Leiomyoma an uncommon benign esophageal tumor

Leiomyoma are rare esophageal masses. Majority remain asymptomatic but may present with dysphagia when more than five centimeters in size. Barium swallow is the initial diagnostic investigation. Small lesion can be observed. Symptomatic and large lesion should undergo prompt surgical enucleation. Here we presented a case of a 35 year old female presenting with progressive dysphagia and gradual weight loss for 5 years along with regurgitation for one year. Clinical examination was unremarkable. Barium study was suggestive of smooth intramural defect with normal mucosa. Computed tomography showed well defined homogenous opacity located intramuraly at the level of junction of middle and distal third of esophagus with normal surrounding structures. Surgical enucleation was done through a right posterolateral thoracotomy. Muscle defect was repaired and checked for possible leaks. Liquid diet was commenced on 5th postoperative day. Patient was discharged on semisolid diet for two weeks with progression to solid meal.

Adaptation of a Community-based Type-2 Diabetes Mellitus Remission Intervention During COVID-19: Empowering Persons Living With Diabetes to Take Control

Background: The Barbados Diabetes Remission Study-2 reported that a community-based low-calorie diet (LCD) for weight loss and diabetes remission was both an acceptable implementation strategy and a clinically effective intervention. This study aimed to examine the adaptability of the face-to-face BDRS-2 protocol into an online modality.Methods: The Iterative Decision‐making for Evaluation of Adaptations framework questions the necessity of the adaptation and the preservation of core elements of the intervention during the adaptation process – these elements were identified as the 12-week intervention duration, weekly monitoring of participants for change in weight and fasting blood glucose and daily 840kcal allowance. The adaptation outcomes were documented using the framework for reporting adaptations and modifications to evidence-based interventions. Implementation effectiveness was determined by fidelity to core intervention elements. Intervention effectiveness was determined from the analysis of clinical data.Results: We decided that an adaptation was needed as the COVID-19 measures to control transmission prohibited in-person interactions, and that key elements of the intervention could be preserved during the adaptation process. Adaptations were made to the following: (1) The context in which the data was collected: participants self-measured at home instead of being measured by community health advocates (CHA) at a community site. (2) The context in which the data was entered: participants first posted their measurements to a mobile application site which was accessible by the CHAs. As with the original protocol, CHAs then entered the measurements into an online database. (3) The formulation of the LCD: participants substituted the liquid formulation for a solid meal plan of equivalent caloric content. There was increased fidelity to the attendance schedule with the online format (1 incomplete entry out of 45 entries), as compared to the face-to-face modality (1 absence out of 20 visits). Regarding the solid meal plan, 1 participant logged difficultly averaging non-exact potion sizes. Weight change ranged from -14.3kgs to 0.4kgs over the 12-week period and all group members achieved induction of diabetes remission. Conclusion: Larger studies are needed to confirm that this adapted online protocol is both acceptable and clinically effective while maintaining fidelity to key elements of the original protocol.Trial Registration: NCT03536377 registered 24th May 2018 at https://clinicaltrials.gov/ct2/show/NCT03536377

Treatment Modalities and the Role of Endoscopy for Delayed Gastric Emptying After Whipple Operation: Analysis of 53 Patients

