Zeynep Erdoğan İyigün, Tolga Ozmen, Serkan İlgün
et al.
Objective: The aim of this study was to evaluate the relationship between subclinical lymphedema identified prior to surgical intervention and clinical lymphedema observed in the late period, the incidence of lymphedema in our cohort, and the associated risk factors.
Materials and Methods: This prospective study was conducted with early-stage breast cancer patients who had been enrolled in a previous study. For diagnosing lymphedema, physical examination, L-Dex® score, and circumferential measurement was used. The L-Dex® score was used as a screening test for preoperative, subclinical lymphedema since there were no clinical findings. Patients with subclinical lymphedema were provided with education and followed up more frequently with regular monitoring.
Results: The mean age of the 217 participants was 56.7±12.7 years (range 29–90), and the mean body mass index was 27.7±3.3 kg/m2 (range 19.3–36.9). Among the 217 patients, lymphedema was detected in 31 (14.7%) at a median follow-up period of 89 months (range 73–108 months). Multivariable analysis of factors associated with late-stage lymphedema revealed positive lymph node count and capsular invasion as significant factors (p = 0.001 for both). Forty (18.4%) had preoperative subclinical lymphedema. At the end of the follow-up period, lymphedema persisted in 11 patients (27.5%) and resolved in 29 patients (72.5%). In multivariable analysis, the positive lymph node count was identified as an independent variable in these patients.
Conclusion: Identifying high-risk patients, regular monitoring, and early intervention can significantly reduce the risk of clinical lymphedema through timely treatment.
Neoplasms. Tumors. Oncology. Including cancer and carcinogens, Medicine
Yamada Kazuya, Matahira Yoshiharu, Takuwa Nagisa
et al.
Nicotine consumption is known to be a risk factor for cardiovascular disease. β-Caryophyllene (BCP), a sesquiterpene with anti-inflammatory properties, was investigated in a randomized, double-blind, placebo-controlled trial to see if smoking cigarettes with BCP-containing capsules could improve aortic stiffness. In this study, 84 adult smokers were randomly assigned to either a BCP group or a placebo group. They smoked capsule-loaded cigarettes for 12 weeks, and various health parameters were measured every 4 weeks. The primary focus was on changes in brachial-ankle pulse wave velocity (baPWV), which measures arterial stiffness. The results showed that blood BCP levels increased only in the BCP group, while nicotine levels rose in both groups. For participants with a high baseline baPWV (≥ 1,400 cm/s), significant reductions in baPWV were observed in the BCP group at weeks 4 and 8. Additionally, baPWV at week 4 was significantly lower in the BCP group compared to the placebo group. No adverse effects were reported. In conclusion, smoking BCP-containing cigarettes improved arterial stiffness in participants with high baseline baPWV without causing any adverse effects.
Devika A Shenoy, Kathryn Radulovacki, Christian Zirbes
et al.
Introduction Paediatric patients with elevated healthcare needs have limited access to care, contributing to insufficient preventive services. Social drivers of health (SDOH), such as inadequate nutrition and poor community support, contribute substantially to paediatric health. In order to promote value-based healthcare, specialty providers like orthopaedic surgeons can serve as an entry point to connect patients to SDOH and primary care resources. The purpose of this short report is to provide a framework for other institutions for an ongoing screening programme.Overview of programme Informed on prior initiatives, we designed a systematic screening programme for SDOH, obesity (via body mass index (BMI)) and primary care access in a paediatric orthopaedics clinic, for English-speaking and Spanish-speaking patients <18 years old. We record age, sex, race/ethnicity, language, orthopaedic condition, Area Deprivation Index and Childhood Opportunity Index from the electronic record previsit. BMI ≥95th percentile triggers referral to a paediatric obesity management programme. An institutional SDOH screen detects financial, food, transportation, housing and utility needs. A positive screen triggers a referral to institution and state-specific resources. A five-question Primary Care Access Screen identifies gaps in primary care access. A positive screen triggers an internal referral to paediatric primary care. Patients are flagged before visits, and screening results are reviewed. Students place referrals for positive screens, finalised by providers. Follow-up occurs at 6 weeks.Data collection We assess screen positivity, referral uptake and completed appointments for all patients at 6 weeks.
