Fat malabsorption in pancreatic cancer: Pathophysiology and management

Exocrine pancreatic insufficiency (EPI) is common in pancreatic ductal adenocarcinoma (PDAC) and may lead to significant nutrition compromise. In the setting of cancer cachexia and gastrointestinal toxicities of cancer treatments, untreated (or undertreated) EPI exacerbates weight loss, sarcopenia, micronutrient deficiencies, and malnutrition. Together, these complications contribute to poor tolerance of oncologic therapies and negatively impact survival. Treatment of EPI in PDAC involves the addition of pancreatic enzyme replacement therapy, with titration to improve gastrointestinal symptoms. Medical nutrition therapies may also be applicable and may include fat-soluble vitamin replacement, medium-chain triglycerides, and, in some cases, enteral nutrition. Optimizing nutrition status is an important adjunct treatment approach to improve quality of life and may also improve overall survival.

Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

ABSTRACT

There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.

Relationships between Habitual Polyphenol Consumption and Gut Microbiota in the INCLD Health Cohort

While polyphenol consumption is often associated with an increased abundance of beneficial microbes and decreased opportunistic pathogens, these relationships are not completely described for polyphenols consumed via habitual diet, including culinary herb and spice consumption. This analysis of the International Cohort on Lifestyle Determinants of Health (INCLD Health) cohort uses a dietary questionnaire and 16s microbiome data to examine relationships between habitual polyphenol consumption and gut microbiota in healthy adults (n = 96). In this exploratory analysis, microbial taxa, but not diversity measures, differed by levels of dietary polyphenol consumption. Taxa identified as exploratory biomarkers of daily polyphenol consumption (mg/day) included Lactobacillus, Bacteroides, Enterococcus, Eubacterium ventriosum group, Ruminococcus torques group, and Sutterella. Taxa identified as exploratory biomarkers of the frequency of polyphenol-weighted herb and spice use included Lachnospiraceae UCG-001, Lachnospiraceae UCG-004, Methanobrevibacter, Lachnoclostridium, and Lachnotalea. Several of the differentiating taxa carry out activities important for human health, although out of these taxa, those with previously described pro-inflammatory qualities in certain contexts displayed inverse relationships with polyphenol consumption. Our results suggest that higher quantities of habitual polyphenol consumption may support an intestinal environment where opportunistic and pro-inflammatory bacteria are represented in a lower relative abundance compared to those with less potentially virulent qualities.

Celiac Disease: An Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guideline

Celiac disease is an autoimmune disorder in which the immune system of genetically susceptible individuals elicits a reaction to gluten causing small intestine damage. If left undiagnosed and untreated, the resulting nutrition malabsorption can lead to anemia, bone disease, growth faltering, or other consequences. The condition is lifelong and lacks a cure; the only treatment is lifelong adherence to a gluten-free diet (GFD). This diet is challenging to follow and adversely influences quality of life; however, it is essential to ensure intestinal recovery and prevent future negative health consequences. The Academy of Nutrition and Dietetics convened an expert panel complemented by a celiac disease patient advocate to evaluate evidence for six topics, including medical nutrition therapy; the GFD; oat consumption; micronutrients; pro-/prebiotics; and the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. This publication outlines the Academy of Nutrition and Dietetics Evidence Analysis Library methods used to complete the systematic review and guideline development, and summarizes the recommendations and supporting evidence. The guidelines affirm that all individuals with celiac disease should follow a GFD (1C, Imperative) that may include gluten-free oats in adults (2D, Conditional). Children should follow a nutritionally adequate GFD that supports healthy growth and development (Consensus, Imperative) and does not unnecessarily restrict gluten-free oats (Consensus, Conditional). The guidelines indicate nutritional care should include routine nutritional assessment (Consensus, Imperative) and medical nutrition therapy (Consensus, Imperative). At this time, the guidelines do not support a recommendation for the addition of the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet (2C, Conditional); prebiotic or probiotic supplementation (2D, Conditional); or micronutrient supplementation (in the absence of nutritional deficiency) (Consensus, Conditional). The 2021 Celiac Disease Evidence-Based Nutrition Guideline will assist registered dietitian nutritionists in providing appropriate evidence-based medical nutrition therapy to support people with celiac disease in achieving and maintaining nutritional health and avoiding adverse celiac disease consequences throughout their lives.

Comparison of predictive equations and indirect calorimetry in critical care: Does the accuracy differ by body mass index classification?

