Hypoglycaemia following upper gastrointestinal surgery: case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Hyperinsulinemic hypoglycemia is relatively recently recognized in persons undergoing bariatric surgery although knowledge and experience with this condition may not be commensurate with the number of such procedures being performed globally. This paper presents a novel case as an example of how such patients may present and how they may be investigated.</p> <p>Case Presentation</p> <p>A 69-year-old man was assessed 3 months post-fundoplication surgery for postprandial hypoglycaemia with neuroglycopenia that became progressively severe. A 72-h fast failed to show hypoglycaemia. During a clinic visit, the patient became confused and had a low plasma glucose, high plasma insulin, and high plasma C-peptide; symptoms were relieved with glucose. No tumours were visualized on CT, MRI, or endoscopic ultrasound. A total body Indium111-octreotide scan was negative. Selective arterial calcium stimulation showed a high insulin gradient in the splenic and superior mesenteric arteries, suggesting diffuse pancreatic beta cell hyperplasia. The patient declined pancreatic resection and recurrent symptomatic hypoglycaemia was successfully prevented with low dose octreotide.</p> <p>Conclusions</p> <p>Although increasingly recognized following bariatric surgery, this is the first reported development of NIPHS (non-insulinoma pancreatogenous hypoglycemia syndrome) following fundoplication surgery, as well as the first documented use of octreotide in post-operative NIPHS. Medical management may be an alternative to surgery for patients with this rare condition.</p

Cell block technique as a complementary method in the clinical diagnosis of cyst-like lesions of the jaw

OBJECTIVE: To evaluate the applicability of the cell block technique as a complementary method for presumptive diagnosis in the analysis of cyst-like aspirates from jaw lesions prior to histopathological diagnosis. MATERIAL AND METHODS: The sample was made up of 17 cyst-like jaw lesions. After puncture, the aspirates were centrifuged, fixed in formalin, embedded in paraffin and processed. All lesions were biopsied and submitted to histopathological examination. RESULTS: In 9 cases, the cytopathological analysis using the cell block method showed a predominant presence of erythrocytes, inflammatory cells and few epithelial cells. In the other 8 cases, the cell block technique demonstrated the presence of parakeratin, whose histopathological analysis confirmed the occurrence of keratocystic odontogenic tumors (KOTs). CONCLUSIONS: According to the studied cases, the cell block method was proven to be a simple, fast and low-cost technique to effectively differentiate KOTs from other lesions with similar clinical and radiographic features. The cell block technique comprises cellular preparations useful to determine a clinical diagnosis and help to develop a therapeutic plan for those lesions

Using routinely collected laboratory and health administrative data to assess influenza vaccine effectiveness: introducing the Flu and Other Respiratory Viruses Research (FOREVER) Cohort

Introduction Annual evaluation of influenza vaccine effectiveness (VE) is required because of frequent changes to circulating and vaccine strains. Traditionally, VE studies enroll patients who fulfill case definitions for respiratory infections and are tested for influenza. VE estimates generated from convenience samples of routinely collected specimens might be biased. Objectives and Approach We assessed the validity of using data from respiratory specimens collected during clinical encounters to estimate VE. We created the Flu and Other Respiratory Viruses Research (FOREVER) Cohort by linking respiratory virus laboratory test results from 2009-2014 from 11 public health and 8 hospital laboratories across Ontario to health administrative databases, including databases with billing claims for physician- and pharmacist-administered influenza vaccines. We evaluated the presence of information and selection biases when using these data and estimated VE in community-dwelling older adults (>65) using the test-negative design under conditions that emulated the inclusion criteria in traditional VE studies. Results The FOREVER Cohort included test results from 283,711 respiratory specimens obtained from 216,730 individuals. The overall linkage proportion to health administrative databases using deterministic and probabilistic linkage methods was 97.5%. Influenza positivity for older adults with unknown lag between illness onset and specimen collection was similar to those for whom illness onset date was documented to be ≤7 days before specimen collection, suggesting minimal outcome misclassification associated with information bias. The likelihood of influenza testing was similar between vaccinated and unvaccinated individuals, suggesting an absence of selection bias that could arise when a case definition for influenza testing is not employed. Lastly, VE estimates were similar under various conditions, demonstrating the robustness of using these data, and were comparable to published estimates. Conclusion/Implications The FOREVER Cohort can be used to estimate VE with negligible bias. Compared to traditional VE studies that are limited to recruited patients, routinely collected specimens create a larger, more generalizable sample. Linkage to health administrative databases can identify those with comorbidities and permit evaluation of VE in high-risk groups

Glycosyl-phosphatidylinositol (GPI)-anchored membrane association of the porcine reproductive and respiratory syndrome virus GP4 glycoprotein and its co-localization with CD163 in lipid rafts

The porcine reproductive and respiratory syndrome virus (PRRSV) glycoprotein 4 (GP4) resembles a typical type I membrane protein in its structure but lacks a hydrophilic tail at the C-terminus, suggesting that GP4 may be a lipid-anchored membrane protein. Using the human decay-accelerating factor (DAF; CD55), a known glycosyl-phosphatidylinositol (GPI) lipid-anchored protein, chimeric constructs were made to substitute the GPI-anchor domain of DAF with the putative lipid-anchor domain of GP4, and their membrane association and lipase cleavage were determined in cells. The DAF-GP4 fusion protein was transported to the plasma membrane and was cleaved by phosphatidylinositol-specific phospholipase C (PI-PLC), indicating that the C-terminal domain of GP4 functions as a GPI anchor. Mutational studies for residues adjacent to the GPI modification site and characterization of respective mutant viruses generated from infectious cDNA clones show that the ability of GP4 for membrane association corresponded to virus viability and growth characteristics. The residues T158 (ω−2, where ω is the GPI moiety at E160), P159 (ω−1), and M162 (ω+2) of GP4 were determined to be important for virus replication, with M162 being of particular importance for virus infectivity. The complete removal of the peptide–anchor domain in GP4 resulted in a complete loss of virus infectivity. The depletion of cholesterol from the plasma membrane of cells reduced the virus production, suggesting a role of lipid rafts in PRRSV infection. Remarkably, GP4 was found to colocalize with CD163 in the lipid rafts on the plasma membrane. Since CD163 has been reported as a cellular receptor for PRRSV and GP4 has been shown to interact with this receptor, our data implicates an important role of lipid rafts during entry of the virus