Background Delayed gastric emptying (DGE) is one of the most common complications after Whipple surgery. This situation delays postoperative oral food intake and prolongs hospitalization. Postoperative DGE often develops due to complications such as intra-abdominal abscess, collections, and anastomosis leaks, and these are called secondary DGE. The pathogenesis of primary DGE is still unknown, and there are insufficient data in the literature about the treatment. In this study, patients undergoing Whipple operation were examined separately as primary and secondary DGE. We discussed the causes and treatments of these patients, and also we aimed to present the therapeutic effect of endoscopy for primary DGE after the Whipple procedure. Methods From March 2014 to March 2018, data of 262 patients who underwent the Whipple procedure were collected prospectively. We observed that postoperative DGE developed in 53 (21.7%) patients. We retrospectively divided the patients by etiology into 2 groups as primary and secondary and graded DGE according to the International Study Group of Pancreatic Surgery. We defined patients who did not have secondary causes such as intra-abdominal abscess as primary DGE. Appropriate interventional procedures were performed for patients with secondary causes. We performed endoscopic intervention with therapeutic intent for patients who had primary DGE. Results The overall rate of DGE was 21.7% (n = 53) among 262 patients undergoing the Whipple procedure. It was observed that in 31 (58.5%) of these 53 patients, DGE was developed due to secondary causes. Interventional procedures were performed to these patients when necessary. A total of 22 (41.5%) patients developed primary DGE. Of these, 9 patients were grade A, 7 were grade B, and 6 were grade C. The mean duration of hospitalization for secondary DGE and primary DGE was 20.36 and 28.7 days, respectively. After endoscopic intervention with therapeutic intent to primary DGE patients, we observed that patients tolerated solid meal after 12 hours in grade B and after 26 hours in grade C patients. Conclusion Delayed gastric emptying, which is a common complication after Whipple operation and which deteriorates the quality of life and prolongs the duration of hospital stay, should be treated according to the cause. In secondary DGE, treatment modalities must be focused on intra-abdominal causes such as hematoma, collection, and abcess. We suggest that the primary DGE which is unresponsive to medical treatments could be treated endoscopically. After endoscopic intervention, patients with primary DGE can be started oral intake on the same day and discharged more quickly.

Changes in Ghrelin and Glucagon following a Low Glycemic Load Diet in Women with PCOS

Context Altered satiety hormones in women with polycystic ovarian syndrome (PCOS) may contribute to obesity. Diets with a low glycemic load (GL) may influence appetite-regulating hormones including glucagon and ghrelin. Objective To test the hypothesis that following a 4-week, eucaloric low vs high GL diet habituation, a low vs high GL meal will increase glucagon and decrease ghrelin to reflect greater satiety and improve self-reported fullness. Methods Secondary analysis of a randomized crossover trial. Participants Thirty women diagnosed with PCOS. Intervention Participants were provided low (41:19:40% energy from carbohydrate:protein:fat) and high (55:18:27) GL diets for 8 weeks each. At each diet midpoint, a solid meal test was administered to examine postprandial ghrelin, glucagon, glucose, insulin, and self-reported appetite scores. Results After 4 weeks, fasting glucagon was greater with the low vs high GL diet (P = .035), and higher fasting glucagon was associated with lesser feelings of hunger (P = .009). Significant diet effects indicate 4-hour glucagon was higher (P < .001) and ghrelin was lower (P = .009) after the low vs high GL meal. A trending time × diet interaction (P = .077) indicates feelings of fullness were greater in the early postprandial phase after the high GL meal, but no differences were observed the late postprandial phase. Conclusion These findings suggest after low GL diet habituation, a low GL meal reduces ghrelin and increases glucagon in women with PCOS. Further research is needed to determine the influence of diet composition on ad libitum intake in women with PCOS.

TRANSCUTANEOUS MULTICHANNEL ELECTROGASTROGRAPHY: NORMAL PARAMETERS IN A BRAZILIAN POPULATION

ABSTRACT BACKGROUND: Electrogastrography (EGG) is a noninvasive technique for the assessment of gastric myoelectrical activity using electrodes placed on the abdominal surface. Changes in gastric myoelectrical activity may be associated with diseases such as gastroparesis, functional dyspepsia, nausea, and recurrent vomiting. In Brazil, no studies to date have assessed gastric myoelectrical activity using multichannel EGG in healthy individuals. OBJECTIVE: To establish normal values of transcutaneous multichannel EGG in healthy Brazilian individuals. METHODS: This was a prospective study including 20 healthy individuals who underwent EGG. Recording was performed during two periods: a preprandial recording was performed for 30 minutes, and a postprandial recording was performed for 30 minutes after a soft-solid meal of 400 kcal (20 grams of proteins, 60 grams of carbohydrates, and 9 grams of fat). RESULTS: We assessed dominant frequency (DF) parameters, %DF distribution, the instability coefficient, and the power ratio (PR). A total of 20 individuals (11 women and 9 men) with a mean age of 39.5±7.4 years were included. Mean DF (95%CI) ranged from 2.4 to 3.1 cpm in the resting phase and 2.6 to 3.2 cpm in the postprandial period. The %DF in normogastria range was >70% in all healthy individuals. We identified that only one individual did not present a positive response to the test meal, and the other 19 individuals showed a PR greater than 1. The instability coefficient did not change significantly with meal intake. CONCLUSION: Multichannel EGG may be applied in future studies to evaluate gastric motility disorders in the Brazilian population.

