Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Amitriptyline intoxication in bullfrogs causes widening of QRS complexes in electrocardiogram

Amitriptyline intoxication is caused by its suicidal or accidental overdose. In the present study, by intravenously injecting 1.5 or 3.0 mg/kg amitriptyline into bullfrogs, we actually revealed that amitriptyline causes the widening of QRS complexes in electrocardiogram (ECG). In simultaneous recordings of the cardiac action potential, amitriptyline decreased the slope of phase 0 in the action potential, indicating the inhibition of the inward sodium currents during this phase. The following treatment with sodium bicarbonate quickly restored the widened QRS complexes in the ECG, demonstrating the counteraction with the sodium channel blockade caused by amitriptyline. The dual recordings of ECG waveforms and the action potential in cardiomyocytes enabled us to demonstrate the mechanisms of characteristic ECG abnormalities caused by amitriptyline intoxication.

Subepicardial burn injuries in bullfrog heart induce electrocardiogram changes mimicking inferior wall myocardial infarction

Using bullfrog hearts, we previously reproduced a ST segment elevation in electrocardiogram (ECG), mimicking human ischemic heart disease. In the present study, by inducing subepicardial burn injuries on the inferior part of the frog heart ventricle, we could reproduce typical ECG changes observed in human inferior wall myocardial infarction, such as the marked elevation of the ST segments in inferior limb leads (II, III, aVF) and their reciprocal depression in the opposite limb leads (I, aVL). Due to the decrease in Na⁺/K⁺-ATPase protein expression, the resting membrane potential of injured cardiomyocytes shifted toward depolarization. Such induced electrical difference between the injured and intact cardiomyocytes was thought to be responsible for the creation of “currents of injury” and the subsequent ST segment changes.

Clinical and imaging selection for CT guided - fluoroscopy 0203 disk treatment

Low Back Pain (LBP) is the most common spine disease and it is the most common cause of absence from work in developed countries. At lumbar level, the natural history of herniated disc is characterized by a disappearance of clinical symptoms in up to 60% with conservative treatment through simple rest for about 6 weeks and reduction of the disk heniation revealed by CT or MR scans within eight to nine months after the onset of back pain. Surgery is considered the treatment of choice for extruded, migrated and free fragment herniated disk associated to clinical symptomatology of cono-cauda syndrome, progressive foot droop and hyperalgic radiculopathy. patients with a small or contained herniated disk, without any benefit from conservative medical treatment, can be candidates for one of minimally invasive percutaneous techniques, whose outcome, though, depends on the characteristics of hernia itself and on the chosen technique. The aim of this paper is to discuss about O2-O3 treatment for symptomatic not extruded herniated disk at lumbar level, highlighting about indication inclusion exclusion criteria and our results.

Non-discogenic low back pain treated with oxygen-ozone: outcome in selected applications

Low back pain and sciatica are highly debilitating conditions affecting all socioeconomic groups at an increasingly early age. They are caused by different often concomitant spinal disorders: disc or facet joint disease, spondylolysis (with or without listhesis), vertebral body and interapophyseal arthrosis, spinal stenosis, radicular and synovial cysts and, more rarely, infections and primary or metastatic cancer. Treatment of low back pain and/or sciatica requires an accurate diagnosis based on thorough history-taking and physical examination followed by appropriate imaging tests, namely computed tomography, and/or magnetic resonance scans in addition to standard and morphodynamics X-rays of the spine. In recent years, several reports have demonstrated the utility of oxygen-ozone therapy in reducing the size of herniated discs. The present study reports on the outcome of oxygen-ozone treatment in 576 patients with non-discogenic low back pain caused by degenerative disease of the posterior vertebral compartment (facet synovitis, Baastrup syndrome, spondylolysis and spondylolisthesis, facet degeneration).

Current status of integrating oncology and palliative care in Japan: a nationwide survey

BACKGROUND

Palliative care (PC) is increasingly recognized as essential for oncology care, and several academic societies strongly recommend integrating oncology and palliative care (IOP) in daily practice. Similarly, the Japanese government encouraged the implementation of IOP through the Cancer Control Act of 2007; however, its detailed progress remains unclear. Therefore, this cross-sectional nationwide survey was conducted to investigate the current status and hospital executive physicians' perception of IOP.

