Extensive Dural Venous Thrombosis With Associated Intracerebral Hemorrhage and Subarachnoid Hemorrhage Due to Protein S Deficiency: A Case Report

Cerebral venous thrombosis (CVT) is an uncommon but potentially severe condition, typically affecting younger individuals, pregnant women, and those with underlying thrombophilia. We report a rare case of a 63-year-old female who presented with altered mental status, facial droop, and slurred speech and was found to have an extensive dural venous thrombosis complicated by intracerebral and subarachnoid hemorrhage due to protein S deficiency. Given her diagnosis of protein S deficiency and thrombosis, careful anticoagulation was initiated, resulting in both clinical and radiographic improvement.

Disseminated Varicella-Zoster Virus Presenting With Pneumonitis and Diffuse Alveolar Hemorrhage in an Immunocompetent Patient

Varicella pneumonitis is typically seen in individuals with risk factors such as male gender, smoking history, and immunocompromised state and is often associated with disseminated infection, whereas primary varicella-zoster virus (VZV) infection usually involves a diffuse vesicular rash and rarely progresses to viral pneumonia. VZV pneumonitis accompanied by disseminated VZV infection is associated with a high mortality rate and may progress to diffuse alveolar hemorrhage in severe cases. In addition to cutaneous lesions, patients typically develop dyspnea, cough, tachypnea, chest pain, fever, and hemoptysis. Here, we present a rare case of disseminated VZV infection in an immunocompetent patient with pneumonitis and diffuse alveolar hemorrhage.

Evaluating ChatGPT Responses on Atrial Fibrillation for Patient Education

Background ChatGPT is a language model that has gained widespread popularity for its fine-tuned conversational abilities. However, a known drawback to the artificial intelligence (AI) chatbot is its tendency to confidently present users with inaccurate information. We evaluated the quality of ChatGPT responses to questions pertaining to atrial fibrillation for patient education. Our analysis included the accuracy and estimated grade level of answers and whether references were provided for the answers. Methodology ChatGPT was prompted four times and 16 frequently asked questions on atrial fibrillation from the American Heart Association were asked. Prompts included Form 1 (no prompt), Form 2 (patient-friendly prompt), Form 3 (physician-level prompt), and Form 4 (prompting for statistics/references). Responses were scored as incorrect, partially correct, or correct with references (perfect). Flesch-Kincaid grade-level unique words and response lengths were recorded for answers. Proportions of the responses at differing scores were compared using the chi-square analysis. The relationship between form and grade level was assessed using the analysis of variance. Results Across all forms, scoring frequencies were one (1.6%) incorrect, five (7.8%) partially correct, 55 (85.9%) correct, and three (4.7%) perfect. Proportions of responses that were at least correct did not differ by form (p = 0.350), but perfect responses did (p = 0.001). Form 2 answers had a lower mean grade level (12.80 ± 3.38) than Forms 1 (14.23 ± 2.34), 3 (16.73 ± 2.65), and 4 (14.85 ± 2.76) (p < 0.05). Across all forms, references were provided in only three (4.7%) answers. Notably, when additionally prompted for sources or references, ChatGPT still only provided sources on three responses out of 16 (18.8%). Conclusions ChatGPT holds significant potential for enhancing patient education through accurate, adaptive responses. Its ability to alter response complexity based on user input, combined with high accuracy rates, supports its use as an informational resource in healthcare settings. Future advancements and continuous monitoring of AI capabilities will be crucial in maximizing the benefits while mitigating the risks associated with AI-driven patient education.

Falling From Laughing: Laughing Gas-Induced Subacute Combined Degeneration From Nitrous Oxide

Laughing gas is becoming increasingly popular as a recreational drug of choice, particularly among young adults. Nitrous oxide, the toxic component of laughing gas, can cause neuronal injury when used in high doses. Through multiple mechanisms, nitrous oxide leads to B12 depletion and subsequent demyelination, particularly in the spinal cord. Here, we present the case of a 27-year-old female who presented with ataxia and was found to have laughing gas-induced subacute combined degeneration from nitrous oxide. After aggressive vitamin B12 repletion and laughing gas cessation for three months, the patient improved.

