The dexmedetomidine "augmented" sedato analgesic cocktail: An effective approach for sedation in prolonged endoscopic retrograde cholangio-pancreatography

BACKGROUND AND AIMS

In absence of any published standard guideline for sedation or anesthesia practice for prolonged therapeutic "endoscopic retrograde cholangio-pancreatography (ERCP)", safe and cost-effective sedation protocol is the need of the hour. Our study aims to evaluate the efficacy of a dexmedetomidine as an add-on for prolonged deep sedation for ERCP and to compare three deep sedation regimens regarding safety and efficacy.

MATERIAL AND METHODS

Forty-five consecutively enrolled patients planned for therapeutic ERCP and assumed to have prolonged procedural duration (>50 min) were divided into three groups in a randomized assessor blinded fashion. Group 1 received propofol and midazolam, Group 2 received the sedato-analgesic cocktail containing ketamine-propofol-midazolam-pentazocine, and the Group 3 received sedate-analgesic cocktail plus dexmedetomidine infusion under monitoring of vital parameters and according to the judgment of the concerned anesthesiologist. Total propofol requirement, episodes of gagging, oxygen desaturation, changes in mean blood pressure (MBP), recovery and satisfaction score of endoscopist, anesthetist and patient were noted and analyzed statistically using one way ANOVA with Bonferroni correction and Chi-square test.

RESULTS

Mean propofol requirement, incidences of gagging and oxygen desaturation was significantly less in Group 2 and 3 compared to Group 1. MBP was more stable and recovery was faster in Group 3. Anesthetist's satisfaction was more with Group 2 and even more with Group 3.

CONCLUSIONS

The sedato-analgesic cocktail was superior to the conventional propofol-midazolam regimen, dexmedetomidine as add-on increased the efficacy and safety of sedate-analgesic cocktail. It reduces propofol requirement, helps to maintain the patient in a safe and more stable level of sedation and increases satisfaction of the anesthetist.

Hairy Polyp of the Nasopharynx Arising from the Eustachian Tube

Hairy polyps of the nasopharynx display characteristic radiological imaging findings, including the presence of fat in the polypoid mass. Furthermore, diagnostic imaging is useful for delineating the site of origin of these lesions, which can facilitate surgical planning. For instance hairy polyps that arise from the right Eustachian tube can be amputated via a trans-nasal approach with endoscopy, but may necessitate a two stage approach in order to avoid injury to critical structures, such as the internal carotid artery. On histology, hairy polyps comprise an outer keratinizing squamous epithelium with adnexal tissue, including hair follicles, and central fibroadipose and cartilaginous tissue. These features are exemplified in this sine qua non radiology-pathology correlation article.

Adenocarcinomas at different positions at the gastro-oesophageal junction show distinct association with gastritis and gastric preneoplastic conditions

OBJECTIVE

Adenocarcinomas at the gastro-oesophageal junction (GOJ) are currently stratified by tumour location. This retrospective study examines the association of preneoplastic conditions and inflammation of the gastric mucosa with GOJ cancer at different locations and compares them with nonjunctional gastric cancers.

PATIENTS AND METHODS

A total of 520 patients with junctional and nonjunctional gastric cancer were assessed for the presence and degree of intestinal metaplasia, glandular atrophy and inflammation in the stomach. Histopathological data were complete for 428 patients (68.9% men, median age 67.7 years), including 172 patients with GOJ cancer (GOJ1: 1-5 cm proximal to the junction, GOJ2: 'true' junctional, GOJ3: 2-5 cm distal to the junction). Gastric inflammation and preneoplastic conditions were scored according to the updated Sydney classification and further stratified into respective operative link on gastritis assessment (OLGA) and operative link on gastritis assessment on intestinal metaplasia (OLGIM) stages.

RESULTS

The prevalence and degree of gastric atrophy and intestinal metaplasia were significantly lower in GOJ1 than GOJ3 (P<0.01). Preneoplastic conditions in the stomach were similar in GOJ3 compared with nonjunctional gastric cancer. GOJ1 were almost exclusively (98.4%) of the intestinal type, whereas GOJ2 and GOJ3 were the diffuse type in 22.6 and 22.4% of the patients (P<0.001). Of all patients, only 8.5 and 12.7% presented with stage III/IV according to OLGA and OLGIM, respectively. However, data for OLGA and OLGIM staging were only available in 61.2 and 67.9% of patients, respectively.

CONCLUSION

GOJ1 are less likely to be associated with gastric pathology compared with GOJ3 or nonjunctional gastric cancer. OLGA or OLGIM staging in patients with advanced gastro-oesophageal cancer seems to be of limited value.

Human rights and ethical considerations for a tobacco-free generation

In recent years, a new tobacco 'endgame' has been proposed: the denial of tobacco sale to any citizen born after a certain year, thus creating new tobacco-free generations. The proposal would not directly affect current smokers, but would impose a restriction on potential future generations of smokers. This paper examines some key legal and ethical issues raised by this proposal, critically assessing how an obligation to protect human rights might limit or support a state's ability to phase out tobacco.

Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy?

OBJECTIVE

Per-oral endoscopic myotomy (POEM) has recently been introduced as a minimal invasive alternative to conventional treatment for achalasia. This study aimed to clarify the feasibility and the short-term clinical efficacy of POEM as compared to laparoscopic Heller myotomy (LHM).

METHODS

Treatment outcomes were prospectively recorded and compared between the procedures in a nonrandomized fashion. Reduction rate (RR) in timed barium esophagogram (TBE) was calculated at 1, 2 and 5 min after barium ingestion as: RR = 1- postoperative barium height/preoperative barium height. Risk factors for treatment failure defined as the proportion of patients with RR <0.5 (1 min) and gastroesophageal reflux (GER) after POEM were analyzed.

RESULTS

Forty-two consecutive patients who underwent POEM were compared to 41 patients who had a LHM during the immediate time period prior to the introduction of POEM. Ninety percent of the cases reported complete symptom relief after POEM. The percentage of esophageal emptying and RR in TBE improved dramatically by both procedures without significant difference. A longer operation time (odds ratio [OR] 32.80, 95%CI 2.99-359.82, p = 0.004) and younger age (OR 26.81, 95%CI 2.09-344.03, p = 0.012) were the independent predictors of treatment failure after POEM. GER was observed in seven patients where previous dilatation (OR 8.59, 95%CI 1.16-63.45, p = 0.035) and higher body mass index (OR 8.69, 95%CI 1.13-66.63, p = 0.037) were the independent predictors for symptomatic GER after POEM.

CONCLUSION

POEM seems to be a safe and effective treatment option for achalasia in the short-term perspective; an effect well comparable to LHM.