METHODS

The questionnaire was developed based on IOP indicators with international consensus. It was distributed to executive physicians at all government-designated cancer hospitals (DCHs, n = 399) and matched non-DCHs (n = 478) in November 2017 and the results were compared.

RESULTS

In total, 269 (67.4%) DCHs and 259 (54.2%) non-DCHs responded. The number of PC resources in DCHs was significantly higher than those in non-DCHs (e.g., full-time PC physicians and nurses, 52.8% vs. 14.0%, p < 0.001; availability of outpatient PC service ≥3 days per week, 47.6% vs. 20.7%, p < 0.001). Routine symptom screening was more frequently performed in DCHs than in non-DCHs (65.1% vs. 34.7%, p < 0.001). Automatic trigger for PC referral availability was limited (e.g., referral using time trigger, 14.9% vs. 15.3%, p = 0.700). Education and research opportunities were seriously limited in both types of hospitals. Most executive physicians regarded IOP as beneficial for their patients (95.9% vs. 94.7%, p = 0.163) and were willing to facilitate an early referral to PC services (54.7% vs. 60.0%, p < 0.569); however, the majority faced challenges to increase the number of full-time PC staff, and < 30% were planning to increase the staff members.

CONCLUSIONS

This survey highlighted a considerable number of IOP indicators met, particularly in DCHs probably due to the government policy. Further efforts are needed to address the serious research/educational gaps.

Effect of voluntary participation on an alternating and a simultaneous prisoner's dilemma

We studied the evolution of cooperation in the framework of evolutionary game theory, implementing voluntary participation in the prisoner's dilemma. Although previous studies have tried to overcome the dilemma by introducing voluntary participation called a "loner," the question of which strategies among various strategies including voluntary participation are adaptive under competitive circumstances is still an unsolved puzzle. Here we have developed a model that consists of all possible strategies using a one-period memory of past actions. This model enables us to analyze a "melting pot" of strategies, wherein several strategies interact and compete with each other. Our results revealed that one strategy, in which one escapes if a partner defects or cooperates if a partner becomes a loner, dominates and maintains cooperation in an alternating prisoner's dilemma game. However, the so-called "win-stay, lose-shift" strategy dominates in a simultaneous prisoner's dilemma game. Our simulations clearly show that voluntary participation in the prisoner's dilemma game works in the alternating situation rather than the simultaneous one.

Role of contrast-enhanced ultrasound to define prognosis and predict response to biotherapy in pancreatic neuroendocrine tumors

PURPOSE

The incidence of neuroendocrine tumors (NETs) is progressively increasing. Most cases arise from the digestive system, where ileum, rectum and pancreas represent the commonest site of origin. Liver metastases are frequently detected at diagnosis or during the follow-up. Contrast-enhanced ultrasound (CEUS) is used in patients with pancreatic NETs (P-NETs) and liver metastases from P-NET but its role has not been standardized. The aim of this retrospective study was to investigate CEUS in patients with P-NETs and liver metastases from P-NET both as prognostic factor and predictor of response to therapy with somatostatin analogues (SSAs).

METHODS

CEUS was performed at the diagnosis of NET and 3, 6 and 12 months after the beginning of SSAs. CEUS pattern was compared with contrast-enhanced computed tomography (CT) pattern.

RESULTS

There was a significant association between CEUS and CT pattern (X ² = 79.0; p < 0.0001). A significant association was found between CEUS pattern and Ki-67 index (X ² = 24.6; p < 0.0001). The hypervascular homogeneous CEUS typical pattern was associated with low tumor grading (G1 or G2) (X ² = 24.0; p < 0.0001). CEUS pattern changed from hypervascular homogeneous in baseline to hypovascular/hypervascular inhomogeneous after SSA therapy, with a significant association between tumor response at CT scan and appearance of hypervascular inhomogeneous pattern at CEUS evaluation (6 months: X ² = 57.0; p < 0.0001; 12 months: X ² = 49.8; p < 0.0001).

CONCLUSIONS

In patients with P-NET, CEUS pattern correlates with tumor grading, being homogeneous in G1-G2 but not in G3 tumors. After therapy with SSAs, CEUS is predictive of response to SSAs. These findings seem to support a role of CEUS as prognostic and predictive factor of response.

