XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

EASL-EORTC clinical practice guidelines : management of hepatocellular carcinoma

CA : A Cancer Journal for Clinicians

EASL–EORTC Clinical Practice Guidelines (CPG) on the management of hepatocellular carcinoma (HCC) define the use of surveillance, diagnosis, and therapeutic strategies recommended for patients with this type of cancer. This is the first European joint effort by the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) to provide common guidelines for the management of hepatocellular carcinoma. These guidelines update the recommendations reported by the EASL panel of experts in HCC published in 2001 [1]. Several clinical and scientific advances have occurred during the past decade and, thus, a modern version of the document is urgently needed. The purpose of this document is to assist physicians, patients, health-care providers, and health-policy makers from Europe and worldwide in the decision-making process according to evidencebased data. Users of these guidelines should be aware that the recommendations are intended to guide clinical practice in circumstances where all possible resources and therapies are available. Thus, they should adapt the recommendations to their local regulations and/or team capacities, infrastructure, and cost– benefit strategies. Finally, this document sets out some recommendations that should be instrumental in advancing the research and knowledge of this disease and ultimately contribute to improve patient care. The EASL–EORTC CPG on the management of hepatocellular carcinoma provide recommendations based on the level of evidence and the strength of the data (the classification of evidence is adapted from National Cancer Institute [2]) (Table 1A) and the strength of recommendations following previously reported systems (GRADE systems) (Table 1B).

http://www.bclc.cat/download/easl-guidelines.pdf

EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma European Association for the Study of the Liver ⇑ , European Organisation for Research and Treatment of Cancer

https://www.emcdda.europa.eu/attachements.cfm/att_231442_EN_INT17_easl-recommendations-on-treatment-of-hepatitis-C.pdf

EASL Recommendations on Treatment of Hepatitis C

Metal-halide perovskites are emerging as an intriguing class of semiconductors with significant potential for photovoltaics. Here, several perovskites are discussed that have been assessed via various experimental techniques to determine the effects of their composition, dimensionality, and structural stability on hot carriers and polaron formation. It will be shown that polarons formed in these systems are strongly affected by the binding energy and nature of the excitons in the materials. Notably, the hot carrier dynamics in perovskites is strongly affected by their low thermal conductivity, which inhibits the dissipation of heat in the material. 

Hot carrier dynamics, relaxation, and the effects of polaron formation in metal-halide perovskites

To the Editor,

The most common cause of mechanical small bowel obstruction is adhesions related to prior abdominal surgery. Cases of mechanical small bowel obstruction following endoscopy have been rarely reported and most of these cases were related to prior colonoscopy [1]. The following is the first report of intestinal obstruction following endoscopic retrograde cholangiopancreatography (ERCP).

An 81-year-old female was admitted for evaluation following an abnormal liver function test and abdominal ultrasound findings of a dilated common bile duct 12 mm in diameter. The patient had been healthy with a prior history of a total hysterectomy for a large uterine myoma 20 years ago. Her vital signs were stable upon admission with blood pressure (BP), 110/67 mmHg; pulse rate, 90 beats/min (bpm); respiratory rate, 18/min; and body temperature, 36.5℃. A physical examination revealed normoactive bowel sounds and no abdominal tenderness or palpable mass. Chest and abdominal X-rays were normal. Laboratory tests indicated increased alkaline phosphate (175 IU/L) and gamma-glutamyl transferase (237 IU/L). On the second day of admission, an ERCP was performed. Cholangiography revealed no specific lesions, apart from a dilated extrahepatic duct. The day after the procedure, on the third day of admission, serum amylase and serum lipase were elevated to 3,491 U/L and 5,887 U/L, respectively, and the patient was managed by restricting oral intake and intravenous hydration. Three days after the procedure, a physical examination and simple abdominal X-ray revealed no abnormalities and serum amylase and lipase levels returned to normal (36 U/L and 20 U/L, respectively). The patient was then started on a liquid oral diet. Two hours after eating, approximately 72 hours after the procedure, the patient complained of sudden-onset, severe, non-radiating abdominal pain. Physical examination revealed abdominal distension and periumbilical tenderness with decreased bowel sounds and paralytic ileus was suspected. Four days after the procedure, the patient's vital signs deteriorated with BP, 81/57 mmHg; pulse rate, 102 bpm; respiratory rate, 26/min; and body temperature, 36.8℃. An abdominal examination revealed board-like rigidity and abdominal X-rays indicated small bowel dilation with a dilated loop (Fig. 1). Emergent abdominal computed tomography (CT) showed diffuse distension of the small bowel loops with gas and fluid, reduced enhancement in the long segment of the ileum (Fig. 2), and swelling of the pancreas. Strangulated mechanical small bowel obstruction was considered to be a likely diagnosis. The patient went to the operating room for an emergency laparotomy. Upon opening the abdomen, a peritoneal fibrotic band was observed between the right pelvic wall and rectosigmoid colon, creating a 2 cm diameter opening with a loop of small bowel confined into the space. Approximately 1.2 m of the ileum was necrotic and nonviable; therefore, the involved tissue was resected, followed by primary anastomosis. Hemorrhagic necrosis of the ileum was noted on the pathology report (Fig. 3). The patient recovered uneventfully and was discharged 10 days postoperatively.