Herbal hepatotoxicity in traditional and modern medicine: actual key issues and new encouraging steps

Plants are natural producers of chemical substances, providing potential treatment of human ailments since ancient times. Some herbal chemicals in medicinal plants of traditional and modern medicine carry the risk of herb induced liver injury (HILI) with a severe or potentially lethal clinical course, and the requirement of a liver transplant. Discontinuation of herbal use is mandatory in time when HILI is first suspected as diagnosis. Although, herbal hepatotoxicity is of utmost clinical and regulatory importance, lack of a stringent causality assessment remains a major issue for patients with suspected HILI, while this problem is best overcome by the use of the hepatotoxicity specific CIOMS (Council for International Organizations of Medical Sciences) scale and the evaluation of unintentional reexposure test results. Sixty five different commonly used herbs, herbal drugs, and herbal supplements and 111 different herbs or herbal mixtures of the traditional Chinese medicine (TCM) are reported causative for liver disease, with levels of causality proof that appear rarely conclusive. Encouraging steps in the field of herbal hepatotoxicity focus on introducing analytical methods that identify cases of intrinsic hepatotoxicity caused by pyrrolizidine alkaloids, and on omics technologies, including genomics, proteomics, metabolomics, and assessing circulating micro-RNA in the serum of some patients with intrinsic hepatotoxicity. It remains to be established whether these new technologies can identify idiosyncratic HILI cases. To enhance its globalization, herbal medicine should universally be marketed as herbal drugs under strict regulatory surveillance in analogy to regulatory approved chemical drugs, proving a positive risk/benefit profile by enforcing evidence based clinical trials and excellent herbal drug quality.

Genetic animal models of malformations of cortical development and epilepsy

Malformations of cortical development constitute a variety of pathological brain abnormalities that commonly cause severe, medically-refractory epilepsy, including focal lesions, such as focal cortical dysplasia, heterotopias, and tubers of tuberous sclerosis complex, and diffuse malformations, such as lissencephaly. Although some cortical malformations result from environmental insults during cortical development in utero, genetic factors are increasingly recognized as primary pathogenic factors across the entire spectrum of malformations. Genes implicated in causing different cortical malformations are involved in a variety of physiological functions, but many are focused on regulation of cell proliferation, differentiation, and neuronal migration. Advances in molecular genetic methods have allowed the engineering of increasingly sophisticated animal models of cortical malformations and associated epilepsy. These animal models have identified some common mechanistic themes shared by a number of different cortical malformations, but also revealed the diversity and complexity of cellular and molecular mechanisms that lead to the development of the pathological lesions and resulting epileptogenesis.

Contributing factors to the development of childhood asthma: working toward risk minimization

Asthma is the most common chronic disease in childhood, and considerable research has been undertaken to find ways to prevent its development and reduce its prevalence. For such interventions to be successful, risk factors for asthma emergence should be identified and clearly defined. Data are robust for some of them, including atopy, viral infections and exposure to airborne irritants, whereas it is less conclusive for others, such as aeroallergen exposure and bacterial infections. Several interventions for asthma prevention, including avoidance and pharmacotherapy, have been attempted. However, most of them have furnished equivocal results. Various issues hinder the establishment of risk factors for asthma development and reduce the effectiveness of interventions, including the complexity of the disease and the fluidity of the developing systems in childhood. In this review, we revisit the evidence on pediatric asthma risk factors and prevention and discuss issues that perplex this field.

Effect of eradication of Helicobacter pylori on expression levels of FHIT, IL-8 and P73 in gastric mucosa of first-degree relatives of gastric cancer patients

Objectives

Helicobacter pylori (H. pylori) infection plays an important role in the carcinogenesis and development of gastric cancer. Eradication of H. pylori can effectively reduce the risk of gastric cancer, but the underlying mechanisms are not fully understood. This study aimed to investigate the effect of eradication of H. pylori on the expression levels of FHIT, IL-8 and P73 in the gastric mucosa of first-degree relatives of gastric cancer patients.

Methods

One hundred and thirty-two patients with functional dyspepsia having first-degree relatives with gastric cancer were prospectively recruited in this study. Nine patients presented with H. pylori infection and family histories of gastric cancer, 61 with H. pylori infection and without family histories of gastric cancer, 6 without H. pylori infection and with family histories of gastric cancer, and 56 without H. pylori infection and family histories of gastric cancer. The protein and mRNA expression levels of FHIT, IL-8 and P73 in gastric mucosa of the subjects were detected by immunohistochemical staining and polymerase chain reaction, respectively.

Results

Compared with the patients without H. pylori infection and family histories of gastric cancer, both the protein and mRNA levels of FIHT significantly decreased in patients with H. pylori infection and/or family histories of gastric cancer, and both the protein and mRNA levels of IL-8 significantly increased. After eradication of H. pylori, both the protein and mRNA levels of FHIT were significantly higher, and both the protein and mRNA levels of IL-8 were significantly lower. However, H. pylori infection and family histories of gastric cancer had no major effect on P73 expression.

Conclusions

Down-regulation of FHIT and up-regulation of IL-8 may be involved in the pathogenesis of H. pylori infection in the first-degree relatives of gastric cancer patients.

Crohn's disease management after intestinal resection: a randomised trial

BACKGROUND

Most patients with Crohn's disease need an intestinal resection, but a majority will subsequently experience disease recurrence and require further surgery. This study aimed to identify the optimal strategy to prevent postoperative disease recurrence.

METHODS

In this randomised trial, consecutive patients from 17 centres in Australia and New Zealand undergoing intestinal resection of all macroscopic Crohn's disease, with an endoscopically accessible anastomosis, received 3 months of metronidazole therapy. Patients at high risk of recurrence also received a thiopurine, or adalimumab if they were intolerant to thiopurines. Patients were randomly assigned to parallel groups: colonoscopy at 6 months (active care) or no colonoscopy (standard care). We used computer-generated block randomisation to allocate patients in each centre to active or standard care in a 2:1 ratio. For endoscopic recurrence (Rutgeerts score ≥i2) at 6 months, patients stepped-up to thiopurine, fortnightly adalimumab with thiopurine, or weekly adalimumab. The primary endpoint was endoscopic recurrence at 18 months. Patients and treating physicians were aware of the patient's study group and treatment, but central reading of the endoscopic findings was undertaken blind to the study group and treatment. Analysis included all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT00989560.

FINDINGS

Between Oct 13, 2009, and Sept 28, 2011, 174 (83% high risk across both active and standard care groups) patients were enrolled and received at least one dose of study drug. Of 122 patients in the active care group, 47 (39%) stepped-up treatment. At 18 months, endoscopic recurrence occurred in 60 (49%) patients in the active care group and 35 (67%) patients in the standard care group (p=0.03). Complete mucosal normality was maintained in 27 (22%) of 122 patients in the active care group versus four (8%) in the standard care group (p=0.03). In the active care arm, of those with 6 months recurrence who stepped up treatment, 18 (38%) of 47 patients were in remission 12 months later; conversely, of those in remission at 6 months who did not change therapy recurrence occurred in 31 (41%) of 75 patients 12 months later. Smoking (odds ratio [OR] 2.4, 95% CI 1.2-4.8, p=0.02) and the presence of two or more clinical risk factors including smoking (OR 2.8, 95% CI 1.01-7.7, p=0.05) increased the risk of endoscopic recurrence. The incidence and type of adverse and severe adverse events did not differ significantly between patients in the active care and standard care groups (100 [82%] of 122 vs 45 [87%] of 52; p=0.51) and (33 [27%] of 122 vs 18 [35%] of 52; p=0.36), respectively.

