The use of cone beam computed tomography in the management of external cervical resorption lesions

AIM

To report the use of cone beam computed tomography in the assessment of external cervical resorption lesions.

SUMMARY

Asymptomatic external cervical resorption lesions were diagnosed radiographically in two patients. Clinical examination in both cases was unremarkable. Cone beam computed tomography scans revealed the true nature of the lesions in three dimensions. The resorption lesion in case 1 was confined predominantly to the buccal aspect of the root, the lesion had not perforated into the root canal. A mucoperiosteal flap was raised to gain access to the lesion, the resorptive lesion was excavated and the defect repaired with glass ionomer cement. In case 2 the cone beam computed tomography scan revealed that the resorptive lesion was more extensive than it appeared radiographically, making the prognosis of reparative treatment very poor. In this case, the patient was advised to have the tooth extracted.

KEY LEARNING POINTS

The true extent of external cervical resorption lesions cannot always be estimated from conventional radiographs. Cone beam computed tomography can be a useful diagnostic tool in the management of external cervical resorption lesions.

A practical guide to endodontic access cavity preparation in molar teeth

The main objective of access cavity preparation is to identify the root canal entrances for subsequent preparation and obturation of the root canal system. Access cavity preparation can be one of the most challenging and frustrating aspects of endodontic treatment, but it is the key to successful treatment. Inadequate access cavity preparation may result in difficulty locating or negotiating the root canals. This may result in inadequate cleaning, shaping and filling of the root canal system. It may also contribute to instrument separation and aberrations of canal shape. These factors may ultimately lead to failure of treatment. Good access cavity design and preparation is therefore imperative for quality endodontic treatment, prevention of iatrogenic problems, and prevention of endodontic failure.

The reported views and experiences of cancer service users from minority ethnic groups: a critical review of the literature

There is growing evidence of inequalities in access to high-quality cancer services between minority and majority ethnic groups. However, little research has been carried out from the perspective of users from minority ethnic groups themselves. This paper reports a review of the British literature exploring the views and experiences of cancer service users from minority ethnic groups. We reviewed 25 qualitative studies that reported the experiences of people from minority ethnic groups. The studies highlighted significant issues and challenges, including comprehension and communication barriers, a lack of awareness of the existence of services and a perceived failure by providers to accommodate religious and cultural diversity. This paper critically discusses some of the explanations commonly invoked for ethnic inequalities in access to high-quality care, such as the belief that the lack of use of services reflects a lack of need. Despite positive initiatives to respond better to the needs of minority groups, we suggest the impact of these remains highly variable. Institutional racism within services is still much in evidence.

Mitochondrial DNA haplogroups and type 2 diabetes: a study of 897 cases and 1010 controls

Mitochondria play a central role in the secretion of insulin by pancreatic beta-cells, and pathogenic mutations of mitochondrial DNA (mtDNA) can cause diabetes. The aetiology of type 2 diabetes has a strong genetic component, raising the possibility that genetic variants of mtDNA alter the risk of developing the disorder. Recent studies have produced conflicting results. By studying 897 UK cases of type 2 diabetes and 1010 population-matched controls, it is shown that European mtDNA haplogroups are unlikely to play a major role in the risk of developing the disorder.

Elevated interleukin-6 levels correlation with anemia, symptom burden, and neurocognitive deficit in cancer patients receiving chemotherapy: Effects of darbepoetin-alfa administered once per cycle for prevention of anemia