Evaluating ChatGPT-3.5 and ChatGPT-4.0 Responses on Hyperlipidemia for Patient Education

Introduction Hyperlipidemia is prevalent worldwide and affects a significant number of US adults. It significantly contributes to ischemic heart disease and millions of deaths annually. With the increasing use of the internet for health information, tools like ChatGPT (OpenAI, San Francisco, CA, USA) have gained traction. ChatGPT version 4.0, launched in March 2023, offers enhanced features over its predecessor but requires a monthly fee. This study compares the accuracy, comprehensibility, and response length of the free and paid versions of ChatGPT for patient education on hyperlipidemia. Materials and methods ChatGPT versions 3.5 and 4.0 were prompted in three different ways and 25 questions from the Cleveland Clinic's frequently asked questions (FAQs) on hyperlipidemia. Prompts included no prompting (Form 1), patient-friendly prompting (Form 2), and physician-level prompting (Form 3). Responses were categorized as incorrect, partially correct, or correct. Additionally, the grade level and word count from each response were recorded for analysis. Results Overall, scoring frequencies for ChatGPT version 3.5 were: five (6.67%) incorrect, 18 partially correct (24%), and 52 (69.33%) correct. Scoring frequencies for ChatGPT version 4.0 were: one (1.33%) incorrect, 18 (24.00%) partially correct, and 56 (74.67%) correct. Correct answers did not significantly differ between ChatGPT version 3.5 and ChatGPT version 4.0 (p = 0.586). ChatGPT version 3.5 had a significantly higher grade reading level than version 4.0 (p = 0.0002). ChatGPT version 3.5 had a significantly higher word count than version 4.0 (p = 0.0073). Discussion There was no significant difference in accuracy between the free and paid versions of hyperlipidemia FAQs. Both versions provided accurate but sometimes partially complete responses. Version 4.0 offered more concise and readable information, aligning with the readability of most online medical resources despite exceeding the National Institutes of Health's (NIH's) recommended eighth-grade reading level. The paid version demonstrated superior adaptability in tailoring responses based on the input. Conclusion Both versions of ChatGPT provide reliable medical information, with the paid version offering more adaptable and readable responses. Healthcare providers can recommend ChatGPT as a source of patient education, regardless of the version used. Future research should explore diverse question formulations and ChatGPT's handling of incorrect information.

Pulmonary Embolism in Patients Admitted With Peripartum Cardiomyopathy: Prevalence, Predictors, and Associated In-Hospital Adverse Events

Introduction Peripartum cardiomyopathy (PPCM) is defined as an idiopathic left ventricular failure with reduced ejection fraction (EF <45%) that affects women in the last month of pregnancy or in the months after giving birth. The pathophysiology remains elusive, resulting in complications with varied severity; one of the most concerning complications is thromboembolism, specifically pulmonary embolism (PE). The purpose of this study was to characterize and evaluate the real-world prevalence, predictors, and outcomes of PE in PPCM. Methods The data were derived from the National Inpatient Sample (NIS) database from January 2016 to December 2019. The primary outcomes assessed were baseline and hospital admission characteristics and comorbidities for patients with PPCM with or without PE. Outcomes for PPCM patients with PE and predictors of mortality for PPCM were also analyzed. Results PE developed in 105 of 4,582 patients with PPCM (2.3%). Patients with PPCM and PE had longer hospital stays (10.86 days ± 1.4 vs. 5.73 ± 0.2 days, p = 0.001) and total charges ($169,487 ± $39,628 vs. $86,116 ± $3,700, p = 0.001). Patients with PE had a higher burden of coagulopathy (13.3% vs. 3.0%, p = 0.01), intracardiac thrombus (6.7% vs. 1.6%, p = 0.01), and iron deficiency anemia (21.0% vs. 12.6%, p = 0.01). Patients without PE were found to have a higher burden of preeclampsia (14.7% vs. 1.9%, p = 0.01) and obstructive sleep apnea (5.4% vs. 1.0%, p = 0.045). Predictors of mortality in patients with PPCM included cardiogenic shock (aOR 13.42, 95% CI 7.50-24.03, p = 0.05), PE (aOR 6.60, 95% CI 2.506-17.39, p = 0.05), non-ST-elevation myocardial infarction (NSTEMI; aOR 3.57, 95% CI 1.35-9.44, p = 0.05), chronic kidney disease (aOR 3.23, 95% CI 1.68-6.22, p = 0.05), and atrial fibrillation (aOR 2.57; 95% CI 1.25-5.30, p = 0.05). Conclusion Although an uncommon complication, PE in PPCM demonstrates an association with higher mortality and financial burden. Along with PE, we found predictors of mortality in PPCM to include atrial fibrillation, NSTEMI, chronic kidney disease, and cardiogenic shock.

