Principales aplicaciones de la ecografía clínica en cuidados paliativos / Main applications of clinical ultrasound in palliative care

Las personas con enfermedades oncológicas avanzadas padecen procesos clínicos intercurrentes y otras manifestaciones relacionadas con la propia progresión tumoral que generan un gran impacto en su calidad de vida. Los profesionales que trabajan en este campo necesitan incorporar nuevos conocimientos y herramientas de diagnóstico y tratamiento que faciliten el manejo de estas personas, de complejidad tan elevada, de la forma menos invasiva posible1. La ecografía clínica (EC) es una de esas herramientas cuyo desarrollo ha sido excepcional en las últimas décadas. Los avances tecnológicos han permitido disponer de equipos de bolsillo cada vez más sofisticados, asequibles económicamente y que pueden ser utilizados allí donde se encuentre la persona enferma como una extensión de la exploración física2. De esta manera el profesional puede dar respuesta a diferentes situaciones o entidades sindrómicas en las que la rentabilidad de la EC puede ser elevada. La pretensión es evitar, en la medida de lo posible, el traslado del paciente al hospital o a una ubicación intrahospitalaria, lo que redunda en su confort y calidad de vida, además de empoderar al profesional en la toma de decisiones clínicas. (AU)

People with advanced cancer suffer from intercurrent clinical conditions and other tumor progression-related manifestations that can have a great impact on their quality of life. Professionals working in this field need to incorporate new knowledge, as well as diagnostic and treatment tools to facilitate the management of these highly complex patients in the least invasive way possible1. Clinical ultrasound (CU) is one of those tools whose development has been exceptional in recent decades. Technological advances have made it possible to have increasingly sophisticated and affordable pocket equipments available, which can be used wherever the patient is as an extension of physical examination2. In this way, a professional can respond to different situations or syndromic conditions in which CU yield may be high. The aim is to avoid, whenever possible, the transfer of patients to in-hospital facilities, which can result in loss of both comfort and quality of life. In addition, an appropriate use of CU can empower the team charged with making clinical decisions. (AU)

The role of glucagon after bariatric/metabolic surgery: much more than an "anti-insulin" hormone.

The biological activity of glucagon has recently been proposed to both stimulate hepatic glucose production and also include a paradoxical insulinotropic effect, which could suggest a new role of glucagon in the pathophysiology type 2 diabetes mellitus (T2DM). An insulinotropic role of glucagon has been observed after bariatric/metabolic surgery that is mediated through the GLP-1 receptor on pancreatic beta cells. This effect appears to be modulated by other members of the proglucagon family, playing a key role in the beneficial effects and complications of bariatric/metabolic surgery. Glucagon serves a dual role after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). In addition to maintaining blood glucose levels, glucagon exhibits an insulinotropic effect, suggesting that glucagon has a more complex function than simply an "anti-insulin hormone".

Ecografía clínica en cuidados paliativos. Principios básicos / Clinical ultrasound in palliative care. Basic principles

La ecografía clínica se emplea cada vez por más profesionales sanitarios de diversas disciplinas asistenciales. En cuidados paliativos existen iniciativas que han puesto de manifiesto la utilidad de sus múltiples aplicaciones, permitiendo ofrecer respuestas a cuestiones diversas, tanto en el hospital como en el domicilio. No debe suponer una perturbación del confort del paciente contribuyendo a evitar la percepción por parte de pacientes y familiares de “abandono tecnológico” en las fases más avanzadas de la enfermedad. El avance tecnológico de estos dispositivos permite disponer de opciones que aúnan precio, portabilidad, sencillez de manejo y calidad de imagen suficiente para satisfacer los requisitos para su empleo en las necesidades asistenciales más habituales en cuidados paliativos. La curva de aprendizaje en su manejo es relativamente rápida, esperando que esta serie de publicaciones con material teórico-práctico en la revista Medicina Paliativa contribuyan a establecer una base de conocimiento para los profesionales interesados en este tema, pudiendo continuarse más adelante con un sistema para una adecuada acreditación de competencias. (AU)