19505

Background: Chemo-naïve sarcoma pts experience severe anemia during chemotherapy (CT) with adriamycin and ifosfamide (AI) resulting in PRBC transfusions (Tx) in >90% of pts. Anemia has a negative impact on quality of life (QOL) and neurocognitive (NC) functions (fx). Preclinical studies suggest that treatment with erythropoietic stimulating agent (ESA) may protect NC fx. The purpose of this study was to evaluate the effects of darbepoetin (Initial dose 500mcg) administered once per cycle on prevention of anemia, transfusions, symptom burden and NC fx. Methods: Pts underwent assessment for neuropsychological tests, symptoms (MDASI), and quality of life (QOL). To determine if NC deficits and Hb were correlated to cytokine levels, serum IL-1, IL-6, and TNF were measured at baseline, after 3 cycles and completion. Results: Baseline median hemoglobin (Hb) was 13.2 g/dL (n=49); however, significantly more NC deficits and symptoms were seen in pts as compared to normal. Interestingly, serum IL-6 levels were significantly elevated as compared to normal at baseline and during treatment (p<0.001), and were negatively correlated with baseline Hb (p=0.003) and significantly associated with NC deficits, QOL and symptoms. Of 45 pts that received > 1 cycle of CT, 38% avoided PRBC Tx. Pts with higher baseline Hb had less sadness and shortness of breath (p<0.01). Pts with higher Hb nadir had lower tingling/numbness (p=0.006). Pts who avoided transfusions had less distress (p=0.032), less sadness (p=0.01), and better motor fx (p=0.005). Conclusions: These findings suggest that cancer pts can have NC deficits prior to CT. Prevention/early intervention with ESA may avoid transfusions, reduce symptom burden, and NC deficit. Significant correlation of anemia, symptoms, and NC deficit with elevated IL-6 levels suggest that anti-IL-6 treatment may improve response to ESA and NC functions.

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No significant financial relationships to disclose.

Beyond race: The impact of ethnicity on the treatment outcome of locally advanced head and neck cancer

16500

Background: Self identified racial groups share an unequal burden of head and neck cancer . Recent evidence suggests that outcome among races is different and the causes are multifactorial. Nonetheless, differences among ethnic groups have not been reported. Herein, we decided to analyze differences in treatment response and outcome among our white and Hispanic patient population treated for locally advanced head and neck cancer. Methods: Patients were identified using the tumor registry. We reviewed retrospectively the data from medical records. 100 white Hispanics (WH) and 50 white non-Hispanics (WNH) diagnosed with locally advanced head and neck cancer and treated at our institution from 2004 to 2005, were eligible for the study. Standard statistical analysis, including Kaplan-Meier survival curve and Cox proportional hazard models were used. P value of <0.05 was considered for statistical significance. Results: Preliminary results reveal that, in our study population, median age at diagnosis, gender, performance status (ECOG 0–2) and squamous cell histology did not differ significantly between the two groups. Stage 4 at diagnosis was more commonly observed in Hispanics as opposed to WNH (85.7% vs 68.6%) (P = 0.1). Surgery was more commonly used as an initial treatment option in Hispanics than WNH (42.8% vs 28.6%) (P = 0.18) while chemotherapy was less likely to be used (78.6% vs. 91.4%) (P = 0.15). Hispanics were more likely to smoke than WNH (P = 0.0003) and were equally exposed to chronic alcohol use. Patients from the Hispanic group were more likely to respond to therapy than whites by Chi-squared analysis but this difference was not statistically significant (P = 0.09). No differences were seen in disease free survival. Kaplan-Meier estimate of median overall survival was 16 months for Hispanics vs. 25 months for whites but this difference did not reach statistical significance (P = 0.26). Final analysis will be available at the time of the annual meeting. Conclusion: In our experience, a trend for decrease overall survival was noted in the Hispanic ethnic group. This may be in part due to more advanced stage at presentation. Nonetheless, in order to definitively answer this question, further research is warranted.

No significant financial relationships to disclose.