Rectal/urinary toxicity after hypofractionated vs. conventional radiotherapy in high risk prostate cancer: systematic review and meta analysis

OBJECTIVE

The aim of our report was to review the literature concerning the toxicity of radiation therapy in patients treated for high-risk prostate cancer, and to evaluate the differences in toxicity between conventional fractionation and hypofractionated treatments, in view of different techniques used in high-risk prostate cancer patients.

MATERIALS AND METHODS

PubMed database has been explored for studies concerning acute and late urinary/gastrointestinal toxicity in high-risk prostate cancer patients treated with radiotherapy. Prospective studies, concerning potential relationship between acute/late genitourinary (GU)/gastrointestinal (GI) toxicity and prostate radiotherapy in patients with high-risk prostate cancer, were included in the final analysis. Data collected from single arm, phase II non-randomized and randomized studies have been evaluated to perform odds ratio for toxicity risk. Furthermore, meta-analysis randomized prospective trials were considered suitable because they had recruited high-risk prostate cancer patients who didn't undergo surgery, with available data on ≥ G2 toxicity frequency.

RESULTS

The initial search provided 606 results, but only 35 manuscripts met all eligibility requirements and were included in this report. In order to perform odds ratio we observed a decrease in late gastrointestinal toxicity for patients treated with hypofractionated schemes compared to CV treated ones. Among patients who underwent conventional treatment, SIB seemed to decrease acute genitourinary side effects; SIB-Hypo treated patients suffered less toxicity than patients treated with hypofractionated- sequential boost schemes. Hypo-SIB schemes would seem less toxic in terms of acute gastrointestinal and late genitourinary side effects than CV-SIB. Therefore, our focus shifted to 6 clinical trials evaluating genitourinary and gastrointestinal toxicity in patients who had been randomized to receive conventional fractionation or hypofractionated treatment, in both cases with IMRT technology. Our meta-analysis of these randomized trials involving patients with high-risk prostate cancer showed a statistically significant increase in late genitourinary toxicity for hypo-treated patients; no difference was observed in acute genitourinary/gastrointestinal toxicity, and in late gastrointestinal toxicity.

CONCLUSIONS

Our analysis doesn't want to establish a definitive truth; very few trials assessed only high risk-class patients. Our purpose is to stimulate further randomized prospective trials focusing both on the effectiveness and toxicity profile (toxicity/effectiveness ratio), taking into account the use of different technologies and doses.

Improvement of luminescence properties of rubidium vanadate, RbVO3, phosphors by erbium doping in the crystal lattice

The thermal quenching effect of RbVO₃ phosphor was effectively improved by Er³⁺ doping into the lattice, as a result, the emission intensity of the phosphor was successfully enhanced.

CTA and DSA Evaluation of Patients with Subarachnoid Haemorrhage

We correlate digital subtraction angiography (DSA) and computed tomography with angiographic 3D reconstruction (CTA) in patients with subarachnoid haemorrhage. 45 patients were evaluated with both techniques (CTA and DSA) within 3–4 days after acute haemorrhage: source CT images, MIP and 4D-angio reconstruction and standard DSA were performed and correlated. The MIP tecnique is very easy and quick to perform and operator independent, while 4D-angio reconstruction requires at least 30 minutes to obtain good quality images.

CTA and DSA were equivalent in demonstrating the presence of all 57 aneurysms in the 45 patients. Most aneurysms were located at the level of the circle of Willis; CTA was not adequate to demonstrate the neck of aneurysms in 7 cases located in of the syphon, vertebral artery and posterior communicating artery; CTA gave a good display of the thrombus within the aneurysm.

Patients could go directly from the CT diagnostic room to the operating room in certain types of aneurysm such as those in the anterior communicating artery or middle cerebral artery in which there is a correlation between site of the haemorrhage and the aneurysm. In the future, improvements in MR technology will also exclude aneurysms in sites difficult to evaluate by CTA such as the syphon, so that DSA will be performed only in selected doubtful cases.

VERO® radiotherapy for low burden cancer: 789 patients with 957 lesions

Purpose

The aim of this retrospective study is to evaluate patient profile, feasibility, and acute toxicity of RadioTherapy (RT) delivered by VERO® in the first 20 months of clinical activity.

Methods

Inclusion criteria: 1) adult patients; 2) limited volume cancer (M0 or oligometastatic); 3) small extracranial lesions; 4) treatment between April 2012 and December 2013 and 5) written informed consent. Two techniques were employed: intensity modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT). Toxicity was evaluated using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer (RTOG/EORTC) criteria.