Clinical ultrasound is being increasingly used by health professionals from various healthcare disciplines. In Palliative Care some initiatives have revealed the usefulness of its multiple applications, allowing to answer various questions both in the hospital and at home. It should not imply a disturbance of patient wellbeing, and helps avoid the perception, both by patients and relatives, of “technological abandonment” in the most advanced phases of disease. The technological advance of these devices allows having options that combine price, portability, ease of use, and sufficient image quality to satisfy the requirements of use in the most common care settings in Palliative Care. The learning curve in its operation is relatively fast, and we hope that this series of publications with theoretical-practical material in the Palliative Medicine journal will contribute to establishing a knowledge base for professionals interested in this topic, which might be later expanded by providing a system for adequate accreditation of competencies. (AU)

Main applications of point-of-care ultrasound in palliative care.

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

Dual effect of RYGB on the entero-insular axis: How GLP-1 is enhanced by surgical duodenal exclusion.

BACKGROUND: The role of the ileum and Glucagon Like Peptide-1 (GLP-1) secretion in the pathophysiological processes underlying the effects of Roux-en-Y gastric bypass (RYGB) on type 2 Diabetes mellitus (T2DM) improvement has been previously determined. However, the roles of duodenal exclusion and Glucose Insulinotropic Peptide (GIP) secretion change is not clear. To clarify this aspect, we compared the pathophysiological mechanisms triggered by RYGB, which implies the early arrival of food to the ileum with duodenal exclusion, and through pre-duodenal ileal transposition (PdIT), with early arrival of food to the ileum but without duodenal exclusion, in a nondiabetic rodent model. METHODS: We compared plasma and insulin, glucose (OGTT), GIP and GLP-1 plasma levels, ileal and duodenal GIP and GLP-1 tissue expression and beta-cell mass for n = 12 Sham-operated, n = 6 RYGB-operated, and n = 6 PdIT-operated Wistar rats. RESULTS: No surgery induced changes in blood glucose levels after the OGTT. However, RYGB induced a significant and strong insulin response that increased less in PdIT animals. Increased beta-cell mass was found in RYGB and PdIT animals as well as similar GLP-1 secretion and GLP-1 intestinal expression. However, differential GIP secretion and GIP duodenal expression were found between RYGB and PdIT. CONCLUSION: The RYGB effect on glucose metabolism is mostly due to early ileal stimulation; however, duodenal exclusion potentiates the ileal response within RYGB effects through enhanced GIP secretion.

Somatostatin: From a supporting actor to the protagonist to explain the long-term effect of sleeve gastrectomy on glucose metabolism.

BACKGROUND: Bariatric/metabolic surgery has become the most effective treatment against type 2 Diabetes mellitus (T2DM). The role of many gastrointestinal hormones in T2DM has been proposed, but the pathophysiological models described vary greatly depending on the anatomical rearrangements after surgery. We focus on somatostatin as a common factor in two of the most commonly performed surgical procedures in a healthy rodent model. We performed sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) and also an experimental surgery without gastric involvement (intestinal resection of 50 % jejunum-ileum portion -IR50 %). METHODS: We used five groups of Wistar rats: fasting control, sham-operated, SG-operated, RYGB-operated and IR50-operated. We analysed several parameters 4 and 23 weeks after surgery: plasma SST-14/28 fractions, plasma glucose, insulin release and SST-producing cell expression in the duodenum and pancreatic islets. RESULTS: Numerous SST-producing cells in the duodenum but a low number in the pancreas and a long-term loss of glucose tolerance were observed in SG and RYGB animals. Additionally, a high plasma SST-28 fraction was found in animals after SG but not after RYGB. Finally, IR50 animals showed no differences versus controls. CONCLUSIONS: In our SG model the amplitude of insulin response after metabolic surgeries, is mediated by SST-28 plasma levels derived from the proportional compensatory effect of gastric SST-producing tissue ablation. In addition, a strong compensatory response to the surgical loss of gastric SST-producing cells, leads to long-term loss of insulin production after SG but not in the others.