Pulmonary Embolism in Patients Admitted With Takotsubo Cardiomyopathy: Prevalence and Associated In-Hospital Adverse Events

Introduction  Takotsubo cardiomyopathy (TCM) is a poorly understood condition typically characterized by abnormal left ventricular wall motion without causative coronary artery disease and typically presents in post-menopausal women after the experience of a physical or emotional stressor. The pathophysiology of TCM is complex and multifactorial, resulting in complications with varied severity; one of the most concerning complications is thromboembolism, specifically, pulmonary embolism (PE), which is understudied in its relation to TCM. The purpose of this study was to characterize and evaluate the real-world prevalence and outcomes of PE in TCM. Methods  Data were derived from the National Inpatient Sample database from January 2016 to December 2019. The primary outcomes assessed were baseline and hospital admission characteristics and comorbidities for patients with TCM with and without PE. Outcomes for TCM patients with PE and predictors of mortality in TCM were also analyzed. Results  PE developed in 788 of 40,120 patients with TCM (1.96%). After multivariate adjustment, PE was found to be independently associated with intracardiac thrombus (adjusted odds ratio (aOR) 2.067; 95% confidence interval (CI): 1.198-3.566; p = 0.009) and right heart catheterization (RHC) (aOR: 1.971; 95% CI: 1.160-3.350; p = 0.012). Mortality in patients with TCM was associated with, among other factors, age in years at admission (aOR: 1.104; 95% CI: 1.010-1.017; p = 0.001), African American race (aOR: 1.191; 95% CI: 1.020-1.391; p = 0.027), Asian or Pacific Islander race (aOR: 1.637; 95% CI: 1.283-2.090; p = 0.001), coagulopathy (aOR: 3.393; 95% CI: 2.889-2.986; p = 0.001), liver disease (aOR: 1.446; 95% CI: 1.147-1.824; p = 0.002), atrial fibrillation (aOR: 1.460; 95% CI: 1.320-1.615; p = 0.001), and pulmonary embolism (aOR: 2.217; 95% CI: 1.781-2.760; p = 0.001). Conclusion  In a large cohort of patients admitted with TCM, we found the prevalence of PE to be 1.96%. PE, along with comorbidities such as coagulopathy and atrial fibrillation, was found to be a significant predictor of mortality in this patient cohort.

Role of serum eosinophil cationic protein in distinct endotypes of chronic rhinosinusitis

BACKGROUND

Serum eosinophil cationic protein (ECP) levels affect the surgical outcome of chronic rhinosinusitis (CRS) with nasal polyps. Primary CRS can be classified into type 2 (T2) and non-T2. We aimed to differentiate the role of serum ECP levels in surgical outcomes between the distinct endotypes of primary CRS.

METHODS

We prospectively enrolled patients with bilateral primary CRS who underwent surgical treatment with postoperative follow-up for at least 12 months. Endotyping and serum parameter measurements were completed within 1 week before surgery.