Guohui Liu,1 Tian Lan,2 Mingyan E,1 Yunlong He,1 Hanqing Hu3 1Department of Radiation Oncology, Harbin Medical University Cancer Hospital, Harbin, 150040, People’s Republic of China; 2Department of Educational Administration, Harbin Medical University Cancer Hospital, Harbin, 150040, People’s Republic of China; 3Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, People’s Republic of ChinaCorrespondence: Hanqing Hu, Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, People’s Republic of China, Email huhanqing@hrbmu.edu.cnObjective: This study aimed to evaluate whether integrating the TeamSTEPPS model with PEARLS structured debriefing improves teamwork competencies and clinical decision-making among radiotherapy residents, compared to traditional simulation teaching, and to assess its broader applicability in medical education.Methods: From June to December 2023, 36 standardized training residents from the Radiotherapy Department of Harbin Medical University Cancer Hospital were selected and randomly assigned to an experimental group and a control group, each with 18 participants, using a random number table The experimental group underwent scenario-based simulation teaching incorporating the TeamSTEPPS model and PEARLS structured debriefing, while the control group received traditional simulation teaching. Post-intervention, a unified quantitative assessment evaluated theoretical knowledge, skill performance, and simulation performance in both groups. Additionally, satisfaction levels were assessed via questionnaire.Results: The experimental group exhibited significantly higher scores in theoretical knowledge (88.55± 6.52) and skill performance (87.68± 18.42) compared to the control group (71.63± 5.69 and 58.96± 11.47, respectively; P< 0.05). The experimental group exhibited statistically significant improvements in teamwork competencies, including communication (23.22± 2.21 vs 21.43± 3.77, P< 0.05), leadership (23.40± 2.22 vs 22.19± 3.51, P< 0.05), situational awareness (18.95± 1.61 vs 17.62± 2.64, P< 0.05), and mutual support (27.93± 2.92 vs 25.69± 5.76, P< 0.05). The experimental group’s higher satisfaction (94.44% vs 77.78%, P< 0.05) underscores the potential of this integrated approach to address systemic challenges in clinical education, such as fragmented teamwork training and insufficient reflective practice. These findings suggest that combining TeamSTEPPS with PEARLS could serve as a replicable framework for multidisciplinary medical training programs aiming to enhance both technical proficiency and collaborative care.Conclusion: The innovative combined teaching method applied in this study to scenario-based simulation teaching in radiation oncology can significantly enhance residents’ theoretical knowledge, skill performance, and team collaboration abilities.This methodology exhibits notable advantages in clinical teaching within the radiotherapy department and with potential applicability to multidisciplinary medical education and standardized residency programs.Keywords: radiation oncology, teaching methods, resident standardized training, simulation teaching, team collaboration
Prabudh Goel, Prativa Choudhury, Vivek Verma
et al.
Background:
A discrepancy between the true and measured value of stretched penile length (SPL) may be a result of errors that can either be systematic or random. Hence, it becomes important to focus on the quality of measurements to prevent any iatrogenic harm to the patients.
Objective:
The objective of this study was to assess the magnitude of intra- and interobserver variations in the measurement of SPL with the SPLINT technique.
Materials and Methods:
SPL was measured prospectively in a cohort of 449 boys aged 0–14 years including 68 infants (substratified into Group I: >4 years, Group II: 4–8 years, and Group III: >8 years) with the SPLINT technique by expert (E: E1 and E2) and trainee (T: T1 and T2) surgeons after completing a three-tiered training module. Intra- and interobserver variability was assessed through descriptive statistics, intraclass correlation (ICC), relative technical error of measurement (rTEM), and reliability or R (%).
Results:
Intraobserver variability: the mean difference between the two readings (E1 and E2) is 0.08 cm (95% confidence interval [CI]: 0.073–0.087), ICC was 0.998 (95% CI: 0.997–0.998), and intraobserver variability ≤0.1 cm in 85% of the participants (n = 370 of 433). The rTEM and reliability (%) were 1.82% and 98.1% (Group I), 1.65% and 98.9% (Group II), and 1.09% and 99.7% (Group III), respectively. The intraobserver variability was observed to be inversely proportional to the age of the participants (correlation coefficient = −0.56). Interobserver variability was calculated separately for expert versus trainee and trainee versus trainee (T-vs-T) measurements. For expert versus expert, ICC, rTEM, and reliability (%) were 0.984, 2.4%, and 96.8% (Group 1), 0.992, 2.07%, and 98.3% (Group 2), and 0.997, 1.38%, and 99.05% (Group 3), respectively. A similar pattern of variability was observed for T-vs-T measurements. The reliability (%) of the SPL by experts is consistently more than that of trainees across all age groups; however, the difference ameliorates with the age of participant.