Kit-stem cell factor (kit ligand) axis in GIST patients treated with imatinib

10046

Background: Gastrointestinal stromal tumors (GISTs) represent the majority of GI mesenchymal neoplasms. Imatinib (Gleevec; STI571; Novartis, Basel, Switzerland) has marked efficacy in the management of GIST; however, little is known of its exact mechanism in GIST. We sought to elucidate expression patterns of stem cell factor (SCF, Kit ligand) and the Kit receptor tyrosine kinase in GIST and tumor-associated endothelial cells (TECs) from patients treated with imatinib. Methods: We constructed a 54 GIST specimen tissue array from patients with GIST surgically resected who received 400–800 mg/day adjuvant imatinib. Arrays were stained for SCF by immunohistochemistry and scored for expression as 0 (none), 1 (weak), or 2 (strong). Expression was correlated to progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier methods. In a second study we collected pre-imatinib core needle biopsies from 15 patients on a phase II prospective, randomized clinical trial of neo-adjuvant and adjuvant imatinib (600mg/day) for the treatment of primary or advanced, resectable GIST. Specimens were stained for phosphorylated-Kit and CD31 and visualized by immunofluorescence and confocal microscopy. Co-localization of markers was correlated to radiographic response by positron emission tomography (PET) and dynamic computed tomography (dCT). Results: 47 of 54 tumors (87%) expressed SCF but there was no significant correlation between SCF expression or intensity with PFS and OS. Interestingly, the majority of GIST tissue from patients on the prospective clinical trial contained pre-imatinib TECs expressing phosphorylated-Kit. 69% and 79% of patients receiving 3–7 days of imatinib responded by PET scan or dCT, respectively. Conclusions: The majority of GISTs express SCF while pre-imatinib TECs were found to express phosphorylated-Kit. Therefore, our results suggest that within the tumor microenvironment there may be Kit/SCF crosstalk between tumor cells and TECs. Whether disruption of this crosstalk plays a role in tumor response or anti-vascular efficacy requires additional investigation.

No significant financial relationships to disclose.

MicroRNA regulation in mantle cell lymphoma

8056

Mantle Cell Lymphoma (MCL) represents only 5–10% of all non-Hodgkins lymphomas, making it an uncommon but difficult form of lymphoma to treat. It has the worst prognosis among the B cell lymphomas with median survival of three years. The genetic hallmark of MCL is a t(11;14) q32 translocation which results in ectopic and dysregulated expression of cyclin D1. Recent comparative genomic hybridization studies have identied Syk as another gene important in the pathogenesis of MCL. Previous studies have suggested that post transcriptional regulation of Cyclin D1 and Syk may be important the pathogenesis of in MCL. MicroRNAs are a new class of abundant small RNAs that play important regulatory roles at the post transcriptional level by binding to the 3’ untranslated region (UTR) of mRNAs blocking either their translation or initiating their degradation. There have been numerous reports of misregulation of microRNAs and their targets in human cancers. We hypothesized that altered microRNA regulation of cyclin D1 and/or Syk may be present in MCL. Based on bioinformatics, we identified 8 microRNAs and their putative docking sites in either Cyclin D1 and Syk. We then examined their integrity in MCL cell lines, and identified a mutation in the 3’UTR of Syk at the docking site of 1 mir-452* and a SNP in mir-458. Using a GFP reporter construct with the mutated Syk 3’UTR we demonstrated that this mutation resulted in altered microRNA function. We also show that mimics of the microRNA leads to down regulation of Syk protein. This data suggests that microRNA regulation of important genes in MCL may be compromised and play a role in the development and progression of this disease.

No significant financial relationships to disclose.

Management of Calculi in A Donor Kidney

INTRODUCTION

We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) and extracorporeal shock wave lithotripsy (ESWL) as means of rendering a donated kidney stone-free in living related and deceased donor renal transplantation.

MATERIAL AND METHODS

Three cases with calculi in donor kidneys were managed; 1 was from a living related donor and 2 were from deceased donors. Immediately after cold perfusion, ExURS was performed with iced saline solution in 2 cases. Access to the collecting system was via the ureteral stump. Calculi were fragmented with pneumatic intracorporeal lithotripsy and fragments were removed with forceps. Posttransplantation ESWL was given to 1 patient for migration of a small lower caliceal calculus in the upper ureter in 1 allograft of a dual-kidney transplantation.