RESULTS

In total, 113 patients were enrolled, including 65 with T2 CRS and 48 with non-T2 CRS. Patients in the T2 CRS group with uncontrolled CRS had significantly higher serum ECP levels than those in patients in the non-T2 CRS group. An optimal cut-off value was obtained at 17.0 μg/L using the receiver operating characteristic curve, attaining a sensitivity of 91.7% and specificity of 56.6%. Multivariate logistic regression analysis showed that a higher serum ECP level was an independent factor for postoperative uncontrolled disease. The hazard ratio was 11.3 for the T2 group, with serum ECP levels over 17.0 μg/L. In the non-T2 group, no parameters were significantly correlated with postoperative uncontrolled CRS.

CONCLUSIONS

Serum ECP levels appear to be a feasible predictor of postoperative uncontrolled disease in patients with T2 CRS as preoperative serum ECP levels >17.0 μg/L in these patients have an approximately 16.7-fold increased risk of postoperative uncontrolled disease and should be closely monitored.

Risk-stratified faecal immunochemical testing (FIT) for urgent colonoscopy in Lynch syndrome during the COVID-19 pandemic

BACKGROUND

Lynch syndrome is a hereditary cancer disease resulting in an increased risk of colorectal cancer. Herein, findings are reported from an emergency clinical service implemented during the COVID-19 pandemic utilizing faecal immunochemical testing ('FIT') in Lynch syndrome patients to prioritize colonoscopy while endoscopy services were limited.

METHODS

An emergency service protocol was designed to improve colonoscopic surveillance access throughout the COVID-19 pandemic in England for people with Lynch syndrome when services were extremely restricted (1 March 2020 to 31 March 2021) and promoted by the English National Health Service. Requests for faecal immunochemical testing from participating centres were sent to the National Health Service Bowel Cancer Screening South of England Hub and a faecal immunochemical testing kit, faecal immunochemical testing instructions, paper-based survey, and pre-paid return envelope were sent to patients. Reports with faecal haemoglobin results were returned electronically for clinical action. Risk stratification for colonoscopy was as follows: faecal haemoglobin less than 10 µg of haemoglobin/g of faeces (µg/g)-scheduled within 6-12 weeks; and faecal haemoglobin greater than or equal to 10 µg/g-triaged via an urgent suspected cancer clinical pathway. Primary outcomes of interest included the identification of highest-risk Lynch syndrome patients and determining the impact of faecal immunochemical testing in risk-stratified colonoscopic surveillance.

RESULTS

Fifteen centres participated from June 2020 to March 2021. Uptake was 68.8 per cent amongst 558 patients invited. For 339 eligible participants analysed, 279 (82.3 per cent) had faecal haemoglobin less than 10 µg/g and 60 (17.7 per cent) had faecal haemoglobin greater than or equal to 10 µg/g. In the latter group, the diagnostic accuracy of faecal immunochemical testing was 65.9 per cent and escalation to colonoscopy was facilitated (median 49 versus 122 days, χ2 = 0.0003, P < 0.001).

CONCLUSION

Faecal immunochemical testing demonstrated clinical value for Lynch syndrome patients requiring colorectal cancer surveillance during the pandemic in this descriptive report of an emergency COVID-19 response service. Further longitudinal investigation on faecal immunochemical testing efficacy in Lynch syndrome is warranted and will be examined under the 'FIT for Lynch' study (ISRCTN15740250).