Results

Between April 2012 and December 2013, 789 consecutive patients (957 lesions) were treated. In 84% of them one lesion was treated and in 16% more than one lesion were treated synchronously/metachronously; first radiotherapy course in 85%, re-irradiation in 13%, and boost in 2% of cases. The treated region included pelvis 46%, thorax 38%, upper abdomen 15%, and neck 1%. Radiotherapy schedules included <5 and >5 fractions in 75% and 25% respectively. All patients completed the planned treatment and an acceptable acute toxicity was observed.

Conclusions

RT delivered by VERO® was administrated predominantly to thoracic and pelvic lesions (lung and urologic tumours) using hypofractionation. It is a feasible approach for limited burden cancer offering short and well accepted treatment with favourable acute toxicity profile. Further investigation including dose escalation and other available VERO® functionalities such as real-time dynamic tumour tracking is warranted in order to fully evaluate this innovative radiotherapy system.

Posterior Fossa Arteriovenous Pial Fistula: Diagnostic and Endovascular Therapeutic Features

Intracranial arteriovenous fistulas (AVFs) are rare vascular cerebral lesions composed of one or more corticalpial arterial feeders directly connected with a single draining vein. They differ from the other AV malformations in that they lack a nidus and are located outside the dural leaflets. Because of high flow and pressure AVFs have a high risk of hemorrhage and if untreated cause death in up to 63% of cases. Treatment can be endovascular or microneurosurgical. We describe an infant with hydrocephalus and raised intracranial pressure and MRI findings of a single dilated venous vessel with a proximal varix in the perimedullary spaces confirmed by CT angiography and DSA that found a single artery-single vein fistula we successfully occluded with GDC coils.

Biomechanics of the Spine

Biomechanics of the spine is a vast area of research that has generated numerous studiesin recent years on the part of doctors (mainly orthopaedic surgeons), bioengineers and physicists. This paper is a short introduction to some of the topics of major interest in spine biomechanics.

The first topic is the development of the spine with a “mechanical” explanation of the physiological curvatures. As the spine is a multiarticular complex structure, understanding the mechanism responsible for its dynamics requires in-depth knowledge of the spine's basic components: the vertebrae and their architecture, the intervertebral joints, the ligaments and muscles. A short morphofunctional description of each of these anatomical parts is given mentioning their biomechanical features.

Of particular interest, in relation to spinal trauma, is the architecture of the cancellous bone of the vertebrae responsible for most resistance to compressive weight loads. This specific characteristic is gradually lost over the years either due to disease or to a progressive resorption of the horizontal lamellae and thinning of the vertical columns typical of osteoporosis.

Numerous studies have been conducted in vivo and in vitro to shed light on the mechanisms leading to particular traumatic lesions or degenerative arthrosis. These have given rise to various theories formulated to account for the distribution of loads and strength in the elements making up the functional spinal unit. These theories include the old “two vertical columns” theory, subsequently replaced by the “three columns theory”, and the latest “four columns” model which divides the spine longitudinally depending on carrying strength. The latest theory was formulated in the wake of in vivo CT studies using an axial loading device which allows axial loads to be applied even though patients are in a supine position.

A short mention is made of the possible biomechanical applications of neuroradiological techniques, namely cine-MR scans, which allow detailed study of the ligaments, muscles and disc, especially the cervical spine under dynamic conditions.

Lastly, the controversial concept of spinal stability and instability is discussed. Further studies are necessary to establish appropriate criteria for treatment of traumatic or degenerative lesions since an impairment to spine statics can result in permanent neurological damage.

Non-Discal Lumbar Radiculopathy: Combined Diagnostic Approach by CT and MR

The goal of this paper was to evaluate the different causes of non-discal radiculopathies and to determine the different sensitivity and specificity of CT and MR.

We reviewed 450 patients with non-discal radiculopathy; CT was performed in all patients while MR was done only in 95 cases. MR was obtained only in case of polyradiculopathy, or if there was a discrepancy between clinical evaluation and CT findings or when sphincteral symptoms were present.

The most frequent cause of non-discal radiculopathy was degenerative disk disease associated with facet joint abnormality and secondary central and lateral spinal canal stenosis. Other causes were neoplastic lesions, traumas, malformations, inflammatory processes and vascular abnormality.

CT was more sensitive and specific in degenerative disc disease while MR was better at evaluating other pathology.