Conclusions:
The study has validated the SPLINT technique by demonstrating a high level of intra- and interobserver reliability. The adequacy of the training modules for SPL measurements described in this study has also been established. Evidence that the SPL can be used as an objective marker of penile dimensions is herewith furnished.
Abstract Skin cutaneous melanoma (SKCM) is a highly malignant form of skin cancer, known for its unfavorable prognosis and elevated mortality rate. RARRES1, a gene responsive to retinoic acid receptors, displays varied functions in various cancer types. However, the specific role and underlying mechanisms of RARRES1 in SKCM are still unclear. GSE15605 was utilized to analyze the expression of RARRES1 in SKCM. Subsequently, the TCGA and GEO databases were employed to investigate the relationships between RARRES1 and clinicopathological parameters, as well as the prognostic implications and diagnostic efficacy of RARRES1 in SKCM. GO, KEGG, and GSEA analyses were conducted to explore the potential functions of RARRES1. Furthermore, the associations between RARRES1 and immune infiltration were examined. Genomic alterations and promoter methylation levels of RARRES1 in SKCM were assessed using cBioPortal, UALCAN, and the GEO database. Finally, RARRES1 expression in SKCM was validated through immunohistochemistry, and its functional role in SKCM progression was elucidated via in vivo and in vitro experiments. We found that RARRES1 was downregulated in SKCM compared with normal tissues, and this low expression was associated with worse clinicopathological features and poor prognosis of SKCM. The diagnostic efficacy of RARRES1, as determined by ROC analysis, was 0.732. Through GO, KEGG, and GSEA enrichment analysis, we identified 30 correlated genes and pathways that were mainly enriched in the tumor immune microenvironment, proliferation, apoptosis, and autophagy. Additionally, RARRES1 expression was found to be positively related to the infiltration of various immune cells in SKCM, particularly macrophages and T helper cells, among others. Analysis of genomic alterations and promoter methylation revealed that shallow deletion and hypermethylation of the RARRES1 promoter could lead to reduced RARRES1 expression. IHC validation confirmed the downregulation of RARRES1 in SKCM. Moreover, overexpression of RARRES1 inhibited the proliferation and migration of A375 cells, promoted apoptosis, and inhibited autophagic flux. In the mouse xenograft model, RARRES1 overexpression also suppressed SKCM tumor growth. Collectively, these findings suggest that RARRES1 may function as a suppressor and could potentially serve as a prognostic biomarker and therapeutic target for SKCM.
Virginia Byers Kraus, Alexander Reed, Erik J. Soderblom
et al.
Objective: To further validate a serum proteomics panel for predicting radiographic (structural) knee OA progression. Design: Serum peptides were targeted by multiple-reaction-monitoring mass spectrometry in the New York University cohort (n = 104). Knee OA progression was defined as joint space narrowing ≥1 in the tibiofemoral compartment of one knee per study participant over a 24-month follow-up. The discriminative ability of an 11-peptide panel was evaluated by multivariable logistic regression and area under the receiver operating characteristic curve (AUC), without and with demographic characteristics of age, sex, and body mass index. The association of each peptide with OA progression was assessed by odds ratios (OR) in multivariable logistic regression models adjusted for demographics. Results: The cohort included 46 (44%) knee OA progressors. The panel of 11 peptides alone yielded AUC = 0.66 (95% CI [0.55, 0.77]) for discriminating progressors from non-progressors; demographic traits alone yielded AUC = 0.66 (95% CI [0.55, 0.77]). Together the 11 peptides and demographics yielded AUC = 0.72 (95% CI [0.62, 0.83]). CRAC1 had the highest odds for predicting OA progression (OR 2.014, 95% CI [0.996, 4.296], p = 0.058). Conclusions: We evaluated a parsimonious serum proteomic panel and found it to be a good discriminator of knee radiographic OA progression from non-progression. Since these biomarkers are quantifiable in serum, they could be deployed relatively easily to provide a simple, cost-effective strategy for identifying and monitoring individuals at high risk of knee OA progression.