Obesity and the Latissimus Dorsi Flap: A Radiologic Study

Introduction: The increasing prevalence of obesity in patients with breast cancer has prompted a reappraisal of the role of the latissimus dorsi flap (LDF) in breast reconstruction. Although the reliability of this flap in obese patients is well-documented, it is unclear whether sufficient volume can be achieved through a purely autologous reconstruction (eg, extended harvest of the subfascial fat layer). Additionally, the traditional combined autologous and prosthetic approach (LDF + expander/implant) is subject to increased implant-related complication rates related to flap thickness in obese patients. The purpose of this study is to provide data on the thicknesses of the various components of the latissimus flap and discuss the implications for breast reconstruction in patients with increasing body mass index (BMI). Methods: Measurements of back thickness in the usual donor site area of an LDF were obtained in 518 patients undergoing prone computed tomography-guided lung biopsies. Thicknesses of the soft tissue overall and of individual layers (e.g., muscle, subfascial fat) were obtained. Patient, demographics including age, gender, and BMI were obtained. Results: A range of BMI from 15.7 to 65.7 was observed. In females, total back thickness (skin, fat, muscle) ranged from 0.6 to 9.4 cm. Every 1-point increase in BMI resulted in an increase of flap thickness by 1.11 mm (adjusted R2 of 0.682, P < .001) and an increase in the thickness of the subfascial fat layer by 0.513 mm (adjusted R2 of 0.553, P < .001). Mean total thicknesses for each weight category were 1.0, 1.7, 2.4, 3.0, 3.6, and 4.5 cm in underweight, normal weight, overweight, and class I, II, III obese individuals, respectively. The average contribution of the subfascial fat layer to flap thickness was 8.2 mm (32%) overall and 3.4 mm (21%), 6.7 mm (29%), 9.0 mm (30%), 11.1 mm (32%), and 15.6 mm (35%) in normal weight, overweight, class I, II, III obese individuals, respectively. Conclusion: The above findings demonstrate that the thickness of the LDF overall and of the subfascial layer closely correlated with BMI. The contribution of the subfascial layer to overall flap thickness tends to increase as a percentage of overall flap thickness with increasing BMI, which is favourable for extended LDF harvests. Because this layer cannot be separated from overall thickness on examination, these results are useful in estimating the amount of additional volume obtained from an extended latissimus harvest technique.

Identifying a sphenoid sinus fungus ball using a nomogram model

Background: Sphenoid sinus fungus ball (SSFB) is a rare entity and usually presents with non-specific symptoms. SSFB could potentially lead to serious orbital and intracranial complications. Computed tomography (CT) scan is usually the first imaging test of the diagnostic workup in patients with specific clinical symptoms. This study aimed to compare the clinical characteristics and CT features between SSFB and unilateral (non-fungus ball) chronic sphenoid rhinosinusitis (USRS) and help differentiate between these two most common inflammatory diseases of the sphenoid sinus. Methods: By retrospective database review, 66 patients with a histopathologic diagnosis of isolated SSFB were recruited for analysis. Fifty-four patients who underwent endoscopic sinus surgery with clinical and histopathological diagnoses of USRS were enrolled as the control group. Clinical characteristics and CT features were evaluated. Results: Headache, rhinorrhoea, nasal obstruction, postnasal dripping, and hyposmia were the most common symptoms in both groups. In the univariate analysis, older age, lower white blood cell counts, irregular surface, bony dehiscence, lateral wall sclerosis, and intralesional hyperdensity (IH) were significant predictors for SSFB. Older age, irregular surface, and IH remained statistically significant in the multivariate analysis. Based on the results of the regression analysis, a nomogram for predicting the probability of SSFB was plotted. Conclusions: We developed a nomogram model as a novel preoperative diagnostic tool for identifying SSFB according to the predictors both in clinical characteristics and on CT features. This could help the clinicians in predicting the probability of SSFB, to reduce ineffective or delayed treatment and occurrence of complications.

Left ventricle geometry, atrial strain, ventricle strain, and hemodynamics across aortic valve before and after transcatheter aortic valve replacements

INTRODUCTION

Transcatheter aortic valve replacements (TAVRs) has become widespread throughout the world. To date, there are no echocardiographic studies of TAVR patients from Southeast Asia (SEA). We sought to evaluate (1) changes in echocardiographic and strain values pre- and post-TAVR (2) relationship between aortic stenosis (AS) severity and strain values, (3) left ventricle geometry in severe AS, (4) relationship of flow rate to dimensionless index (DVI) and acceleration time (AT), and (5) effect of strains on the outcome.