CT still represents a satisfactory technique in evaluating patients with non-discal radiculopathy; MR must be also performed in case of discrepancy between clinical evaluation and CT findings.

Directly MR examination should be reserved for patients presenting sphincteral symptoms.

Percutaneous Treatment of Herniated Lumbar Disc by Intradiscal Oxygen-Ozone Injection

We report our experience of treating lumbar herniated disc by intradiscal injection of an oxygen-ozone mixture. Ozone (03, MW = 48) is a triatomic molecule, having antiviral, disinfectant and antiseptic properties. Several mechanisms of action have been proposed to explain the efficacy of the treatment:

analgesic action; anti-inflammatory action; oxidant action on the proteoglycan in the nucleus pulposus.

We treated 93 patients (50 women, 43 men) aged from 24 to 45 yrs (average age 38 yrs) from June 1996 to April 1998.

All patients presented sciatica and/or low back pain, lasting two or more months; patients had in the mean time received both medical and physical therapy with mild or no benefit.

Diagnostic tests in all patients included plain film x-ray, CT and/or MR at the level of the lumbar spine disclasing a herniated or protruded disc with nerve root or thecal sac compression.

We divided patients to be treated in to two groups: the first one group included 35 patients already selected for surgery who presented herniated or protruded disc with radicular pain with associated neurological deficit (hypoesthesia and partial loss of reflex). Those patients had already had medical and physical therapy for two or more months and agreed to try the percutaneous treatment before surgery. CT or MR in this group demonstrated the presence of intraforaminal, extra or sub-ligamentary and sequestrated herniated disc. The second group included 58 patients with radicular pain but without neurological deficit; patients in this group had received medical and/or physical therapy for two or more months and CT showed the presence of a small subligamentary herniated or protruded disc.

We considered the results according to the modified MacNab method.

In the first group we had “failure” in all patients; in seven cases the symptoms improved for one month, but recurred later on. In the second group 45 patients had “success” showing complete clinical recovery within five to six days after treatment, all remained without symptoms up to six months or more of follow-up. The remaining 13 patients presented the same symptoms again within three months after a temporary clinical recovery. The goal of this study was to present this new technique that can also be compared with a previous study of different percutaneous treatment. Clinical and neuroradiological indications and the contraindications are well known, and must be followed to achieve good results and avoid complications.

Development of an E-learning System for the Endoscopic Diagnosis of Early Gastric Cancer: An International Multicenter Randomized Controlled Trial

Background

In many countries, gastric cancer is not diagnosed until an advanced stage. An Internet-based e-learning system to improve the ability of endoscopists to diagnose gastric cancer at an early stage was developed and was evaluated for its effectiveness.

Methods

The study was designed as a randomized controlled trial. After receiving a pre-test, participants were randomly allocated to either an e-learning or non-e-learning group. Only those in the e-learning group gained access to the e-learning system. Two months after the pre-test, both groups received a post-test. The primary endpoint was the difference between the two groups regarding the rate of improvement of their test results.

Findings

515 endoscopists from 35 countries were assessed for eligibility, and 332 were enrolled in the study, with 166 allocated to each group. Of these, 151 participants in the e-learning group and 144 in the non-e-learning group were included in the analysis. The mean improvement rate (standard deviation) in the e-learning and non-e-learning groups was 1·24 (0·26) and 1·00 (0·16), respectively (P < 0·001).

Interpretation

This global study clearly demonstrated the efficacy of an e-learning system to expand knowledge and provide invaluable experience regarding the endoscopic detection of early gastric cancer (R000012039).

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This report establishes that an e-learning system on the Internet can improve the diagnostic ability of endoscopists.

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Countless endoscopists worldwide can access the system to learn how to make an endoscopic diagnosis of early gastric cancer.

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The e-learning system could be modified to provide education regarding endoscopic diagnosis in other organs.

This is the first report to demonstrate how an e-learning system based on the Internet can improve the diagnostic ability of gastrointestinal endoscopists worldwide. There is no limit to the number of endoscopists who can access the system and benefit from this opportunity to learn how to make an endoscopic diagnosis of early gastric cancer. This e-learning system could be modified to provide education regarding endoscopic diagnosis in other organs such as the large intestine and the esophagus, as well as the stomach. It may contribute to human welfare and health by reducing the mortality from gastrointestinal cancer.