Steven M. Hadley BA, John J. Peabody MD, Sarah Westvold MPH
et al.
Category: Ankle; Trauma Introduction/Purpose: It remains unclear whether ankle fracture pattern as described by the Weber classification—a reproducible method describing the level of fracture with respect to the distal tibiofibular syndesmosis—impacts outcomes. Patient Reported Outcome Measurement Information System (PROMIS) is a validated measure of outcomes after foot and ankle surgery. To our knowledge, no study has compared PROMIS scores between Weber subtypes. Our study thus examines whether Weber fracture subtype impacts surgical outcomes as measured by PROMIS scores. We hypothesize that both Weber B and Weber C fracture patterns will not have a significant difference in PROMIS scores when anatomically reduced during operative repair. This study is the largest evaluating PROMIS scores of Weber fracture subtypes. Methods: All 782 patients who underwent surgical repair of an ankle fracture at Northwestern between January 1, 2016 and December 31, 2021 were retrospectively reviewed. Two foot and ankle fellowship trained orthopedic surgeons independently reviewed all radiographs and stratified them by Weber fracture subtype, fixation technique, and reduction quality at final follow-up. Patients with multiple injuries at time of presentation, pilon variants, and who identified as a part of vulnerable populations were excluded. Of the 703 patients included, 218 completed a post-operative PROMIS physical function (PF) and pain interference (PI) computerized adaptive test. Subsequently, only the 200 closed Weber B and Weber C fractures were included for final analysis. The Mann-Whitney U test was used to compare differences in PROMIS scores. The Kruskal-Wallis test was used when comparisons were between three or more groups. Results: No significant difference existed between Weber B and Weber C fractures anatomically reduced intraoperatively in terms of mean PF (52.19 ± 9.84 vs. 53.59 ± 9.46, p=0.52) and PI (48.30 ± 8.74 vs. 46.77 ± 7.86, p=0.33). Analysis of those with anatomic reduction at minimum one-year follow-up found no significant difference between Weber B’s and Weber C’s with regard to mean PF (51.46 ± 9.97 vs. 53.67 ± 9.51, p=0.32) and PI (47.76 ± 9.15 vs. 47.68 ± 7.75, p=0.67). Compared to lower BMIs, BMIs of 30 or greater had significantly worse mean PF (p=0.02) and PI (p=0.01). Compared to males, females had worse mean PF (49.88 ± 7.99 vs. 57.92 ± 10.78, p< 0.001) and PI (49.10 ± 8.56 vs. 45.54 ± 8.03, p< 0.01). Conclusion: Weber classification remains a reliable method for categorizing fracture subtypes. We can conclude that anatomic reduction and fixation can return patients with both Weber C and Weber B fractures back to population mean functional outcomes. Although Weber C fractures with known syndesmotic injury result in larger soft tissue trauma, anatomic surgical reduction and fixation can achieve equivalent outcomes to patients with lower energy Weber B fractures. BMI, sex, and age affect functional outcomes following operative repair and may help surgeons guide patient expectations during recovery.
Seyeon Oh, Do-Young Rhee, Sosorburam Batsukh
et al.
Caveolin-1 (Cav-1) induces cellular senescence by reducing extracellular signal-regulated kinase (ERK)1/2 phosphorylation and activating p53 via inhibition of mouse double minute 2 homolog (MDM2) and sirtuin 1 (Sirt1), promoting cell cycle arrest and decreasing fibroblast proliferation and collagen synthesis. High-intensity focused ultrasound (HIFU) treatment increases collagen synthesis, rejuvenating skin. Using H<sub>2</sub>O<sub>2</sub>-induced senescent fibroblasts and the skin of 12-month-old mice, we tested the hypothesis that HIFU increases collagen production through Cav-1 modulation. HIFU was administered at 0.3, 0.5, or 0.7 J in the LINEAR and DOT modes. In both models, HIFU administration decreased Cav-1 levels, increased ERK1/2 phosphorylation, and decreased the binding of Cav-1 with both MDM2 and Sirt1. HIFU administration decreased p53 activation (acetylated p53) and p21 levels and increased cyclin D1, cyclin-dependent kinase 2, and proliferating cell nuclear antigen levels in both models. HIFU treatment increased collagen and elastin expression, collagen fiber accumulation, and elastin fiber density in aging skin, with 0.5 J in LINEAR mode resulting in the most prominent effects. HIFU treatment increased collagen synthesis to levels similar to those in Cav-1-silenced senescent fibroblasts. Our results suggest that HIFU administration increases dermal collagen and elastin fibers in aging skin via Cav-1 modulation and reduced p53 activity.