Peptide Tyrosine-Tyrosine Triggers GLP-2-Mediated Intestinal Hypertrophy After Roux-en-Y Gastric Bypass.

PURPOSE : Intestinal remodeling and adaptation of the alimentary limb after Roux-en-Y gastric bypass (RYGB) play an important role in the pathophysiological events that lead to type 2 diabetes mellitus (T2DM) improvement. Intestinal absorptive loop hypertrophy and growth following surgery have been related to GLP-2 secretion by ileal L-cells. The secretion of peptide tyrosine-tyrosine (PYY) enterohormone after a meal has been proposed as a trigger for ileal secretion of GLP-1. Our aim is to determine the role of PYY as a GLP-2 secretion modulator as an adaptation result in the alimentary limb after RYGB. METHOD: We used a non-obese euglycemic rodent model. Circulating glucose, insulin, PYY, and GLP-2 were measured in the experimental and control groups. We used four groups: fasting control, Sham-operated, RYGB-operated (RYGB), and RYGB-operated and treated with BIIE0246 (RYGB + BII). BIIE0246 is a NPY2 receptor antagonist in L-cells. Intestinal glucose transporters and GLP-1 and PYY gut expression and hypertrophy were analyzed after 12 weeks of surgery. RESULTS: RYGB increased PYY3-36 plasma levels in rats with or without BII treatment. A high-insulin response was observed in the RYGB group but not in the control or RYGB + BII groups. BIIE0246 treatment limited plasma GLP-2 levels. In the alimentary intestinal limb, hypertrophy and SGLT1 and GLUT1 expression appeared to be reduced after RYGB compared to controls. CONCLUSION: The postprandial ileal PYY secretion is enhanced after RYGB. This increase mediates GLP-2 release through its binding to the Y2 receptor on L-cells. This mechanism plays a role in alimentary limb hypertrophy after surgery.

Sleeve Gastrectomy and Roux-En-Y Gastric Bypass. Two Sculptors of the Pancreatic Islet.

Several surgical procedures are performed for the treatment of obesity. A main outcome of these procedures is the improvement of type 2 diabetes mellitus. Trying to explain this, gastrointestinal hormone levels and their effect on organs involved in carbohydrate metabolism, such as liver, gut, muscle or fat, have been studied intensively after bariatric surgery. These effects on endocrine-cell populations in the pancreas have been less well studied. We gathered the existing data on these pancreatic-cell populations after the two most common types of bariatric surgery, the sleeve gastrectomy (SG) and the roux-en-Y gastric bypass (RYGB), with the aim to explain the pathophysiological mechanisms underlying these surgeries and to improve their outcome.

The histomorphometric parameters of endocrine pancreas after bariatric surgery in healthy animal models.

BACKGROUND: The aim of this study is to describe in depth how different bariatric surgeries affect to the cellularity of ß-cells in the pancreatic islet. There are much data regarding the possible physiological mechanisms involved in resolution of type 2 diabetes after bariatric surgery. But these data usually are controversial. We reported a direct influence of bariatric surgical technique on endocrine pancreas cellular turnover. Some surgeries increase proliferation processes of the ß-cells. Our objective is to report the histomorphometric mechanism that these techniques stimulate over the cellularity of pancreatic islet. METHOD: To this purpose, we used adult male Wistar rats to undergo the different techniques. We developed three surgical techniques (Sleeve gastrectomy and Y-Roux Gastric bypass as the most usual bariatric techniques, and a purely malabsorptive technique); moreover two control groups were performed (Sham and fasting controls). RESULTS: We completed a sequence of morphometric studies to conclude the behaviour of endocrine pancreatic ß-cell islet, correlating several histomorphometry parameters. CONCLUSION: Our purpose was to show a comprehensive interpretation to the consequences that bariatric surgeries had on the pancreatic islets cellularity. Moreover, we included the main tests to report the cellularity in histological samples.