INTERPRETATION

Treatment according to clinical risk of recurrence, with early colonoscopy and treatment step-up for recurrence, is better than conventional drug therapy alone for prevention of postoperative Crohn's disease recurrence. Selective immune suppression, adjusted for early recurrence, rather than routine use, leads to disease control in most patients. Clinical risk factors predict recurrence, but patients at low risk also need monitoring. Early remission does not preclude the need for ongoing monitoring.

FUNDING

AbbVie, Gutsy Group, Gandel Philanthropy, Angior Foundation, Crohn's Colitis Australia, and the National Health and Medical Research Council.

Adenocarcinoma arising from heterotopic pancreas at the third portion of the duodenum

A 62-year-old Japanese man presented to our hospital with a history of weight loss of 6 kg in 4 mo. Imaging examinations revealed a tumor located on the third portion of the duodenum with stenosis. We suspected duodenal carcinoma and performed pancreas-preserving segmental duodenectomy. Adenocarcinoma arising from a heterotopic pancreas at the third portion of the duodenum was finally diagnosed by immunohistochemical staining. Malignant transformation in the duodenum arising from a heterotopic pancreas is extremely rare; to our knowledge, only 13 cases have been reported worldwide, including the present case. The most common location of malignancy is the proximal duodenum at the first and descending portion. Herein, we describe the first case of adenocarcinoma arising from a heterotopic pancreas, which was located in the third portion of the duodenum, with a review of the literature.

Epileptogenic but MRI-normal perituberal tissue in Tuberous Sclerosis Complex contains tuber-specific abnormalities

INTRODUCTION

Recent evidence has implicated perituberal, MRI-normal brain tissue as a possible source of seizures in tuberous sclerosis complex (TSC). Data on aberrant structural features in this area that may predispose to the initiation or progression of seizures are very limited. We used immunohistochemistry and confocal microscopy to compare epileptogenic, perituberal, MRI-normal tissue with cortical tubers.

RESULTS

In every sample of epileptogenic, perituberal tissue, we found many abnormal cell types, including giant cells and cytomegalic neurons. The majority of giant cells were surrounded by morphologically abnormal astrocytes with long processes typical of interlaminar astrocytes. Perituberal giant cells and astrocytes together formed characteristic "microtubers". A parallel analysis of tubers showed that many contained astrocytes with features of both protoplasmic and gliotic cells.

CONCLUSIONS

Microtubers represent a novel pathognomonic finding in TSC and may represent an elementary unit of cortical tubers. Microtubers and cytomegalic neurons in perituberal parenchyma may serve as the source of seizures in TSC and provide potential targets for therapeutic and surgical interventions in TSC.

Clinical impact of gastroenterologist-administered propofol during esophagogastroduodenoscopy: a randomized comparison at a single medical clinic

BACKGROUND

Although midazolam is widely used during endoscopic procedures by endoscopists, propofol has been recently favored for its rapid action and metabolism. The aim of this study is to compare the clinical advantages between propofol and midazolam use during screening esophagogastroduodenoscopy (EGD) for gastric cancer and post-procedure management at a medical clinic.

METHODS

One hundred six healthy patients aged 20-69 years requesting sedation for screening EGD from October 2012 to May 2013 at a single clinic in Japan were randomly assigned to propofol (n = 54) or midazolam (n = 52). Medications were given by bolus injection, and the dose was adjusted by body weight. Sedation level and tolerability during EGD and recovery time were assessed. Sedation level and tolerability were evaluated by American Society of Anesthesiologists responsiveness levels and four levels of the gag reflex, respectively. For safety purposes, endoscopists and nurses were trained in administering propofol and an anesthesiologist was on call at all times.

RESULTS

No statistically significant differences were found between the two groups in sedation level and patient tolerability. Full recovery time in the propofol group (4.7 min) was significantly shorter than that in the midazolam group (24 min, P < 0.01).

CONCLUSIONS

Regarding post-procedure management of patients in a medical clinic, propofol use might not necessitate a recovery room and excessive assessment tasks because of rapid recovery time without any prolonged reaction, which causes patient compliance. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000009142.).

The role of adult living donor liver transplantation and recent advances

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

Myenteric plexitis at the proximal resection margin is a predictive marker for surgical recurrence of ileocaecal Crohn's disease

AIM

Identifying predictors for the recurrence of Crohn's disease (CD) after surgery to improve disease surveillance or targeted therapy is rational. The purpose of this study was to examine the relationship between myenteric plexitis (MP) and clinical or surgical recurrence.

METHOD

Between 2000 and 2010, patients who underwent primary ileocaecal resection for CD at a single tertiary referral centre were identified. The histopathology was retrospectively reviewed for MP at the resection margins. The severity of MP was graded from 0 to 3 using a previously described classification. Information on demographics, surgical details and evidence of clinical or surgical recurrence was obtained from medical records.

RESULTS

There were 86 patients (49 women) of median age 31.5 (interquartile ratio 23.5-41.0) years. Seventy-six and 77 specimens were assessable for proximal and distal MP. Proximal MP was present in 53 (69.7%) patients and was classified as mild, moderate or severe in 30 (39.5%), 14 (18.4) and nine (11.8%). MP at the distal resection margin was present in 40 (51.9%). Forty (46.5%) patients developed clinical recurrence of whom 16 (18.6%) required surgery. Clinical factors that predicted recurrence included age > 40 (P = 0.001) and the presence of an anastomosis (P = 0.023). On univariate analysis severe plexitis (Grade 3 MP) was also associated with surgical recurrence (P = 0.035).

CONCLUSION

This retrospective study supports the association between MP at the proximal resection margin and surgical recurrence.

mTOR signaling in epilepsy: insights from malformations of cortical development

Over the past decade enhanced activation of the mammalian target of rapamycin (mTOR)-signaling cascade has been identified in focal malformations of cortical development (MCD) subtypes, which have been collectively referred to as "mTORopathies." Mutations in mTOR regulatory genes (e.g., TSC1, TSC2, AKT3, DEPDC5) have been associated with several focal MCD highly associated with epilepsy such as tuberous sclerosis complex (TSC), hemimegalencephaly (HME; brain malformation associated with dramatic enlargement of one brain hemisphere), and cortical dysplasia. mTOR plays important roles in the regulation of cell division, growth, and survival, and, thus, aberrant activation of the cascade during cortical development can cause dramatic alterations in cell size, cortical lamination, and axon and dendrite outgrowth often observed in focal MCD. Although it is widely believed that structural alterations induced by hyperactivated mTOR signaling are critical for epileptogenesis, newer evidence suggests that mTOR activation on its own may enhance neuronal excitability. Clinical trials with mTOR inhibitors have shown efficacy in the treatment of seizures associated with focal MCD.