Acceleration of Gastric Emptying by Insulin-Induced Hypoglycemia is Dependent on the Degree of Hypoglycemia

Context Hypoglycemia is a major barrier to optimal glycemic control in insulin-treated diabetes. Recent guidelines from the American Diabetes Association have subcategorized “non-severe” hypoglycemia into level 1 (<3.9 mmol/L) and 2 (<3 mmol/L) hypoglycemia. Gastric emptying of carbohydrate is a major determinant of postprandial glycemia but its role in hypoglycemia counter-regulation remains underappreciated. “Marked” hypoglycemia (~2.6 mmol/L) accelerates gastric emptying and increases carbohydrate absorption in health and type 1 diabetes, but the impact of “mild” hypoglycemia (3.0-3.9 mmol/L) is unknown. Objective To determine the effects of 2 levels of hypoglycemia, 2.6 mmol/L (“marked”) and 3.6 mmol/L (“mild”), on gastric emptying in health. Design, Setting, and Subjects Fourteen healthy male participants (mean age: 32.9 ± 8.3 years; body mass index: 24.5 ± 3.4 kg/m2) from the general community underwent measurement of gastric emptying of a radiolabeled solid meal (100 g beef) by scintigraphy over 120 minutes on 3 separate occasions, while blood glucose was maintained at either ~2.6 mmol/L, ~3.6 mmol/L, or ~6 mmol/L in random order from 15 minutes before until 60 minutes after meal ingestion using glucose-insulin clamp. Blood glucose was then maintained at 6 mmol/L from 60 to 120 minutes on all days. Results Gastric emptying was accelerated during both mild (P = 0.011) and marked (P = 0.001) hypoglycemia when compared to euglycemia, and was more rapid during marked compared with mild hypoglycemia (P = 0.008). Hypoglycemia-induced gastric emptying acceleration during mild (r = 0.57, P = 0.030) and marked (r = 0.76, P = 0.0014) hypoglycemia was related to gastric emptying during euglycemia. Conclusion In health, acceleration of gastric emptying by insulin-induced hypoglycemia is dependent on the degree of hypoglycemia and baseline rate of emptying.

A Comparison of Intermittent and Continuous Exercise Bouts at Different Intensities on Appetite and Postprandial Metabolic Responses in Healthy Men

Exercise intensity affects many potential postprandial responses, but there is limited information on the influence of exercise modality. Therefore, the aim of this study was to investigate if the nature of exercise at two different intensities would affect gastric emptying rate (GER), appetite and metabolic responses following ingestion of a semi-solid meal. Twelve healthy men completed, in a random order, four 60-min cycles at 60% VO2peak (MOD), 40% VO2peak (LOW) and in a continuous (CON) or intermittent (INT) manner. INT consisted of 20 × 1-min exercise bouts with 2-min rest breaks. INT and CON were matched for total work output at each intensity. GER of the post-exercise meal was measured for 2 h using the 13C-breath method. Blood glucose, substrate utilisation and appetite ratings were measured at regular intervals throughout all trials and 24-h energy intake (EI) post-trials was assessed. GER-Delta over Baseline (DOB) was lower (p < 0.05) on MOD-INT vs. MOD-CON from 30–120 min post-meal. Blood glucose was higher mid-exercise (p < 0.05) on MOD-INT vs. MOD-CON. Although post-exercise LOW-CON was significantly higher than LOW-INT (p < 0.05), blood glucose was also higher 30-min post-meal ingestion on both CON trials compared to INT (p < 0.001). No interaction effect was observed for perceived appetite responses 2 h after meal ingestion (all p > 0.05). 24-h post-trial EI was similar between LOW-CON vs. LOW-INT (p > 0.05), although MOD-INT vs. MOD-CON 3500 ± 1419 vs. 2556 ± 989 kCal: p < 0.001 was elevated. In summary, MOD-INT exercise delays GER without stimulating perceived appetite in the 2 h period after meal ingestion, although EI was greater in the 24-h post-trial.