BACKGROUND

Nutrition support professionals are tasked with estimating energy requirements for critically ill patients. Estimating energy leads to suboptimal feeding practices and adverse outcomes. Indirect calorimetry (IC) is the gold standard for determining energy expenditure. However, access is limited, so clinicians must rely on predictive equations.

METHODS

A retrospective chart review of critically ill patients who underwent IC in 2019 was conducted. The Mifflin-St Jeor equation (MSJ), Penn State University equation (PSU), and weight-based nomograms were calculated using admission weights. Demographic, anthropometric, and IC data were extracted from the medical record. Data were stratified by body mass index (BMI) classifications, and relationships between estimated energy requirements and IC were compared.

RESULTS

Participants (N = 326) were included. Median age was 59.2 years, and BMI was 30.1. The MSJ and PSU were positively correlated with IC in all BMI classes (all P < 0.001). Median measured energy expenditure was 2004 kcal/day, which was 1.1-fold greater than PSU, 1.2-fold greater than MSJ, and 1.3-fold greater than weight-based nomograms (all P < 0.001).

CONCLUSION

Despite the significant relationships between measured and estimated energy requirements, the significant fold-differences suggest that using predictive equations leads to significant underfeeding, which may result in poor clinical outcomes. Clinicians should rely on IC when available, and increased training in the interpretation of IC is warranted. In the absence of IC, the use of admission weight in weight-based nomograms could serve as a surrogate, as these calculations provided the closest estimate to IC in participants with normal weight and overweight, but not obesity.

The Evaluation and Management of Macronutrient Deficiency Dermatoses

In industrialized countries, nutritional dermatoses are likely underdiagnosed and result in increased disease morbidity and utilization of hospital resources. These findings underscore the need for physicians to be able to correctly identify these deficiencies. Nutritional dermatoses may be split into micronutrient deficiencies and macronutrient deficiencies. This article is intended to serve as a supplement to a two-part review of micronutrient deficiency dermatoses and highlights cutaneous findings in patients with protein-energy malnutrition and essential fatty acid deficiency. This article reviews the evaluation, cutaneous manifestations, and management of macronutrient deficiencies.

Identification of Malnutrition Risk Using Malnutrition Screening Tool in an Ambulatory Pancreas Clinic

OBJECTIVES

The aim of this project was to assess malnutrition risk in a well-defined cohort of pancreatic diseases.

METHODS

We performed a retrospective, cross-sectional study of 401 subjects with available malnutrition screening tool scores who received care at a single outpatient pancreas clinic during a 6-month study period. Univariate analyses were performed to compare demographic, anthropometric, symptoms/diseases, and risk for malnutrition characteristics across 3 strata of diseases: acute pancreatitis (n = 141), chronic pancreatitis (n = 193), and other pancreatic diagnoses (n = 67).

RESULTS

A total of 18% of subjects were identified as at risk for malnutrition, including 25% who reported involuntary weight loss and/or decreased appetite. Subjects categorized as at risk for malnutrition were more likely to have gastrointestinal symptoms. Although the nutrition consultation rates were higher in subjects at risk for malnutrition (P = 0.03), 66% did not receive a clearly indicated dietary evaluation or management recommendations. One fifth of all patients in an ambulatory pancreas clinic are identified as at risk for malnutrition using a simple, validated tool.

CONCLUSIONS

The majority of patients at increased risk for nutritional complications did not receive nutritional recommendations.

The Epidemiology, Impact, and Diagnosis of Micronutrient Nutritional Dermatoses Part 1: Zinc, Selenium, Copper, Vitamin A, and Vitamin C

Dermatologists play a critical role in diagnosing and managing nutritional deficiencies as they often present with cutaneous findings. Traditionally, nutritional dermatoses are taught in the context of developing countries, famine, population displacement, and poor healthcare access; however, in the United States, common risk factors include chronic liver disease, alcoholism, psychiatric disease, bariatric surgery, inflammatory bowel disease, and hemodialysis. Additionally, nutritional dermatoses may be underdiagnosed in the United States and result in increased morbidity and utilization of hospital resources. There is a need for providers in developed nations to identify these deficiencies, and this review aims to meet that practice gap and provide relevant context to these diseases for dermatologists. This two-part review series will focus on the epidemiology, impact, appearance, and diagnostic modalities for micronutrient deficiencies, including zinc, selenium, copper, and vitamins A and C in part one. The companion review will focus on the B-complex vitamins.

