement

Background: Most orthopedists are right-handed. However, osteoarthritis occurs with equal frequency over both sides. Does perfect and effective arthroplasty surgery require ambidextrous motor skills? Objectives: In this study, we aimed to investigate the clinical features of arthroplasty for hip and knee joints (THR and TKR) on different sides affected by orthopedist laterality. Patients and Methods: All right-handed orthopedists performed 64 right and 52 left primary THR among 100 patients, and 115 right and 118 left primary TKR among 192 patients. Clinical and surgical features were retrospectively reviewed and analyzed. The body mass index (BMI), inner diameter of acetabular cup liners (ACD), diameter of the femoral head (FHD), diameter of the femoral stem (FSD), and the femoral neck length (FNL) were included in THR-receiving patients. The BMI, femoral component (FC) size, tibial plate (TP) size, and thickness of articular surface inserts (ASI) were included in TKR-receiving patients. Results: No significant differences were observed in ACD, FHD and FSD between patients receiving right and left THR groups (p = 0.16, 0.11, and 0.05, respectively). Similarly, there were no significant differences in FC, TP, and ASI between patients receiving right and left TKR groups (p = 0.06, 0.80, and 0.46, respectively). However, FNL in left THR group was significantly longer than that in right THR group (p = 0.01). Conclusion: This study showed that dexterity or proprioception in handedness had no affect on bone resection and thicknesses of the polyethylene in TKR and acetabular reaming and femoral canal rasping in THR. However, it did lead to differences in femoral neck resection. Right-handed orthopedists significantly tend to perform excessive femoral neck cutting or prefer the larger size of FNL when performing left side THR, while no differences occur when performing TKR.

Minimally Invasive Open Reduction and Internal Fixation for Osteoporotic Vertebral Compression Fractures: Technical Report and Mid-Term Outcomes

Background: Traditional open instrumentation may cause surgical complications due to fragile bones and induce medical comorbidities in senile patients. Vertebroplasty and kyphoplasty are palliative augmentation procedures that have been associated with increased risks of cement leakage, adjacent fractures and non-union. Objective: The aim of this study was to describe a novel approach for the union of osteoporotic vertebral compression fractures with minimally invasive open reduction and internal fixation. Patients and Methods: Seven consecutive patients with intractable back pain without neurological deficits due to osteoporotic vertebral compression fractures were treated using minimally invasive fixation with intra-vertebral expandable pillars and artificial bone substitute. The clinical symptoms and image findings were recorded. Results: All of the patients reported relief of back pain, and the height of the vertebral bodies was well restored. X-ray findings obtained 2 to 4 years after the procedures showed fracture healing and favorable formation of the callus confirmed in the anterior longitudinal ligament. Conclusion: This mini-open procedure with intravertebral devices is an effective and reliable technique for osteoporotic vertebral compression fractures and may avoid complications related to traditional open spinal instrumentation procedures and augmentation with bone cement.

Impairment of gastrointestinal quality of life in severely obese patients

AIM: To investigate the common gastro-intestinal symptoms and quality of life in severely obese subjects.

Direct medical cost of radiation therapy for cancer patients in Taiwan

Background and purpose: The rising cost of health care is of concern worldwide, in particular, for cancer care. The costs of treatment, including chemotherapeutic drugs and radiotherapy, are no exceptions. The purpose of this study is to explore the direct medical cost of radiotherapy and the annual increasing trend of expenditures in Taiwan. Methods: This study utilized data retrieving from the original claim data of the reimbursement of the Health Insurance Research Database (HIRD) derived from Taiwan’s Health Insurance (HI) program. Detailed data on the direct medical cost within the radiotherapy process for beneficences were extracted from inpatient expenditures by admissions (DD) and ambulatory care expenditures by visits (CD) database according to the reimbursed expenditure code of radiotherapy from January 1, 2000 to December 31, 2005. Prescriptions for radiotherapy were retrieved and the direct medical costs for radiotherapy were collected based on the NHI reimbursement price list of 2005. The annual increasing trend of expenditures was also explored according to the perspective of Bureau Health Insurance of Taiwan. Results: The total direct medical costs of radiotherapy for cancer patients were increasing from 2000 to 2005, which were estimated to US $7.80 million, US $8.09 million, US $7.58 million, US $10.7 million, US $12.2 million and US $15.9 million in 2000, 2001, 2002, 2003, 2004 and 2005, respectively. The increased percentage corresponded to the total healthcare expenditures claimed was increased substantially from 0.82% in 2000 to 1.22% in 2005. The total direct medical costs within the radiotherapy process were also increased gradually if identified by different types of radiotherapy and teaching hospital levels. The direct medical costs attribute to radiotherapy, compared to total health care expenditures in Taiwan, were similar to the costs of anticancer drugs for cancer patients annually. Conclusions: The direct medical costs of radiation therapy increased substantially each year. Further cost analysis on radiation therapy is needed in years beyond 2005.

Modeling the impact of surveillance activities combined with physical distancing interventions on COVID-19 epidemics at a local level

Physical distancing and contact tracing are two key components in controlling the COVID-19 epidemics.Understanding their interaction at local level is important for policymakers.We propose a flexible modeling framework to assess the effect of combining contact tracing with different physical distancing strategies.Using scenario tree analyses,we compute the probability of COVID-19 detection using passive surveillance,with and without contact tracing,in metropolitan Barcelona.The estimates of detection probability and the frequency of daily social contacts are fitted into an age-structured susceptible-exposed-infectious-recovered compartmental model to simulate the epidemics considering different physical distancing scenarios over a period of 26 weeks.With the original Wuhan strain,the probability of detecting an infected individual without implementing physical distancing would have been 0.465,0.515,0.617,and 0.665 in designated age groups(0e14,15e49,50e64,and>65),respectively.As the physical distancing measures were reinforced and the disease circulation decreased,the interaction between the two interventions resulted in a reduction of the detection probabilities;however,despite this reduction,active contact tracing and isolation remained an effective supplement to physical distancing.If we relied solely on passive surveillance for diagnosing COVID-19,the model required a minimal 50%(95%credible interval,39e69%)reduction of daily social contacts to keep the infected population under 5%,as compared to the 36%(95%credible interval,22e56%)reduction with contact tracing systems.The simulation with the B.1.1.7 and B.1.167.2 strains shows similar results.Our simulations showed that a functioning contact tracing program would reduce the need for physical distancing and mitigate the COVID-19 epidemics.