Smoke exposure, wheezing, and asthma development: a systematic review and meta-analysis in unselected birth cohorts

BACKGROUND

The understanding of the role of smoking exposure in the induction of wheezing and asthma in children is important for prevention.

METHODS

A systematic review of literature and a meta-analysis were conducted to identify studies on unselected prospective birth cohorts. The effect of exposure to maternal/parental smoking on the induction of current wheezing or asthma was evaluated in children aged 6 months, <6 years, and ≥6 years. Pooled odds ratios (OR) with 95% confidence intervals (CI) were estimated.

RESULTS

We identified 43 papers. Exposure to maternal prenatal smoking was associated with an increased risk of wheezing in <6-year-olds (OR 1.36; 95% CI: 1.19-1.55) and of wheezing or asthma in ≥6-year-olds (OR: 1.22, 95% CI: 1.03-1.44). A positive association (OR: 1.24, 95% CI: 1.11-1.38) was also found in the only three studies that evaluated exposure to maternal prenatal smoking alone. Postnatal exposures to maternal/parental smoking were associated with wheezing in <6-year-olds (OR: 1.21; 95% CI: 1.13-1.31 and OR: 1.30; 95% CI: 1.13-1.51), although it was often impossible to separate the role of postnatal from that of prenatal exposure; data in schoolchildren are limited and this precluded a meta-analysis. No clear association was found between exclusive postnatal exposure and wheezing or asthma.

CONCLUSIONS

We confirmed an important role of prenatal exposure to maternal smoking on the induction of wheezing and asthma in offspring, particularly in the first years of life. More studies with a consistent number of subjects only exposed to smoke postnatally are needed to better investigate the harmful effects on the induction of wheezing or asthma, particularly in schoolchildren.

The multidisciplinary health care team in the management of stenosis in Crohn's disease

Background

Stricture formation is a common complication of Crohn’s disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD.

Methods

A Medline search was performed, using “Inflammatory Bowel Disease”, “stricture”, “Crohn’s Disease”, “Ulcerative Colitis”, “endoscopic balloon dilatation” and “strictureplasty” as keywords. A selection of clinical cohort studies and systematic reviews were reviewed.

Results

Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery.

Conclusion

Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment.

ImmunoPET of tissue factor expression in triple-negative breast cancer with a radiolabeled antibody Fab fragment

PURPOSE

To date, there is no effective therapy for triple-negative breast cancer (TNBC), which has a dismal clinical outcome. Upregulation of tissue factor (TF) expression leads to increased patient morbidity and mortality in many solid tumor types, including TNBC. Our goal was to employ the Fab fragment of ALT-836, a chimeric anti-human TF mAb, for PET imaging of TNBC, which can be used to guide future TNBC therapy.

METHODS

ALT-836-Fab was generated by enzymatic papain digestion. SDS-PAGE and FACS studies were performed to evaluate the integrity and TF binding affinity of ALT-836-Fab before NOTA conjugation and (64)Cu-labeling. Serial PET imaging and biodistribution studies were carried out to evaluate the tumor targeting efficacy and pharmacokinetics in the MDA-MB-231 TNBC model, which expresses high levels of TF on the tumor cells. Blocking studies, histological assessment, as well as RT-PCR were performed to confirm TF specificity of (64)Cu-NOTA-ALT-836-Fab.

RESULTS

ALT-836-Fab was produced with high purity, which exhibited superb TF binding affinity and specificity. Serial PET imaging revealed rapid and persistent tumor uptake of (64)Cu-NOTA-ALT-836-Fab (5.1 ± 0.5 %ID/g at 24 h post-injection; n = 4) and high tumor/muscle ratio (7.0 ± 1.2 at 24 h post-injection; n = 4), several-fold higher than that of the blocking group and tumor models that do not express significant level of TF, which was confirmed by biodistribution studies. TF specificity of the tracer was also validated by histology and RT-PCR.

CONCLUSION

(64)Cu-NOTA-ALT-836-Fab exhibited prominent tissue factor targeting efficiency in MDA-MB-231 TNBC model. The use of a Fab fragment led to fast tumor uptake and good tissue/muscle ratio, which may be translated into same-day immunoPET imaging in the clinical setting to improve TNBC patient management.

Brain somatic mutations in MTOR cause focal cortical dysplasia type II leading to intractable epilepsy

Focal cortical dysplasia type II (FCDII) is a sporadic developmental malformation of the cerebral cortex characterized by dysmorphic neurons, dyslamination and medically refractory epilepsy. It has been hypothesized that FCD is caused by somatic mutations in affected regions. Here, we used deep whole-exome sequencing (read depth, 412-668×) validated by site-specific amplicon sequencing (100-347,499×) in paired brain-blood DNA from four subjects with FCDII and uncovered a de novo brain somatic mutation, mechanistic target of rapamycin (MTOR) c.7280T>C (p.Leu2427Pro) in two subjects. Deep sequencing of the MTOR gene in an additional 73 subjects with FCDII using hybrid capture and PCR amplicon sequencing identified eight different somatic missense mutations found in multiple brain tissue samples of ten subjects. The identified mutations accounted for 15.6% of all subjects with FCDII studied (12 of 77). The identified mutations induced the hyperactivation of mTOR kinase. Focal cortical expression of mutant MTOR by in utero electroporation in mice was sufficient to disrupt neuronal migration and cause spontaneous seizures and cytomegalic neurons. Inhibition of mTOR with rapamycin suppressed cytomegalic neurons and epileptic seizures. This study provides, to our knowledge, the first evidence that brain somatic activating mutations in MTOR cause FCD and identifies mTOR as a treatment target for intractable epilepsy in FCD.

Operative interventions for extrahepatic portomesenteric venous aneurysms and long-term outcomes

BACKGROUND

Extrahepatic portal venous aneurysms (PVAs) are rare, and the pathogenesis is not fully understood. The optimum management of these patients is unknown.

METHODS

Consecutive patients with PVA were identified over an 18-year period (1992-2010). A retrospective review was conducted. Clinical presentation, modality of diagnosis, surgical treatment, 30-day morbidity and mortality, and follow-up are reported.

RESULTS

Four patients were identified who underwent surgical management of an extrahepatic PVA. Operative technique using left renal vein, femoral vein panel graft, polytetrafluoroethylene (ePTFE) graft, and segmental aneurysm wall resected with aneurysmorrhaphy is described. Early complications occurred in 1 patient with an ePTFE graft. The patient returned to the operating room for bleeding. In addition, the same patient had a late graft thrombosis 6 years postoperatively when the anticoagulation was discontinued for pregnancy. The remainder of the patients recovered without complication, and their repairs are still patent with a mean follow-up of 78 months (17-144 months). There were no mortalities in the series.