The Effect of the Low FODMAP Diet on Gastrointestinal Symptoms, Behavioral Problems and Nutrient Intake in Children with Autism Spectrum Disorder: A Randomized Controlled Pilot Trial

Some research suggests that GI symptoms seen in children with ASD may relate to behavior problems. The objective of this pilot study was to assess the effect of the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet on GI and behavioral problems in children with ASD. At follow-up, the low FODMAP diet group had significant relief in some GI problems compared with both baseline in the group and control group. At baseline and at follow-up, there were no significant differences in behavioral problems between the low FODMAP diet group and the control group. Randomized controlled studies including larger sample sizes are needed to confirm the effects of low FODMAP diets in children with autism who have gastrointestinal problems.

Does the Healthy Eating Index and Mediterranean Diet Score Identify the Nutritional Adequacy of Dietary Patterns in Chronic Pancreatitis?

BACKGROUND

Chronic pancreatitis (CP) is a progressive, irreversible disease characterized by maldigestion and frequently accompanied by epigastric pain, exocrine insufficiency, and/or endocrine insufficiency. There is limited information about the dietary patterns in CP from which to guide medical nutrition therapy recommendations.

METHODS

Study design was a cross-sectional, case-control study comparing subjects with CP (n = 52) to healthy controls (n = 48). Vioscreen™ food frequency questionnaire was used to assess the dietary pattern and nutrient intake in both groups. Dietary quality scores (the Healthy Eating Index, Mediterranean Diet score), and daily energy, macronutrient, and micronutrient intake levels were compared between groups.

ANALYSIS

Two sample t tests and Wilcoxon rank sum tests were used to evaluate differences in continuous variables, and Chi-squared tests were used for categorical variables.

RESULTS

CP was associated with a lower body mass index (BMI) (24 vs. 31 mg/kg²; p < 0.001), lower HEI (57 vs. 65; p = 0.002), and aMED scores (29 vs. 32; p = 0.043) compared to healthy controls. Subjects with CP in the highest BMI quartile had the highest median aMED score compared to those in the lowest BMI quartile. There were no differences in kilocalories, macronutrients, or fat-soluble vitamin intake between groups, with the exception that vitamin K intake was lower in the CP group.

CONCLUSIONS

The overall quality of dietary intake is lower in subjects with CP compared to controls when assessed by two independent nutritional measurement tools. Further research is needed to examine contributing factors, such as food insecurity and coexisting endocrine or exocrine insufficiency, to dietary patterns in patients with CP from which to guide evidence-based recommendations for medical nutritional therapy.

Nutritional Aspects of Acute Pancreatitis

The goal of nutritional support in acute pancreatitis is to reduce inflammation, prevent nutritional depletion, correct a negative nitrogen balance, and improve outcomes. Enteral nutrition (EN) in severe acute pancreatitis (SAP) should be preferred to parenteral nutrition. It maintains the integrity of the gut barrier, decreases intestinal permeability, downregulates the systemic inflammatory response, maintains intestinal microbiota equilibrium, and reduces the complications of the early phase of SAP, improving morbidity and possibly improving mortality, and it is less expensive. Further studies to understand optimal timing of nutrition, route of delivery of EN, and the type of nutrition and nutrients are necessary.

Application of a low polyphenol or low ellagitannin dietary intervention and its impact on ellagitannin metabolism in men

SCOPE

Plant polyphenols are widespread in the American diet, yet estimated intake is uncertain. We examine the application of the Polyphenol Explorer® (PED) database to quantify polyphenol and ellagitannin (ET) intake of men with prostate cancer and tested the implementation of diets restricted in polyphenols or ETs.

METHODS AND RESULTS

Twenty-four men enrolled in a 4-week trial were randomized to usual, low-polyphenol or low-ET diet. Estimated polyphenol and ET intakes were calculated from 3-day diet records utilizing the PED. Urine and plasma metabolites were quantified by UPLC-MS. Adherence to the restricted diets was 95% for the low polyphenol and 98% for low-ET diet. In the usual diet, estimated dietary polyphenol intake was 1568 ± 939 mg/day, with coffee/tea beverages (1112 ± 1028 mg/day) being the largest contributors and estimated dietary ET intake was 12 ± 13 mg/day. The low-polyphenol and low-ET groups resulted in a reduction of total polyphenols by 45% and 85%, respectively, and omission of dietary ETs. UPLC analysis of urinary host and microbial metabolites reflect ET intake.