MATERIALS AND METHODS

Retrospective study of 112 TAVR patients in our centre from 2009 to 2020. The echocardiographic and strain images pre (within 1 month), post (day after), and 6 months post-TAVR were analyzed by expert echocardiographer.

RESULTS

The ejection fraction (EF) increased at 6 months (53.02 ± 12.12% to 56.35 ± 9.00%) (p=0.044). Interventricular septal thickness in diastole (IVSd) decreased (1.27 ± 0.21 cm to 1.21 ± 0.23 cm) (p=0.038) and left ventricle internal dimension in diastole (LVIDd) decreased from 4.77 ± 0.64 cm to 4.49 ± 0.65 cm (p=0.001). No changes in stroke volume index (SVI pre vs 6 months p=0.187), but the flow rate increases (217.80 ± 57.61 mls/s to 251.94 ± 69.59 mls/s, p<0.001). Global longitudinal strain (GLS) improved from -11.44 ± 4.23% to -13.94 ± 3.72% (p<0.001), left atrial reservoir strain (Lar-S) increased from 17.44 ± 9.16% to 19.60 ± 8.77% (p=0.033). Eight patients (7.5%) had IVSd < 1.0 cm, and 4 patients (3.7%) had normal left ventricle (LV) geometry. There was linear relationship between IVSd and mean PG (r=0.208, p=0.031), between GLS to aortic valve area (AVA) and aortic valve area index (AVAi) (r = - 0.305, p=0.001 and r= - 0.316, p= 0.001). There was also relationship between AT (r=-0.20, p=0.04) and DVI (r=0.35, p<0.001) with flow rate. Patients who died late (after 6 months) had lower GLS at 6 months. (Alive; -13.94 ± 3.72% vs Died; -12.43 ± 4.19%, p=0.001).

CONCLUSION

At 6 months, TAVR cause reverse remodelling of the LV with the reduction in IVSd, LVIDd, and improvement in GLS and LAr-S. There is a linear relationship between GLS and AVA and between IVSd and AVA.

A 21-Year-Old Man With a Cough

CASE PRESENTATION

A 21-year-old male African American college student from Southern California, with no significant medical history, was visiting family in southwestern Texas when he presented to the hospital with 1 week history of cough, shortness of breath, lower back pain, and a 10-pound weight loss.

Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis

OBJECTIVE

The COVID-19 pandemic has had a major global impact on endoscopic services. This reduced capacity, along with public reluctance to undergo endoscopy during the pandemic, might result in excess mortality from delayed cancer diagnosis. Using the UK's National Endoscopy Database (NED), we performed the first national analysis of the impact of the pandemic on endoscopy services and endoscopic cancer diagnosis.

DESIGN

We developed a NED COVID-19 module incorporating procedure-level data on all endoscopic procedures. Three periods were designated: pre-COVID (6 January 2020 to 15 March), transition (16-22 March) and COVID-impacted (23 March-31 May). National, regional and procedure-specific analyses were performed. The average weekly number of cancers, proportion of missing cancers and cancer detection rates were calculated.

RESULTS

A weekly average of 35 478 endoscopy procedures were performed in the pre-COVID period. Activity in the COVID-impacted period reduced to 12% of pre-COVID levels; at its low point, activity was only 5%, recovering to 20% of pre-COVID activity by study end. Although more selective vetting significantly increased the per-procedure cancer detection rate (pre-COVID 1.91%; COVID-impacted 6.61%; p<0.001), the weekly number of cancers detected decreased by 58%. The proportion of missing cancers ranged from 19% (pancreatobiliary) to 72% (colorectal).

CONCLUSION

This national analysis demonstrates the remarkable impact that the pandemic has had on endoscopic services, which has resulted in a substantial and concerning reduction in cancer detection. Major, urgent efforts are required to restore endoscopy capacity to prevent an impending cancer healthcare crisis.