CONCLUSIONS

Operative intervention for portomesenteric venous aneurysm can be done safely in select patients and should be considered in those with symptoms, rapid growth, mural thrombus, or aneurysms ≥4 cm in diameter. Repair with an autogenous interposition graft affords good long-term patency. Aneurysmorrhaphy may be performed if the remaining venous wall is of good quality.

Lectin RCA-I specifically binds to metastasis-associated cell surface glycans in triple-negative breast cancer

Introduction

Triple-negative breast cancer (TNBC) patients often face a high risk of early relapse characterized by extensive metastasis. Previous works have shown that aberrant cell surface glycosylation is associated with cancer metastasis, suggesting that altered glycosylations might serve as diagnostic signatures of metastatic potential. To address this question, we took TNBC as an example and analyzed six TNBC cell lines, derived from a common progenitor, that differ in metastatic potential.

Methods

We used a microarray with 91 lectins to screen for altered lectin bindings to the six TNBC cell lines. Candidate lectins were then verified by lectin-based flow cytometry and immunofluorescent staining assays using both TNBC/non-TNBC cancer cells. Patient-derived tissue microarrays were then employed to analyze whether the staining of Ricinus communis agglutinin I (RCA-I), correlated with TNBC severity. We also carried out real-time cell motility assays in the presence of RCA-I. Finally, liquid chromatography-mass spectrometry/tandem spectrometry (LC-MS/MS) was employed to identify the membrane glycoproteins recognized by RCA-I.

Results

Using the lectin microarray, we found that the bindings of RCA-I to TNBC cells are proportional to their metastatic capacity. Tissue microarray experiments showed that the intensity of RCA-I staining is positively correlated with the TNM grades. The real-time cell motility assays clearly demonstrated RCA-I inhibition of adhesion, migration, and invasion of TNBC cells of high metastatic capacity. Additionally, a membrane glycoprotein, POTE ankyrin domain family member F (POTEF), with different galactosylation extents in high/low metastatic TNBC cells was identified by LC-MS/MS as a binder of RCA-I.

Conclusions

We discovered RCA-I, which bound to TNBC cells to a degree that is proportional to their metastatic capacities, and found that this binding inhibits the cell invasion, migration, and adhesion, and identified a membrane protein, POTEF, which may play a key role in mediating these effects. These results thus indicate that RCA-I-specific cell surface glycoproteins may play a critical role in TNBC metastasis and that the extent of RCA-I cell binding could be used in diagnosis to predict the likelihood of developing metastases in TNBC patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-015-0544-9) contains supplementary material, which is available to authorized users.

Clinical use of azelnidipine in the treatment of hypertension in Chinese patients

Background

Hypertension is the most common chronic disease and the calcium channel antagonist is the most popularly used antihypertensive drug in Chinese patients. Azelnidipine is a third generation and long-acting dihydropyridine calcium channel antagonist. A series of research has demonstrated that azelnidipine produced an effective antihypertensive effect in patients with essential hypertension. Now it is need to summarize clinical use of azelnidipine in the treatment of hypertension in Chinese patients.

Methods

Relevant literature was identified by performing searches in PubMed and CNKI (China National Knowledge Infrastructure), covering the period from January 2003 (the year azelnidipine was launched) to July 2014. We included studies that described pharmacology of azelnidipine, especially the pharmacokinetics, clinical efficacy, and safety and tolerability of azelnidipine in a Chinese population. The full text of each article was strictly reviewed, and data interpretation was performed.

Results

In Chinese healthy volunteers, a single-dose oral administration of azelnidipine 8–16 mg had a peak plasma concentration of 1.66–23.06 ng/mL and time to peak plasma concentration was 2.6–4.0 hours and the area under the plasma concentration versus time curve from time 0 hour to 96 hours was 17.9–429 ng/mL·h and elimination half-life was 16.0–28.0 hours. A number of clinical trials have demonstrated that azelnidipine produced a significant reduction in blood pressure in Chinese patients with mild-to-moderate hypertension, which was similar to that of other effective antihypertensive drugs such as amlodipine, zofenopril, and nifedipine. In addition to its antihypertensive effect, azelnidipine had other cardiovascular protective effects as well, like anti-oxidative action, decreasing heart rate, and improving systolic and diastolic function. Azelnidipine was generally well tolerated in Chinese patients and no severe adverse events were observed.

Conclusion

Azelnidipine is effective and safe in the treatment of hypertension in Chinese patients.

Monitoring asthma in children

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence.

The role of PET-CT in radiotherapy planning of solid tumours

Background

PET-CT is becoming more and more important in various aspects of oncology. Until recently it was used mainly as part of diagnostic procedures and for evaluation of treatment results. With development of personalized radiotherapy, volumetric and radiobiological characteristics of individual tumour have become integrated in the multistep radiotherapy (RT) planning process. Standard anatomical imaging used to select and delineate RT target volumes can be enriched by the information on tumour biology gained by PET-CT. In this review we explore the current and possible future role of PET-CT in radiotherapy treatment planning. After general explanation, we assess its role in radiotherapy of those solid tumours for which PET-CT is being used most.

Conclusions

In the nearby future PET-CT will be an integral part of the most radiotherapy treatment planning procedures in an every-day clinical practice. Apart from a clear role in radiation planning of lung cancer, with forthcoming clinical trials, we will get more evidence of the optimal use of PET-CT in radiotherapy planning of other solid tumours.

A single-centre prospective, cohort study of the natural history of acute pancreatitis

BACKGROUND

The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors.

AIMS

To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis.

METHODS

196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed.

RESULTS

40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold.

CONCLUSIONS

Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.

Mechanistic target of rapamycin (mTOR) in tuberous sclerosis complex-associated epilepsy

BACKGROUND

Tuberous sclerosis complex is a multiorgan disease resulting from a mutation of one of two TSC genes. The two gene products form a functional complex that regulates the mTOR signaling pathway (mTOR initially represented mammalian target of rapamycin, but increasingly the term mechanistic target of rapamycin is used to reflect the ubiquitous occurrence of mTOR). Epilepsy is the most common neurological symptom of tuberous sclerosis complex, occurring in 80% to 90% of affected individuals over the course of their lifetimes and causing significant morbidity and mortality. The mechanistic target of rapamycin (mTOR) signaling pathway is intricately involved in multiple cellular functions--including protein synthesis, cell growth and proliferation, and synaptic plasticity--which may influence neuronal excitability and precipitate epileptogenesis. Recent preclinical and clinical studies have increased interest in the potential role of mTOR inhibitors for the treatment of tuberous sclerosis complex-related epilepsy.

METHODS

Medline and PubMed database searches were used to identify relevant studies and other information on tuberous sclerosis complex-related epilepsies, the mTOR pathway, and current advances in treatment approaches.