Sergio Quilici Belczak, PhD, Felipe Coelho Neto, PhD, Walter Junior Boim de Araújo, PhD
et al.
We have reported a case of a 36-year-old woman with flank and pelvic pain and hematuria. She had posterior nutcracker syndrome and pelvic varices involving one anterior and three posterior renal veins (including one major vein). We used a complete endovascular approach, which included stent implantation in the major posterior renal vein and left gonadal vein embolization. During a 12-month follow-up period, the patient had had no symptoms and good computed tomography results. Endovascular treatment represents a safe and successful option for patients with nutcracker syndrome and pelvic varices involving the anterior and posterior renal veins.
Surgery, Diseases of the circulatory (Cardiovascular) system
Being one of the most lethal malignant tumors worldwide, pancreatic carcinoma (PC) shows strong invasiveness and high mortality. In tumorigenesis and progression, the role played by long-chain noncoding RNAs (lncRNAs) cannot be ignored. This article mainly probes into the function of lncRNA ZFAS1 in PC. ZFAS1 expression in PC and normal counterparts retrieved from the Genotype-Tissue Expression (GTEx) project and The Cancer Genome Atlas (TCGA) database was analysed by GEPIA2. Its expression profile in clinical specimens and human PC cell strains was quantified using qRT-PCR. Measurements of BxPC-3 cell multiplication and invasiveness employed CCK-8, plate clone formation test, and Transwell chamber assay. ZFAS1’s impact on lipid content in BxPC-3 cells was detected. RNA pulldown and RIP assays analyzed the interaction of ZFAS1 with U2AF2 and HMGCR in BxPC-3 cells. Finally, the impacts of U2AF2 and HMGCR on the biological behavior of BxPC-3 were observed. ZFAS1 was kept at a high level in PC tissues versus the normal counterparts. ZFAS1 gene knockout remarkably suppressed PC cell multiplication and invasiveness and decreased the contents of free fatty acids, total cholesterol, triglycerides, and phospholipids. Mechanistically, ZFAS1 stabilized HMGCR mRNA through U2AF2, thus increasing HMGCR expression and promoting PC lipid accumulation. Meanwhile, reduced PC cell viability and invasiveness were observed after downregulating U2AF2 and HMGCR. As an oncogene of PC, ZFAS1 can modulate lipometabolism and stabilize HMGCR mRNA expression by binding with U2AF2 in PC, which is a candidate target for PC diagnosis and treatment.
Meningokel adalah kondisi kegagalan fusi selubung saraf medulla spinalis yang umum ditemui pada pasien pediatrik. Koreksi meningokel dilakukan dalam posisi prone yang memerlukan tatalaksana anestesi yang hati-hati. Fisiologi neonatus dan infant berbeda dengan orang dewasa, karena fungsi fisiologis system organ masih imatur dan menyebabkan safety margin terbatas, sehingga pilihan obat adalah yang metabolismenya tidak tergantung pada fungsi hati dan ginjal normal. Dalam bidang neuroanestesi pediatrik, penggunaan remifentanil semakin luas, karena onset cepat, efek analgesik poten dan eliminasi cepat. Seorang bayi laki-laki, usia 7 bulan dengan berat badan 7 kg, diagnosis meningokel lumbosacral dilakukan tindakan eksisi meningokel. Pasien diberikan remifentanil 1 mcg/kgbb selama 1 menit dilanjutkan dengan remifentanil kontinyus 0.05-1mcg/kgbb/mnt. Induksi dengan propofol, diberikan atracurium sebelum intubasi. Selama operasi kondisi stabil, tidak terjadi episode bradikardi dan pascaoperasi pasien langsung diekstubasi. Penggunaan remifentanil menjadi pilihan karena onset cepat, efek analgesik poten, eliminasi cepat dan memberikan stabilitas hemodinamik selama operasi. Operasi dengan posisi prone pada pasien pediatrik memerlukan kehati-hatian terutama saat memposisikan pasien, dimana harus yakin pipa ett tidak mengalami dislokasi atau kinking, mencegah efek penekanan pada mata dan pencegahan terjadinya neuropati perioperatif. Pemakaian remifentanil pada kasus ini memberikan stabilitas hemodinamik yang baik dan pulih sadar yang cepat.