CONCLUSION

PED is a useful database for assessing exposure to polyphenols. Diets restricted in total polyphenol or ET intake are feasible and UPLC assessment of ET metabolites is reflective of dietary intake.

Spontaneous splenic rupture--a rare complication of amyloidosis

We present a case of spontaneous rupture of the spleen, an uncommon complication of systemic amyloidosis. Amyloid deposition leading to capsular distension and increased vascular fragility is thought to predispose the spleen to rupture spontaneously.

The routine use of cystoscopy with the Burch procedure

OBJECTIVE

We sought to determine the incidence of unsuspected injury to the lower urinary tract as detected by intraoperative cystoscopy when the Burch procedure is performed.

STUDY DESIGN

We reviewed the records of 181 women who underwent pelvic surgery, which included a Burch retropubic urethropexy for genuine stress urinary incontinence, between Jan 1, 1998, and Dec 31, 1999. All patients underwent intraoperative cystoscopy at the completion of the Burch procedure after the administration of intravenous indigo carmine dye.

RESULTS

There were 6 (3.3%) injuries to the lower urinary tract. Five of the injuries were cystotomies that had been recognized during operation. One obstructed left ureter was detected by cystoscopy and relieved by the release of left paravaginal repair sutures. No unsuspected injuries that were detected by cystoscopy were attributable to the Burch procedure.

CONCLUSIONS

The lower urinary tract injury rate was 3.3%. All but one injury was recognized before cystoscopy. The one injury was attributed to concomitant paravaginal repair and not to the Burch procedure.

Fate, effects and potential environmental risks of ethylene glycol: a review

The fate, effects, and potential environmental risks of ethylene glycol (EG) in the environment were examined. EG undergoes rapid biodegradation in aerobic and anaerobic environments (approximately 100% removal of EG within 24 h to 28 days). In air, EG reacts with photo-chemically produced hydroxyl radicals with a resulting atmospheric half-life of 2 days. Acute toxicity values (LC(50)s and EC(50)s) were generally >10,000 mg/l for fish and aquatic invertebrates. The data collectively show that EG is not persistent in air, surface water, soil, or groundwater, is practically non-toxic to aquatic organisms, and does not bioaccumulate in aquatic organisms. Potential long-term, quasi-steady state regional concentrations of EG estimated with a multi-media model for air, water, soil, and sediment were all less than predicted no effect concentrations (PNECs).

Xanthogranulomatous cholecystitis

Clinical, radiological and pathological findings in 31 patients with xanthogranulomatous cholecystitis have been reviewed. The spectrum of presentation was similar to that of cholelithiasis but fewer patients had biliary colic (17 per cent) and there were more complications (32 per cent). Four patients had a biliary fistula and four a perforated gallbladder with abscess formation. Patients characteristically had gallstones. Appearances often mimicked carcinoma of the gallbladder at ultrasonography and/or laparotomy, with xanthogranulomatous tissue extending to adjacent structures. Xanthogranulomatous cholecystitis and carcinoma of the gallbladder coexisted in three patients. The possibility should be considered that an 'inoperable tumour' of the gallbladder may in fact be xanthogranulomatous cholecystitis, a benign condition that frozen-section biopsy may confirm.

Accelerated atherogenesis occurs following platelet destruction and increases in megakaryocyte size and DNA content

Platelets and megakaryocytes have a role in atherogenesis. In this study the effect of platelet destruction, caused by injection of serum containing anti-platelet antibodies, on the development of atheroma and on megakaryocyte size and DNA content was studied in rabbits on a high cholesterol diet. Seven days after destruction of the circulating platelets a significant (150% and 300% in two separate studies) increase in the area of atheroma in the aorta was demonstrated. Histological examination revealed that large quantities of extracellular lipid and connective tissue were present in these plaques. The acceleration of atherogenesis in this model was found to be preceded by a significant increase in megakaryocyte size and in the frequency of megakaryocytes with a high DNA content. Platelets derived from large, high ploidy megakaryocytes may be of importance for the development of the atherosclerotic lesion. Neither the endothelial permeability as assessed by injection of Evans blue nor the prostacyclin production by the aorta of animals injected with anti-platelet serum were significantly different from the aortas of control animals.