RESULTS

Although current management strategies that provide symptomatic relief are effective at reducing the frequency of seizures in individuals with tuberous sclerosis complex, there is further room for the exploration of therapies that directly address hyperactive mTOR signaling--the underlying etiology of the disease. The role of the antiepileptic effect of mTOR inhibition was first demonstrated in knockout TSC1 mouse models. Additionally, several case studies demonstrated a positive effect on seizure frequency and severity in patients with pharmacoresistant epilepsy. In a phase 1/2 clinical trial with 28 patients, clinically relevant reduction in overall seizure frequency was documented in individuals treated with the mTOR inhibitor everolimus. In a phase 3 trial evaluating the role of everolimus in subependymal giant cell astrocytoma, seizures were a secondary end point. Because the median seizure frequency was zero in this study, the analysis was inconclusive.

CONCLUSION

Various preclinical models provide substantial evidence for the role of mTOR inhibition in the treatment of epilepsy in individuals with tuberous sclerosis complex. Preliminary clinical studies provide supportive evidence for a role of mTOR inhibition in the management of tuberous sclerosis complex-associated epilepsy and pave the way for new randomized placebo-controlled studies. This article reviews current treatment recommendations for the management of tuberous sclerosis complex-associated epilepsy as well as the rationale and evidence to support the use of mTOR inhibitors.

The analysis of clinico-pathologic characteristics in patients who underwent surgery due to stricturing and non-perineal fistulizing forms of Crohn's disease: a retrospective cohort study

BACKGROUND

The diagnosis of Crohn's disease is based mainly on the patient's history and clinical examination and supported by serologic, radiologic, endoscopic, and histologic findings.

AIMS

The main purpose of the present study was to evaluate in a retrospective manner the clinico-pathological characteristics of patients who underwent surgery due to stricturing or non perineal fistulizing Crohn's disease.

MATERIAL AND METHODS

Between January 2007 and June 2012, 75 patients who were operated on for stricturing and non-perineal fistulizing forms of Crohn's disease were analyzed according to their clinico-pathological characteristics.

RESULTS

The L3 localization (Montreal Classification) was detected significantly more often in the non-perineal fistulizing group than in the stricturing group (P < 0.03). Wound infection (18 patient, 24%) was the most commonly observed postoperative complication, followed by postoperative ileus (5 patients, 6.7%) and intraabdominal abscess (4 patients, 5.2%). The distribution of postoperative complications according to the two groups was not significantly different (P = 0.772). Submucosal fibrosis, ulcers and transmural inflammation were the three most common histopathological signs in resected specimens from both groups. Pseudopolyps, microabscess, granuloma, mononuclear inflammation and deep fissures were significantly far more frequent in the non perineal fistulizing group when compared to the stricturing group (P < 0.05). On the other hand, superficial ulcers were significantly more frequent in the stricturing group (P = 0.007).

CONCLUSION

No specific clinical feature was found to differentiate patients with the stricturing form of Crohn's disease from the fistulizing form. However, histopathological analysis of the resected specimens revealed significant differences in some parameters between the two disease forms.

Microencapsulated human mesenchymal stem cells decrease liver fibrosis in mice

BACKGROUND & AIMS

Mesenchymal stem cell (MSC) transplantation was shown to be effective for the treatment of liver fibrosis, but the mechanisms of action are not yet fully understood. We transplanted encapsulated human MSCs in two mouse models of liver fibrosis to determine the mechanisms behind the protective effect.

METHODS

Human bone marrow-derived MSCs were microencapsulated in novel alginate-polyethylene glycol microspheres. In vitro, we analyzed the effect of MSC-conditioned medium on the activation of hepatic stellate cells and the viability, proliferation, cytokine secretion, and differentiation capacity of encapsulated MSCs. The level of fibrosis induced by bile duct ligation (BDL) or carbon tetrachloride (CCl4) was assessed after intraperitoneal transplantation of encapsulated MSCs, encapsulated human fibroblasts, and empty microspheres.

RESULTS

MSC-conditioned medium inhibited hepatic stellate cell activation and release of MSC secreted anti-apoptotic (IL-6, IGFBP-2) and anti-inflammatory (IL-1Ra) cytokines. Viability, proliferation, and cytokine secretion of microencapsulated MSCs were similar to those of non-encapsulated MSCs. Within the microspheres, MSCs maintained their capacity to differentiate into adipocytes, chondrocytes, and osteocytes. 23% (5/22) of the MSC clones were able to produce anti-inflammatory IL-1Ra in vitro. Microencapsulated MSCs significantly delayed the development of BDL- and CCl4-induced liver fibrosis. Fibroblasts had an intermediate effect against CCl4-induced fibrosis. Mice transplanted with encapsulated MSCs showed lower mRNA levels of collagen type I, whereas levels of matrix metalloproteinase 9 were significantly higher. Human IL-1Ra was detected in the serum of 36% (4/11) of the mice transplanted with microencapsulated MSCs.

CONCLUSIONS

MSC-derived soluble molecules are responsible for an anti-fibrotic effect in experimental liver fibrosis.

Management and conduct of vascular diseases of the portal system

Aneurysms and thromboses of the portal vein are rare pathologies of the portal system that commonly follow an asymptomatic course. The vast majority of cases are diagnosed as incidental findings during imaging studies. Symptoms of aneurysms are the result of mass effects, while thrombosis symptoms are a function of the liver's ability to form a collateral circulation network in the thrombosis. The scant experience with such cases poses a dilemma for patient management and so the vast majority of authors choose an expectant approach with rigorous patient surveillance and only intervene in symptomatic patients. We report one case of an aneurysm of the portal vein and one case of portal vein thrombosis and discuss management and observation of these patients.

Importance of EEG in validating the chronic effects of drugs: suggestions from animal models of epilepsy treated with rapamycin

PURPOSE

The development of new drugs for the treatment of epilepsy is a major challenge for modern neurology and its first steps demand basic research. Preclinical studies on animal models of epilepsy are mainly based on the analysis of brain electrical activity to detect seizures, when they are not just limited to behavioral tests like the Racine scale.

METHODS

In the present review, we discuss the importance of using time-locked video and EEG recordings (Video-EEG) coupled with behavioral tests as tools to monitor and analyze the effects of anti-epileptic drugs in pre-clinical research. Particularly, we focus on the utility of a multimodal approach based on EEG/behavioral analysis to study the beneficial effects of chronic rapamycin treatment as a potential anti-epileptogenic therapy for a broad spectrum of epilepsy, including both genetic (as in tuberous sclerosis complex) and acquired diseases.

RESULTS

Changes and synchronization of neuronal activity of different areas have been correlated with specific behavior in both physiological and pathological conditions. In the epileptic brain, during a seizure there is an abnormal activation of many cells all at once, altering different networks.

CONCLUSION

A multimodal approach based on video, EEG analysis and behavioral tests would be the best option in preclinical studies of epilepsy.