Trimebutine Maleate Monotherapy for Functional Dyspepsia: A Multicenter, Randomized, Double-Blind Placebo Controlled Prospective Trial

Background and Objectives: Functional dyspepsia (FD) is one of the most common functional gastrointestinal disorders; it has a great impact on patient quality of life and is difficult to treat satisfactorily. This study evaluates the efficacy and safety of trimebutine maleate (TM) in patients with FD. Materials and Methods: A multicenter, randomized, double-blind, placebo controlled, prospective study was conducted, including 211 patients with FD. Participants were randomized to receive TM 300 mg twice per day (BID, 108 patients) or placebo BID (103 patients) for 4 weeks. The Glasgow Dyspepsia Severity Score (GDSS) was used to evaluate the relief of dyspepsia symptoms. Moreover, as a pilot secondary endpoint, a substudy (eight participants on TM and eight on placebo) was conducted in to evaluate gastric emptying (GE), estimated using a 99mTc-Tin Colloid Semi Solid Meal Scintigraphy test. Results: Of the 211 patients enrolled, 185 (87.7%) (97 (52.4%) in the TM group and 88 (47.6%) in the placebo group) completed the study and were analyzed. The groups did not differ in their demographic and medical history data. Regarding symptom relief, being the primary endpoint, a statistically significant reduction in GDSS for the TM group was revealed between the first (2-week) and final (4-week) visit (p-value = 0.02). The 99 mTc-Tin Colloid Semi Solid Meal Scintigraphy testing showed that TM significantly accelerated GE obtained at 50 min (median emptying 75.5% in the TM group vs. 66.6% in the placebo group, p = 0.036). Adverse effects of low to moderate severity were reported in 12.3% of the patients on TM. Conclusion: TM monotherapy appears to be an effective and safe approach to treating FD, although the findings presented here warrant further confirmation.

Hypothesis on the glucose production’s communication model between thebrain and other internal organs, especially the stomach and liver

After reviewing the research results for six months, from September 2019 through February 2020, the author identified a probable internal communication model between the nervous system and certain vital internal organs, specifically the stomach and liver regarding postprandial plasma glucose (PPG) production. The author used a continuous glucose monitor device to collect 50,000 glucose data during the past 665 days. He focused on studying the relationships among different food nutritional contents, cooking methods, food material’s physical phases, and different characteristics and variants from his glucose waveform patterns. In this study, he focused on the three major meal groups based on food nutritional ingredients, meal’s preparation, and cooking methods of eggs, squash, and cabbage to create soup-based (liquid) meal and pan-fried (solid) meal. The PPG waveforms from these three meal groups demonstrated that soup-based liquid food produced a much lower glucose value than the pan-fried solid food. Although both liquid and solid meals have similar identical nutritional ingredients, he questions why did this occur? His hypothesis is that his PPG differences are due to specific physical phase of his finished meal either “liquid” or “solid”, which is his ready-to-eat meal’s final physical “phase” that determines his PPG characteristics and waveforms. The author utilized his GH-Method: math-physical medicine (MPM) approach to explore a T2D patient’s glucose production situation from a scientific view of the brain and nervous system’s functionalities. If this specific approach and above interpretation are accurate, we can then “trick” our brain into producing a “lesser” amount of glucose after food intake without altering or sacrificing the needed food nutritional balance. As a result, T2D patients can simply change their cooking method in order to lower both of their peak PPG values and their average PPG levels.