Electron microscopy to differentiate intestinal spirochaetosis from other conditions

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Megakaryocyte and vascular changes in rabbits on a short-term high cholesterol diet

The effect of a short-term high cholesterol diet on thrombopoiesis and vascular ultrastructure was evaluated in rabbits. Six pairs of male litter-mate rabbits were randomized pairwise to feeding with either 2 g of cholesterol daily in addition to their normal diet or normal diet alone for 7 days. A significant 12-fold increase in median serum cholesterol (P less than 0.035) and an insignificant decrease in platelet count (P = 0.07) were found in the animals fed a high cholesterol diet. In these animals the total and cytoplasmic megakaryocyte size measured as planimetric areas in bone marrow sections were significantly decreased (P less than 0.035). No statistically significant difference in the megakaryocyte DNA content measured by flow cytometry in marrow suspensions enriched for megakaryocytes by density gradient centrifugation and centrifugal elutriation was observed between the cholesterol-fed animals and controls. Light microscopic, transmission and scanning electron microscopic examination of the aorta in both groups of animals showed a morphologically intact endothelium without any adhesion of blood-borne cells to the luminal surface. Transmission electron microscopic studies showed that cells with ultrastructural features resembling smooth muscle cells were present in the intima of the aortas of the animals on the high cholesterol diet, but not in control animals. A decrease in the size of bone marrow megakaryocytes and the occurrence of intimal smooth muscle cells are found in rabbits fed a high cholesterol diet for 7 days. These cellular events may be important features in early atherogenesis.

Pericardial heterografts: why do these valves fail?

Eighteen explanted pericardial heterografts were studied (16 standard Ionescu-Shiley, one Hancock, and one Mitroflow). Regurgitation was the reason given for explantation of all the Ionescu-Shiley valves. The other two valves were removed for technical reasons. All the Ionescu-Shiley valves had commissural tears and there was concomitant gross calcification in 10 of the 16 valves. In addition, an apparent increase in cusp area had caused "leaflet sagging". The explanted leaflets were thicker and stiffer than leaflets from an unimplanted valve. These features were confirmed directly with an animal model of subcutaneous implantation. Examination with an electron microscope revealed that these changes in mechanical properties seemed to be linked to fiber separation and infiltration by an amorphous proteinlike matrix. The durability of the glutaraldehyde-fixed pericardium depended on a number of factors. Early and midterm failure appeared to be stress induced. Predisposition to high mechanical stresses near the stent was exacerbated by the changes induced by the host environment. This problem was aggravated further in the Ionescu-Shiley valves by stress concentrations around the hole associated with the holding suture. In the long term, collagen disruption associated with leaflet flexure was followed by secondary calcification at the boundary between the intact and disrupted material.

Association between necropsy evidence of disseminated intravascular coagulation and coagulation variables before death in patients in intensive care units

The necropsy findings in 21 patients on an intensive care unit, on whom coagulation studies had been performed immediately before death, were assessed. Eleven of the patients were retrospectively studied and 10 were reviewed consecutively in a prospective study. Fifteen patients (eight retrospective and seven prospective) had evidence of disseminated intravascular coagulation. Microthrombi were most often found in the lungs and kidneys. The most common abnormal coagulation tests in patients with necropsy evidence of disseminated intravascular coagulation were raised serum concentrations of fibrinogen and fibrin degradation products, prolonged prothrombin time, and reduced platelet counts. Reduced fibrinogen concentrations and a prolonged thrombin time were the least commonly observed abnormalities. There was no difference in either the prevalence or magnitude of abnormality of any particular coagulation variable test result between those patients with evidence of disseminated intravascular coagulation at necropsy and those without.

Lipoprotein lipase activity in skeletal muscle and adipose tissue of marathon runners after simple and complex carbohydrate-rich diets