MEK-ERK1/2-dependent FLNA overexpression promotes abnormal dendritic patterning in tuberous sclerosis independent of mTOR

Abnormal dendritic complexity is a shared feature of many neurodevelopmental disorders associated with neurological defects. Here, we found that the actin-crosslinking protein filamin A (FLNA) is overexpressed in tuberous sclerosis complex (TSC) mice, a PI3K-mTOR model of neurodevelopmental disease that is associated with abnormal dendritic complexity. Both under- and overexpression of FLNA in wild-type neurons led to more complex dendritic arbors in vivo, suggesting that an optimal level of FLNA expression is required for normal dendritogenesis. In Tsc1(null) neurons, knocking down FLNA in vivo prevented dendritic abnormalities. Surprisingly, FLNA overexpression in Tsc1(null) neurons was dependent on MEK1/2 but not mTOR activity, despite both pathways being hyperactive. In addition, increasing MEK-ERK1/2 activity led to dendritic abnormalities via FLNA, and decreasing MEK-ERK1/2 signaling in Tsc1(null) neurons rescued dendritic defects. These data demonstrate that altered FLNA expression increases dendritic complexity and contributes to pathologic dendritic patterning in TSC in an mTOR-independent, ERK1/2-dependent manner.

CDK14 expression is down-regulated by cigarette smoke in vivo and in vitro

In this study, DNA arrays have been employed to monitor gene expression patterns in testis of mice exposed to tobacco smoke for 24 weeks and compared to control animals. The results of the analysis revealed significant changes in expression of several genes that may have a role in spermatogenesis. Cdk14 was chosen for further characterization because of a suggested role in the testis and in regulation of Wnt signaling. RT-PCR analysis confirmed down regulation of Cdk14 in mice exposed to cigarette smoke (CS). Cdk14 is expressed in all testicular cells; spermatogonia- and Sertoli-derived cell lines treated with cigarette smoke extract (CSE) in vitro showed down-regulation of CDK14 mRNA and protein levels as well as down-regulation of β-catenin levels. CS-induced down-regulation of CDK14 mRNA and protein levels was also observed in several lung epithelium-derived cell lines including primary normal human bronchial epithelial cells (NHBE), suggesting that the effect is not restricted to the testis. Similar to testicular cells, CS-induced down-regulation of CDK14 in lung cells correlated with decreased levels of β-catenin, a finding suggesting impaired Wnt signaling. In the lungs, CDK14 was localized to the alveolar and bronchial epithelium.

Prescribing patterns of the four most commonly used sedatives in endoscopic examination in Korea: propofol, midazolam, diazepam, and lorazepam

As the sedative use increases due to the effectiveness and relatively safe profile, the abuse potential is also increasing. This study was conducted to examine the usage of four sedative agents in endoscopic examination and to compare the propofol use with the other three sedatives. Using National Health Insurance claims data from 2008 to 2012, we identified the number of cases of conscious sedation during endoscopy using one or more of the following agents: propofol, midazolam, diazepam, and lorazepam. The general characteristics of patients and medical service providers were analyzed, and the regional and annual distributions of frequency of use were compared. We also identified patient cases with excessive number of endoscopic examinations. Among the total of 3,156,231 sedatives users, midazolam was the most commonly used agent (n=2,845,250, 90.1%). However, the largest increase in patient number, which increased from 11,410 in 2008 to 28,170 in 2012, was observed with propofol. While the majority of patients received an annual endoscopy, we identified several suspected abuse cases of patients receiving endoscopies repetitively as many as 114 times in five years. The rise of sedative use in endoscopic examinations and several patient cases of repeated sedative administration suggest a potential risk for abuse. Medical service providers should be cautious when using sedatives and carefully review each patient's medical history prior to the procedure.

Case of Orbital Mucosa-Associated Lymphoid Tissue Lymphoma Associated with Serous Retinal Detachment

We present a case of orbital mucosa-associated lymphoid tissue (MALT) lymphoma accompanied by a serous retinal detachment (SRD). A 44-year-old man who developed uveitis accompanied by a SRD in the right eye was referred to the Chiba National Hospital. B-mode ultrasonography and magnetic resonance imaging (MRI) showed a thickened choroidal membrane and a retrobulbar mass. Although topical steroid treatments improved the inflammation, the SRD did not improve. He was then referred to the Chiba University Hospital. Two months later, the retrobulbar mass had increased, and a partial resection biopsy combined with flow cytometry was performed. The final diagnosis was MALT lymphoma. After R-CHOP (rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy, signs of the tumour could not be detected and the SRD was reduced. We conclude that the SRD was most likely due to the infiltration of lymphoma cells and also to choroidal circulatory disturbances. Retrobulbar malignant lymphomas associated with a SRD are very rare and difficult to diagnosis without biopsy, but because early diagnosis is helpful in deciding the appropriate therapy, we recommend partial biopsy.

Variations in care: a retrospective database analysis of healthcare utilization patterns for patients with inflammatory bowel disease

BACKGROUND

Biologic therapy has been shown to be effective in achieving and maintaining remission in the treatment of inflammatory bowel disease (IBD). However, their impact on healthcare resource utilization is not well understood. This study explored the impact of biologic use on IBD-related hospital admissions and emergency room visits and healthcare expenditures.

METHODS

This study used a retrospective cohort design to analyze data from the MarketScan Commercial and Medicare databases (Truven Health Analytics Inc.) for the years 2006-2010. Patients were identified using ICD-9 diagnosis codes for IBD and age 18 or older at time of initial diagnosis. Linear models were used to predict the probability of an IBD-related hospitalization or ER visit and healthcare expenditures with binary variables indicating use of biologics in the current year and in the previous 2 years, as well as patient- and area-level control variables.

RESULTS

Patients using biologics in the current year were 14.1-17.6% more likely to be hospitalized for IBD. However, biologic use in the previous year was associated with a 3.8-5.6% reduction in hospitalizations, and biologic use 2 years prior was associated with a 1-2.8% reduction in hospitalizations in the current year. Similar results are found for ER visits. All indicators for biologic use were associated with increased expenditures.

CONCLUSIONS

There was a negative association between lagged use of biologics and the proportion of patients with IBD-related hospitalizations and ER visits. This finding may suggest that increased use of biologics over time is associated with a decrease in IBD-related healthcare utilization.

Estrogen supplementation to progesterone as luteal phase support in patients undergoing in vitro fertilization: systematic review and meta-analysis

Meta-analyses have found conflicting results with respect to the use of progesterone or progesterone plus estrogen as luteal phase support for in vitro fertilization (IVF) protocols involving gonadotropins and/or gonadotropin-releasing hormone analogs. The aim of the present study was to perform an updated meta-analysis on the efficacy of progesterone versus progesterone plus estrogen as luteal phase support. We searched the MEDLINE, Cochrane Library, and Google Scholar databases (up to March 18, 2014). The search terms were (estrogen OR estradiol OR oestradiol) AND (progesterone) AND (IVF OR in vitro fertilization) AND (randomized OR prospective). We did not limit the form of estrogen and included subjects who contributed more than 1 cycle to a study. The primary outcome was clinical pregnancy rate. Secondary outcomes were ongoing pregnancy rate, fertilization rate, implantation rate, and miscarriage rate. A total of 11 articles were included in the present analysis, with variable numbers of studies assessing each outcome measure. Results of statistical analyses indicated that progesterone plus estrogen treatment was more likely to result in clinical pregnancy than progesterone alone (pooled odds ratio 1.617, 95% confidence interval 1.059-2.471; P = 0.026). No significant difference between the 2 treatment regimens was found for the other outcome measures. Progesterone plus estrogen for luteal phase support is associated with a higher clinical pregnancy rate than progesterone alone in women undergoing IVF, but other outcomes such as ongoing pregnancy rate, fertilization rate, implantation rate, and miscarriage rate are the same for both treatments.