RESULTS

Access to the renal collecting system and stone fragmentation was technically successful in both cases. Indwelling ureteral stents were kept during transplantation in all cases. There were no intraoperative or postoperative ureteral complications. Following ESWL, stone was fragmented and cleared on its own within a week. At mean follow up of 2.2 years no new stone formed in any recipient or donor.

CONCLUSIONS

ExURS was technically feasible to render a stone-bearing kidney stone- free without compromising ureteral integrity or renal allograft function. ESWL could be performed at a later date.

Glomerular filtration rate is a major determinant of the relationship between 25-hydroxyvitamin D and parathyroid hormone

The reference range for 25-hydroxyvitamin D (25-OHD) remains uncertain, and it is not clear as to whether interpretation of circulating 25-OHD would be aided by simultaneous measurement of serum parathyroid hormone (PTH). We wanted to define the level of serum 25-OHD associated with a raised serum PTH and to examine the determinants of the relationship between serum 25-OHD and serum PTH concentration. We retrospectively examined data for patients who had a 25-OHD measurement and other biochemical variables over a 12-month period in our center. We found that 28% of patients had a serum 25-OHD level below 50 nmol/L and serum PTH level in the normal reference range, whereas 24% had a serum 25-OHD level below 50 nmol/L with a serum PTH value above the normal reference range. At a serum 25-OHD level of 80 nmol/L, 1.5% had an elevated serum PTH and, at 50 nmol/L, 8% had raised serum PTH. Further examination showed that for patients with low serum 25-OHD, low glomerular filtration rate (GFR) was a major determinant of the PTH response. These data confirm an inverse correlation between serum 25-OHD and serum PTH. Minimal numbers of patients (1.5% of the study group) have a raised serum PTH at a serum 25-OHD level of 80 nmol/L. GFR is a major determinant of the PTH response to decreasing serum levels of 25-OHD.

Towards understanding the schizophrenia code: an expanded convergent functional genomics approach

Identifying genes for schizophrenia through classical genetic approaches has proven arduous. Here, we present a comprehensive convergent analysis that translationally integrates brain gene expression data from a relevant pharmacogenomic mouse model (involving treatments with a psychomimetic agent - phencyclidine (PCP), and an anti-psychotic - clozapine), with human genetic linkage data and human postmortem brain data, as a Bayesian strategy of cross validating findings. Topping the list of candidate genes, we have three genes involved in GABA neurotransmission (GABRA1, GABBR1, and GAD2), one gene involved in glutamate neurotransmission (GRIA2), one gene involved in neuropeptide signaling (TAC1), two genes involved in synaptic function (SYN2 and KCNJ4), six genes involved in myelin/glial function (CNP, MAL, MBP, PLP1, MOBP and GFAP), and one gene involved in lipid metabolism (LPL). These data suggest that schizophrenia is primarily a disorder of brain functional and structural connectivity, with GABA neurotransmission playing a prominent role. These findings may explain the EEG gamma band abnormalities detected in schizophrenia. The analysis also revealed other high probability candidates genes (neurotransmitter signaling, other structural proteins, ion channels, signal transduction, regulatory enzymes, neuronal migration/neurite outgrowth, clock genes, transcription factors, RNA regulatory genes), pathways and mechanisms of likely importance in pathophysiology. Some of the pathways identified suggest possible avenues for augmentation pharmacotherapy of schizophrenia with other existing agents, such as benzodiazepines, anticonvulsants and lipid modulating agents. Other pathways are new potential targets for drug development. Lastly, a comparison with our earlier work on bipolar disorder illuminates the significant molecular overlap between schizophrenia and bipolar disorder.

Idiopathic hypertrophic spinal pachymeningitis: report of two cases with typical MR imaging findings

SUMMARY

Two patients with a chronic progressive myelopathy were successfully surgically treated and idiopathic hypertrophic spinal pachymeningitis (IHSP) was found on histology. In both patients, an extensive extramedullary mass of low T2 signal with peripheral contrast enhancement was compressing the spinal cord on MR imaging. This imaging appearance in patients with chronic progressive myelopathy should suggest the diagnosis of IHSP.