Does Smoking Status Influence Health-Related Quality of Life Outcome Measures in Patients Undergoing ACDF?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology.

METHODS

Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value <.05 was considered significant.

RESULTS

A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P = .010), lower VAS neck pain than current (P = .035) and former (P = .014) smokers, as well as lower VAS arm pain than former smokers (P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P = .030) and former smokers (P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis.

CONCLUSIONS

Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

BowelScope: Accuracy of Detection Using Endocuff Optimisation of Mucosal Abnormalities (the B-ADENOMA Study): a multicentre, randomised controlled flexible sigmoidoscopy trial

OBJECTIVES

Adenoma detection rate (ADR) is an important quality marker at lower GI endoscopy. Higher ADRs are associated with lower postcolonoscopy colorectal cancer rates. The English flexible sigmoidoscopy (FS) screening programme (BowelScope), offers a one-off FS to individuals aged 55 years. However, variation in ADR exists. Large studies have demonstrated improved ADR using Endocuff Vision (EV) within colonoscopy screening, but there are no studies within FS. We sought to test the effect of EV on ADR in a national FS screening population.

DESIGN

BowelScope: Accuracy of Detection Using ENdocuff Optimisation of Mucosal Abnormalities was a multicentre, randomised controlled trial involving 16 English BowelScope screening centres. Individuals were randomised to Endocuff Vision-assisted BowelScope (EAB) or Standard BowelScope (SB). ADR, polyp detection rate (PDR), mean adenomas per procedure (MAP), polyp characteristics and location, participant experience, procedural time and adverse events were measured. Comparison of ADR within the trial with national BowelScope ADR was also undertaken.

RESULTS

3222 participants were randomised (53% male) to receive EAB (n=1610) or SB (n=1612). Baseline demographics were comparable between arms. ADR in the EAB arm was 13.3% and that in the SB arm was 12.2% (p=0.353). No statistically significant differences were found in PDR, MAP, polyp characteristics or location, participant experience, complications or procedural characteristics. ADR in the SB control arm was 3.1% higher than the national ADR.

CONCLUSION

EV did not improve BowelScope ADR when compared with SB. ADR in both arms was higher than the national ADR. Where detection rates are already high, EV is unable to improve detection further.

TRIAL REGISTRATION NUMBERS

NCT03072472, ISRCTN30005319 and CPMS ID 33224.

Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial

OBJECTIVE

Low adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC).

DESIGN

Patients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured.

RESULTS

1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, P<0.001). EV patients had higher detection of mean adenomas per procedure, sessile serrated polyps, left-sided, diminutive, small adenomas and cancers (cancer 4.1% vs 2.3%, P=0.02). EV removal rate was 4.1%. Median intubation was a minute quicker with EAC (P=0.001), with no difference in caecal intubation rate or withdrawal time. EAC was well tolerated but caused a minor increase in discomfort on anal intubation in patients undergoing colonoscopy with no or minimal sedation. There were no significant EV adverse events.

CONCLUSION

EV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection.

TRIAL REGISTRATION NUMBER

NCT02552017, Results; ISRCTN11821044, Results.

Association between fetal fraction on cell-free DNA testing and first-trimester markers for pre-eclampsia

OBJECTIVES

To evaluate the association between fetal fraction on cell-free DNA (cfDNA) testing and first-trimester markers for pre-eclampsia, and to investigate the possible association of low fetal fraction with increased risks for pre-eclampsia (PE) and fetal growth restriction (FGR).

METHODS

This was a retrospective cohort study including all women with a singleton pregnancy who had risk calculation for PE and FGR between 11 + 0 and 13 + 6 weeks' gestation and who also had cfDNA as a primary or secondary screening test for chromosomal abnormalities at any gestational age at two fetal medicine clinics in Sydney and Melbourne, Australia, between March 2013 and May 2017. Logarithmically transformed fetal fraction results were adjusted for gestational age and maternal characteristics. Associations with mean arterial pressure (MAP), mean uterine artery pulsatility index (UtA-PI), pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF), and risks for PE < 34 weeks, PE < 37 weeks and FGR < 37 weeks were analyzed using correlation analysis and univariable and multivariable linear regressions.

