Association of statins with nonalcoholic fatty liver disease in patients with diabetes

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in patients with diabetes; limited data suggested that statins may reduce the risk of NAFLD progression. This study aimed to examine the association between statins and the development or progression of NAFLD in veterans with diabetes. In a new-user negative control design, we conducted a retrospective propensity score (PS)-matched cohort study of patients with diabetes between 2003 and 2015. After excluding patients with other causes of liver disease, we formed PS using 85 characteristics. The primary outcome was a composite NAFLD progression outcome. Primary analysis examined odds of outcome in PS-matched cohort. Post-hoc analysis included a PS-matched cohort of statin users with intensive lowering of low-density lipoprotein-cholesterol (LDL-C) vs low-intensity lowering. We matched 34,102 pairs from 300,739 statin users and 38,038 non-users. The composite outcome occurred in 8.8% of statin users and 8.6% of non-users (odds ratio (OR) 1.02, 95% confidence interval (95% CI) 0.97-1.08). In the post-hoc analysis, intensive lowering of LDL-C compared to low-intensity showed increased NAFLD progression (OR 1.21, 95% CI 1.13-1.30). This study showed that statin use in patients with diabetes was not associated with decreased or increased risk of NAFLD progression. Intensive LDL-C lowering, compared to low-intensity LDL-C lowering, was associated with an increased risk of NAFLD progression.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Measurement of the major ignored burden of multiple myeloma, pernicious anaemia and of other haematological conditions on partners and family members: A cross-sectional study

BACKGROUND

Having a haematological condition can adversely affect the quality of life (QoL) of family members/partners of patients. It is important to measure this often ignored burden in order to implement appropriate supportive interventions.

OBJECTIVE

To measure current impact of haematological conditions on the QoL of family members/partners of patients, using the Family Reported Outcome Measure-16 (FROM-16).

METHODS

A cross-sectional study, recruited online through patient support groups, involved UK family members/partners of people with haematological conditions completing the FROM-16.

RESULTS

183 family members/partners (mean age = 60.5 years, SD = 13.2; females = 62.8%) of patients (mean age = 64.1, SD = 12.8; females = 46.4%) with 12 haematological conditions completed the FROM-16. The FROM-16 mean total score was 14.0 (SD = 7.2), meaning 'a moderate effect on QoL'. The mean FROM-16 scores of family members of people with multiple myeloma (mean = 15.8, SD = 6.3, n = 99) and other haematological malignancies (mean = 13.9, SD = 7.8, n = 29) were higher than of people with pernicious anaemia (mean = 10.7, SD = 7.5, n = 47) and other non-malignant conditions (mean = 11, SD = 7.4, n = 56, p < .01). Over one third (36.1%, n = 183) of family members experienced a 'very large effect' (FROM-16 score>16) on their quality of life.

CONCLUSIONS

Haematological conditions, in particular those of malignant type, impact the QoL of family members/partners of patients. Healthcare professionals can now, using FROM-16, identify those most affected and should consider how to provide appropriate holistic support within routine practice.

Responsiveness and minimal important change of the Family Reported Outcome Measure (FROM-16)

BACKGROUND

The FROM-16 is a generic family quality of life (QoL) instrument that measures the QoL impact of patients' disease on their family members/partners. The study aimed to assess the responsiveness of FROM-16 to change and determine Minimal Important Change (MIC).

METHODS

Responsiveness and MIC for FROM-16 were assessed prospectively with patients and their family members recruited from outpatient departments of the University Hospital Wales and University Hospital Llandough, Cardiff, United Kingdom. Patients completed the EQ-5D-3L and a global severity question (GSQ) online at baseline and at 3-month follow-up. Family members completed FROM-16 at baseline and a Global Rating of Change (GRC) in addition to FROM-16 at follow-up. Responsiveness was assessed using the distribution-based (effect size-ES, standardized response mean -SRM) and anchor-based (area under the receiver operating characteristics curve ROC-AUC) approaches and by testing hypotheses on expected correlation strength between FROM-16 change score and patient assessment tools (GSQ and EQ-5D). Cohen's criteria were used for assessing ES. The AUC ≥ 0.7 was considered a good measure of responsiveness. MIC was calculated using anchor-based (ROC analysis and adjusted predictive modelling) and distribution methods based on standard deviation (SD) and standard error of the measurement (SEM).

RESULTS

Eighty-three patients with 15 different health conditions and their relatives completed baseline and follow-up questionnaires and were included in the responsiveness analysis. The mean FROM-16 change over 3 months = 1.43 (SD = 4.98). The mean patient EQ-5D change over 3 months = -0.059 (SD = 0.14). The responsiveness analysis showed that the FROM-16 was responsive to change (ES = 0.2, SRM = 0.3; p < 0.01). The ES and SRM of FROM-16 change score ranged from small (ES = 0.2; SRM = 0.3) for the distribution-based method to large (ES = 0.8, SRM = 0.85) for anchor-based methods. The AUC value was above 0.7, indicating good responsiveness. There was a significant positive correlation between the FROM-16 change scores and the patient's disease severity change scores (p < 0.001). The MIC analysis was based on data from 100 family members of 100 patients. The MIC value of 4 was suggested for FROM-16.

CONCLUSIONS

The results of this study confirm the longitudinal validity of FROM-16 which refers to the degree to which an instrument is able to measure change in the construct to be measured. The results yield a MIC value of 4 for FROM-16. These psychometric attributes of the FROM-16 instrument are useful in both clinical research as well as clinical practice.