Using Remifentanyl For Pediatrik Patient With Meningocele Underwent Meningocelectomy Under General Anesthesia
Abstract
Meningocele is failure of the neural tube to close during first trimester pregnancy which is the most common conditions in pediatrik patient. Correction is performed under prone position with carefull anesthestic procedure. The physiology of neonates and infants are different from that of adults. Immaturity of their vital organ systems narrows the safety margin of perioperative management including anesthesia. Remifentanil is becoming increasingly popular for this purpose. Remifentanil has favorable characteristics for anesthesia in neonates such as rapid onset, potent analgesic effect, and rapid elimination. A baby boy 7 months old, 7 kg, with meningocele lumbosacral underwent meningocelectomy. The patient was given remifentanil 1 mcg/kgbw/iv in one minute and continuous 0.05-0.1 mcg/kgbw/mnt. Induction with propofol iv, atracurium before intubation. Stability hemodynamic during the operation, no episode of bradycardia and patient extubated early after the operation. Remifentanil is an ultra-short-acting opioid, with rapid onset, produces profound analgesia, rapid offset and good stability of hemodynamic during the operation. The operations are carried out prone, careful positioning is paramount to avoid complications like dislodging or kinking of the endotracheal tube, corneal abrasion or perioperative neuropathy. Using remifentanyl in this case report given good hemodynamic stability dan rapid emergence.
Zoltán Lóderer, Tamás Vereb, Róbert Paczona
et al.
Abstract Background The surgical management of malignant tumors in the head and neck region often leads to functional and esthetic defects that impair the quality of life of the patients. Reconstruction can be solved with prostheses in these cases, but various types of microsurgical free flaps can provide a better clinical outcome. Case presentation In this case report, the tumor and parts of the involved facial muscles and nerve were excised surgically from a 42-year-old patient after a third relapse of basal cell carcinoma in the left midface. The tissue defect was reconstructed with an anterolateral thigh chimeric type I fascio-myocutaneous flap, where the facial palsy was restored with a segmental branch of the femoral nerve and the involved mouth corner elevator muscles for the segmented vastus lateralis muscle. The 6-month follow-up revealed a good esthetic outcome, the soft tissue defect reconstruction with good functional activity of the reconstructed facial nerve and with acceptable mimic movements. There has been no subsequent recurrence. Conclusions It is concluded that the chimeric type I anterolateral fascio-myocutaneous free flap can offer a good option for the esthetic and functional reconstruction of an extensive tissue defect in the maxillofacial region.
Background. Roux-en-Y gastric bypass (RYGB) is a commonly performed, effective bariatric procedure; however, rarely, complications such as postprandial hypoglycemia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) may ensue. Management of refractory NIPHS is challenging. We report a case that was successfully treated with RYGB reversal. Case Report. A 58-year-old male with history of RYGB nine months earlier for morbid obesity presented for evaluation of postprandial, hypoglycemic seizures. Testing for insulin level, insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, and cortisol stimulation was unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fast was completed without hypoglycemia. Mixed meal testing demonstrated endogenous hyperinsulinemic hypoglycemia (EHH) and selective arterial calcium stimulation testing (SACST) was positive. Strict dietary modifications, maximal medical therapy, gastrostomy tube feeding, and stomal reduction failed to alleviate symptoms. Ultimately, he underwent laparoscopic reversal of RYGB. Now, 9 months after reversal, he has markedly reduced hypoglycemia burden. Discussion. Hyperfunctioning islets secondary to exaggerated incretin response and altered intestinal nutrient delivery are hypothesized to be causative in NIPHS. For refractory cases, there is increasing skepticism about the safety and efficacy of pancreatic resection. RYGB reversal may be successful.
Diseases of the endocrine glands. Clinical endocrinology