A comparison of the influence of simple and complex carbohydrate (CHO) consumption on adipose tissue- and skeletal muscle-lipoprotein lipase activity (AT-LPLA, SM-LPLA) was examined. Twenty male marathon runners were divided into two equal dietary groups: simple-CHO and complex-CHO. Half of the subjects in each group consumed either a low-CHO (15% energy [E] intake), or a mixed diet (50% CHO) for 3 days. Immediately following this dietary period, the subjects consumed a CHO-rich diet (70% E intake) predominant in simple-CHO or in complex-CHO for an additional 3 days. Thereafter, all subjects returned to a normal mixed diet. Skeletal muscle biopsies, adipose tissue aspirations, and venous blood samples were obtained prior to dietary manipulation (PRE), upon completion of the 6 day diet (POST I), and 2 weeks after returning to a normal diet (POST II). The samples were analysed for AT-LPLA, SM-LPLA, serum insulin, and free fatty acids (FFA), and blood glucose, and lactate. SM-LPLA fell 71% from PRE values of 0.39 +/- 0.30 mu mol.g-1.h-1 to POST I values of 0.11 +/- 0.09 mu mol.g-1.h-1 (means +/- SD) (p less than 0.05), after a complex-CHO diet. However, the simple-CHO diet did not alter SM-LPLA. AT-LPLA similarly decreased (p less than 0.05) after the complex-CHO diet, and no significant decrease was noted after the simple-CHO diet.(ABSTRACT TRUNCATED AT 250 WORDS)

Simple and complex carbohydrate-rich diets and muscle glycogen content of marathon runners

The effects of simple-carbohydrate (CHO)- and complex-CHO-rich diets on skeletal muscle glycogen content were compared. Twenty male marathon runners were divided into four equal groups with reference to dietary consumption: depletion/simple, depletion/complex, nondepletion/simple, and nondepletion/complex. Subjects consumed either a low-CHO (15% energy [E] intake), or a mixed diet (50% CHO) for 3 days, immediately followed by a high-CHO diet (70% E intake) predominant in either simple-CHO or in complex-CHO (85% of total CHO intake) for another 3 days. Skeletal muscle biopsies and venous blood samples were obtained one day prior to the start of the low-CHO diet or mixed diet (PRE), and then again one day after the completion of the high-CHO diet (POST). The samples were analysed for skeletal muscle glycogen, serum free fatty acids (FFA), insulin, and lactate and blood glucose. Skeletal muscle glycogen content increased significantly (p less than 0.05) only in the nondepletion/simple group. When groups were combined, according to the type of CHO ingested and/or utilization of a depletion diet, significant increases were observed in glycogen content. Serum FFA decreased significantly (p less than 0.05) for the nondepletion/complex group only, while serum insulin, blood glucose, and serum lactate were not altered. It is concluded that significant increases in skeletal muscle glycogen content can be achieved with a diet high in simple-CHO or complex-CHO, with or without initial consumption of a low-CHO diet.

Xanthogranulomatous cholecystitis: clinicopathological study of 13 cases

In a retrospective three year study 13 cases of xanthogranulomatous cholecystitis (XGC) (seven female, six male) were found in 724 gallbladders (1.8%), an estimated incidence of 1.7 cases per 100,000 population per annum. Symptoms often began with an episode of acute cholecystitis and persisted for up to five years. There was extension of xanthogranulomatous tissue into adjacent organs in nine cases. Three patients had fistulae from the gallbladder, one to skin, and two to the duodenum; this is the first report of this complication in XGC. In two patients XGC sufficiently resembled carcinoma for the surgeon to request intraoperative frozen section diagnosis. There was a high rate of postoperative infective complication, with one subphrenic abscess and three wound infections (one fatal), two in patients with fistulae.

Failure of a bioprosthetic mitral valve due to attachment of a residual chorda

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Pericardial heterografts. Toward quality control of the mechanical properties of glutaraldehyde-fixed leaflets

The mechanical properties of five different, equally distributed, and randomly oriented sites in natural and glutaraldehyde-fixed calf pericardial sacs were investigated. Identical sites in different sacs were obtained by placing a template over each sac and using the ligaments still attached to the pericardium as a reference frame. Mean maximum extension of the fixed tissue was statistically significantly greater than that of natural tissue at the same degree of stress. There was no significant difference in thickness from position to position within a sac, from sac to sac, or from the natural to fixed pericardium. However, the extensibility of one particular site was significantly greater than that of other positions in the pericardial sac. This position lay entirely in a well-defined sector that emanated radially from the pericardial ligaments. Light and electron microscopy showed no difference in collagen structure in the five positions studied. In contrast, both the content and ultrastructure of the tissue elastin differed in the region of high extensibility compared with those sites studied in the remainder of the sac. This region contained coarse condensed elastin whereas the other sites had fine elastin dispersed diffusely throughout the tissue. These results suggest that pericardial heterografts of uniform thickness may be harvested from any position in calf pericardium. However, unless the region of coarse condensed elastin is excluded, leaflets with significantly different mechanical properties may be produced.