RESULTS

In total, 4317 singleton pregnancies that underwent cfDNA testing with fetal fraction reported were included. Significant prediction of fetal fraction was provided by gestational age, conception by in-vitro fertilization, maternal age, body mass index, chronic hypertension, diabetes mellitus, South Asian ethnicity and being parous without history of PE or FGR. Fetal fraction was associated inversely with MAP and UtA-PI and associated positively with PAPP-A and PlGF. The lower the fetal fraction, the higher were the risks for PE < 34 weeks, PE < 37 weeks and FGR < 37 weeks (P < 0.001 for all).

CONCLUSIONS

There is a significant association between fetal fraction result and first-trimester markers for adverse pregnancy outcome. Low fetal fraction is associated with an increased risk for pregnancy complication, but its capacity to act an as independent first-trimester marker in an algorithm for screening for PE and FGR requires further research. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Hip Synovial Fluid Cell Counts in Children From a Lyme Disease Endemic Area

BACKGROUND

Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated.

METHODS

We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type.

RESULTS

Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303-209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789-73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis.

CONCLUSIONS

In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis.

LSD1 demethylates HIF1α to inhibit hydroxylation and ubiquitin-mediated degradation in tumor angiogenesis

Lysine-specific demethylase 1 (LSD1), which has been considered as a potential therapeutic target in human cancer, has been known to regulate many biological functions through its non-histone substrates. Although LSD1-induced hypoxia-inducible factor alpha (HIF1α) demethylation has recently been proposed, the effect of LSD1 on the relationship between HIF1α post-translational modifications (PTMs) and HIF1α-induced tumor angiogenesis remains to be elucidated. Here, we identify a new methylation site of the HIF1α protein antagonized by LSD1 and the interplay between HIF1α protein methylation and other PTMs in regulating tumor angiogenesis. LSD1 demethylates HIF1α at lysine (K) 391, which protects HIF1α against ubiquitin-mediated protein degradation. LSD1 also directly suppresses PHD2-induced HIF1α hydroxylation, which has a mutually dependent interplay with Set9-mediated HIF1α methylation. Moreover, the HIF1α acetylation that occurs in a HIF1α methylation-dependent manner is inhibited by the LSD1/NuRD complex. HIF1α stabilized by LSD1 cooperates with CBP and MTA1 to enhance vascular endothelial growth factor (VEGF)-induced tumor angiogenesis. Thus, LSD1 is a key regulator of HIF1α/VEGF-mediated tumor angiogenesis by antagonizing the crosstalk between PTMs involving HIF1α protein degradation.

Clinical analysis of submucosal Medpor implantation for empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) describes symptomatology and radiographic findings after surgeries on turbinates.The treatment of ENS is still debatable.

PURPOSE

To analyse clinical outcomes of submucosal Medpor® implantation for ENS.

METHODS

A total of 18 patients underwent submucosal Medpor® implantation from 2006 to 2011. We applied SNOT-22 (SinoNasalOutcome Test) for statistical survey of the patients' symptoms before and after surgery.

RESULTS

Two patients were lost to follow up after the surgery. Most of the patients developed ENS-related symptoms gradually within 2 years to 16 years after the previous nasal surgery or treatment. The sites of submucosal implantation are mainly septum and nasal floor, unilaterally or bilaterally. There is a significant improvement of SNOT-22 pre-operatively to one year post-operatively.

CONCLUSIONS

The symptomatolgy remains the most important point when dealing with patients with ENS. Submucosal implantation of Medpor® is a feasible surgical treatment to ENS. A positive cotton test is suggested for the surgical indication and planning.