Figure 1

Plain abdominal X-ray 4 days after the endoscopic retrograde cholangiopancreatography procedure revealed small bowel dilation with a dilated loop.





Figure 2

Abdominal computer tomography 4 days after the endoscopic retrograde cholangiopancreatography procedure shows pneumatosis intestinalis and decreased enhancement of the ileum wall.





Figure 3

Surgical specimen of the small bowel with hemorrhagic necrosis observed through the entire resected region.



The median interval between an initial obstetric operation and small-bowel obstruction is 5.3 years [2]. Therefore, the risk of spontaneous adhesive small bowel obstruction was low in this case since the patient had not developed a small bowel obstruction 20 years after hysterectomy. Reports of small bowel obstructions following colonoscopy note that each of the cases occurred in patients who had previously had surgery, thus suggesting that adhesive small bowel obstruction was initiated by colonoscopy [3]. Additionally, the interval between initial endoscopy and mechanical small bowel obstruction following endoscopy was between 1 to 3 days [1]. In this case, we propose that ERCP initiated a mechanical intestinal obstruction 72 hours after the procedure.

A review of the literature failed to identify any reports of strangulated small bowel obstruction after ERCP. Only a small number of case reports have described mechanical small bowel obstruction following colonoscopy and only one case of small bowel pseudo-obstruction after esophagogastroscopy has been reported [1,4]. Several mechanisms have been proposed as contributing factors to intestinal obstruction following endoscopy, including increased sympathetic tone due to high pressure in the bowel. This is caused by inf lation of the intestine and encapsulation of the small bowel by adhesion with air insufflations through an incompetent ileocecal valve [1]. We suggest two additional mechanisms. First, we hypothesize that the small bowel was forcefully encapsulated into the opening by high pressure during the ERCP procedure. Second, we hypothesize that decreased motility of the small bowel was related to mild acute pancreatitis [5] that aggravated bowel strangulation. This is supported by results from the emergent CT showing swelling of the pancreas on the fourth day after ERCP with normal amylase and lipase levels.

Mechanical small bowel obstruction following endoscopy is rare, but can be a significant complication. Physicians should consider it as a possible diagnosis when a patient has a history of previous abdominal surgery, small bowel obstruction, or acute abdominal pain following endoscopic procedures.

Strangulated small bowel obstruction following endoscopic retrograde cholangiopancreatography.

Drought-simulation facility for assessing tolerance and risks of genetically modified crops

Sarcopenia is associated with obesity and might also be responsible for other disorders. Here, we investigated the prevalence of sarcopenia and its predictors in obese subjects. Subjects who underw...

Do Young Kim

Papers

Hot carrier dynamics, relaxation, and the effects of polaron formation in metal-halide perovskites

Strangulated small bowel obstruction following endoscopic retrograde cholangiopancreatography.

Drought-simulation facility for assessing tolerance and risks of genetically modified crops

Predictors of Sarcopenia in an Obese Asian Population.

Treatment with Ramucirumab-paclitaxel in a metastatic gastric cancer patient undergoing hemodialysis: A case report.