Role of exclusive enteral nutrition in the preoperative optimization of patients with Crohn's disease following immunosuppressive therapy

We conducted a study to evaluate the impact of the exclusive enteral nutrition (EEN) on perioperative outcome in Crohn's disease (CD) patients following immunosuppressive therapy. Patients with CD followed at a referral center between January 2001 and March 2014 who underwent abdominal surgery were identified. Patients were divided into 4 groups: patients not exposed to immunosuppressive agents in the previous 8 weeks before surgery (group 1); patients received immunosuppressive medications without preoperative drug-free interval (group 2); patients had preoperative immunosuppressants-free interval (group 3); patients treated with adding EEN to preoperative immunosuppressants-free interval regimen (group 4). Urgent operation requirement, stoma creation, postoperative complications, readmission, and reoperation were compared in patients among groups. Overall, 708 abdominal surgeries performed in 498 CD patients were identified. Three hundred seventy-six (53.11%) surgeries performed in those receiving preoperative immunosuppressive medications. Compared with other groups, group 2 had increased postoperative complications, more frequent urgent operation, and higher rate of stoma creation. Patients in group 4 were found to have better outcome including lower rate of stoma creation (P < 0.05), and decreased incidence of postoperative complications (P < 0.05) compared with group 2 and group 3. Additionally, decreased urgent operation requirement (P < 0.05) and extended preoperative drug-free interval (P < 0.001) were observed in the group 4 than those in the group 3. Preoperative optimization of CD following immunosuppressive therapy by EEN prolongs the immunosuppressants-free interval, reduces the risk of urgent surgery and reoperation, and most importantly, decreases complications after abdominal surgery.

Optimizing perioperative Crohn's disease management: Role of coordinated medical and surgical care

AIM: To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating medical therapy after Crohn’s disease (CD) surgery at a tertiary care referral center.

METHODS: CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery.

RESULTS: Eighty-eight patients met study inclusion criteria with 92% (n = 81) of patients returning for surgical follow-up compared to only 41% (n = 36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P < 0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery.

CONCLUSION: Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.

Inflammatory bowel disease in an underdeveloped region of Northeastern Brazil

AIM: To evaluate the demographic characteristics and clinical phenotypes of inflammatory bowel disease (IBD) in a geographic area in Northeastern Brazil.

METHODS: This retrospective study was conducted at the Hospital of the Federal University of Piauí in Northeastern Brazil. Demographic characteristics and clinical phenotypes of IBD were analyzed in relation to the time of diagnostic confirmation, which was defined as the date of disease onset. Data were collected between January 2011 and December 2012 and included all census patients 18 years of age or older during that period for whom there was diagnostic confirmation of Crohn’s disease (CD), ulcerative colitis (UC), or unclassified colitis according to the Montreal criteria. We also analyzed the period of time between the onset of clinical manifestations and the diagnosis of IBD (delay in the diagnosis). Statistical analyses included means and standard deviations for numeric variables and the Pearson χ² adherence test for nominal variables. The annual index occurrence and overall prevalence of IBD at our institution were also calculated, with P values < 0.05 indicating statistical significance. This study was approved by the Institutional Ethics and Research Committee.

RESULTS: A total of 252 patients with IBD were included, including 152 (60.3%) UC patients and 100 (39.7%) CD patients. The clinical and demographic characteristics of all patients with IBD showed a female to male ratio of 1.3:1.0 and a mean age of 35.2 (SD = 14.5) years. In addition, the majority of patients were miscegenated (171, 67.9%), had received higher education (157, 62.4%), lived in urban areas (217, 86.1%), and were under the age of 40 years (97, 62.5%). For patients with CD, according to the Montreal classification, the predominant features present from the onset of disease were an age between 17 and 40 years (A2); colonic disease location (L2); and nonstricturing, nonfistulizing disease behavior (B1). However, approximately one-quarter of all CD patients demonstrated perineal involvement. We also observed considerable delay in the diagnosis of IBD throughout the entire study period (mean = 35.5 mo). In addition, the annual index occurrence rose from 0.08 to 1.53 cases/10⁵ inhabitants/year during the study period, and the prevalence rate was 12.8 cases/10⁵ inhabitants in 2012. Over the last two decades, there was a noted increase in the frequency of IBD in the study area.

CONCLUSION: In this study, there was a predominance of patients with UC, young people under 40 years of age, individuals with racial miscegenation, and low annual incomes.

The diagnostic value of clinical symptoms in women and men presenting with chest pain at the emergency department, a prospective cohort study

Background

Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking.

Methodology

Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes.

Results

A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).

Conclusion

The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

Endobronchial ultrasound-guided transbronchial needle aspiration is a sensitive method to evaluate patients who should not undergo pulmonary metastasectomy†

OBJECTIVES

Pulmonary metastasectomy is considered an effective treatment in selected patients with extrapulmonary cancer and oligometastatic disease. We know that the presence of mediastinal lymph node metastases reduces survival significantly, but the mediastinum is rarely evaluated before metastasectomy in these patients. We prospectively evaluated how endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) could identify metastases to the mediastinal lymph nodes in patients referred for pulmonary metastasectomy.

METHODS

All patients with extrapulmonary cancer and oligometastatic disease confined to the lungs on positron emission tomography-computed tomography, and who were considered eligible for pulmonary metastasectomy, routinely underwent EBUS-TBNA of the mediastinal lymph nodes. If EBUS-TBNA did not reveal malignant spread, the patient subsequently underwent pulmonary metastasectomy with systematic sampling of mediastinal lymph nodes for histological evaluation.

RESULTS

One hundred and three eligible patients were referred for EBUS-TBNA during a 4-year period. The primary cancers were located in the colon/rectum (n = 64), kidney (n = 16) and other sites (n = 23). EBUS-TBNA sampled 248 lymph nodes and adequate cytology was obtained in 93 patients (90%). EBUS-TBNA found lymph node metastases in 17 patients (16.5%) and during subsequent pulmonary metastasectomy in the remaining 86 patients 1 (1.0%) had a lymph node metastasis. The sensitivity, specificity, NPV and PPV of EBUS-TBNA for diagnosis of mediastinal lymph node metastasis were 94.4, 100, 98.8 and 100%, respectively.

CONCLUSIONS

EBUS-TBNA is a sensitive minimally invasive modality for evaluation of mediastinal lymph node metastases in patients with oligometastatic pulmonary disease. It allows surgeons to select patients who will not benefit from pulmonary metastasectomy.