Endoscopic Ultrasound Guided Liver Palpation As a Screening Tool for Advanced Fibrosis and Cirrhosis in Patients with Suspected Metabolic Dysfunction-Associated Steatotic Liver Disease: A Pilot Study

BACKGROUND AND AIMS

Endoscopic liver "palpation" can be performed by indenting the liver surface under endoscopic ultrasound (EUS). Indentation depth is measured with sonographic calipers. We hypothesize that fibrotic livers are more difficult to indent, and indentation can accurately predict liver fibrosis staging. We compared EUS-guided liver palpation to conventional screening modalities in patients with suspected metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

This was a cross-sectional pilot study. Consecutive patients at three hospitals between 2021-2023 underwent EUS-guided palpation with liver biopsy. Liver palpation was compared to Fibrosis-4 index (FIB-4), AST to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS), and transient elastography in predicting fibrosis staging on histology. Area under the receiver operator characteristic (AUROC) curve analysis was performed.

RESULTS

73 patients were included. Mean age was 49.1 and 71.2% were female. Mean body mass index was 41.1. Indentation depth was negatively correlated with fibrosis stage (Kruskal-Willis test, p<0.0001). EUS palpation demonstrated c-statistic of 0.79 and 0.95 discriminating advanced fibrosis and cirrhosis respectively. EUS-liver palpation was superior to NFS in predicting advanced fibrosis (p=0.0057) and superior to APRI and NFS predicting cirrhosis (p=0.0099 and 0.045 respectively). EUS palpation was not significantly different versus FIB-4. EUS palpation was superior to transient elastography in predicting cirrhosis (p=0.045). Using optimal cut-offs, indentation measurement ≤3.5mm yielded 100% predictive value ruling in advanced fibrosis, and ≥4.0mm yielded 100% predictive value ruling out cirrhosis.

CONCLUSIONS

EUS liver palpation is a novel, accurate, and easy-to-use screening tool for advanced fibrosis and cirrhosis in patients with MASLD.

Mapping of Family Reported Outcome Measure (FROM-16) scores to EQ-5D: algorithm to calculate utility values

OBJECTIVE

Although decision scientists and health economists encourage inclusion of family member/informal carer utility in health economic evaluation, there is a lack of suitable utility measures comparable to patient utility measures such those based on the EQ-5D. This study aims to predict EQ-5D-3L utility values from Family Reported Outcome Measure (FROM-16) scores, to allow the use of FROM-16 data in health economic evaluation when EQ-5D data is not available.

METHODS

Data from 4228 family members/partners of patients recruited to an online cross-sectional study through 58 UK-based patient support groups, three research support platforms and Welsh social services departments were randomly divided five times into two groups, to derive and test a mapping model. Split-half cross-validation was employed, resulting in a total of ten multinomial logistic regression models. The Monte Carlo simulation procedure was used to generate predicted EQ-5D-3L responses, and utility scores were calculated and compared against observed values. Mean error and mean absolute error were calculated for all ten validation models. The final model algorithm was derived using the entire sample.

RESULTS

The model was highly predictive, and its repeated fitting using multinomial logistic regression demonstrated a stable model. The mean differences between predicted and observed health utility estimates ranged from 0.005 to 0.029 across the ten modelling exercises, with an average overall difference of 0.015 (a 2.2% overestimate, not of clinical importance).

CONCLUSIONS

The algorithm developed will enable researchers and decision scientists to calculate EQ-5D health utility estimates from FROM-16 scores, thus allowing the inclusion of the family impact of disease in health economic evaluation of medical interventions when EQ-5D data is not available.

Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial

BACKGROUND

The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention.

METHODS

In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete.

FINDINGS

Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups.

INTERPRETATION

For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines.

FUNDING

US National Institutes of Health.

Non-Users and Limited Users of Cochlear Implants in Pediatric Patients: A Retrospective Cross-Sectional Study

To determine the prevalence of non-use and limited use of cochlear implants. To find out the reasons for the same. This study was carried out among the paediatric patients who underwent cochlear implantation under the SHP* scheme in Civil Hospital, Ahmedabad between 2013 and 2020.

STUDY DESIGN

Retrospective cross-sectional study.

STUDY SETTING

Civil Hospital Ahmedabad.

SAMPLE SIZE

150 paediatric patients. Patients were selected based on a random number generator. The data was collected through a telephonic interview based upon a preformed questionnaire. The study indicates that out of a total 150 participants, 109 (72.7%) used their cochlear implant regularly while 41 (27.3%) did not. Major issue faced by the participants was in the external device -damage to the device and monetary issues for its repair. The participants who have dropped the usage of their implants faced issues mostly after 2 years of usage. The age group of less than 3 years showed 15.6% of non-usage, while the age group of 3-6 years showed an increase to 34.5% of non-users. The age group of more than 6 years showed an even higher proportion (41.3%) of non-users. It is recommended that the government ensures the follow-up of the patients undergoing cochlear implantation for at least 2 years after the surgery. The proportion of non-users in the consecutive increasing age groups saw a rise in number. Therefore, it is recommended to divert the resources towards lower age groups to facilitate a better outcome.

A Review on Endoscopic Management of Acute Cholecystitis: Endoscopic Ultrasound-Guided Gallbladder Drainage and Endoscopic Transpapillary Gallbladder Drainage

A percutaneous cholecystostomy tube (PCT) is the conventionally favored nonoperative intervention for treating acute cholecystitis. However, PCT is beset by high adverse event rates, need for scheduled reintervention, and inadvertent dislodgement, as well as patient dissatisfaction with a percutaneous drain. Recent advances in endoscopic therapy involve the implementation of endoscopic transpapillary drainage (ETP-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which are increasingly preferred over PCT due to their favorable technical and clinical success combined with lower complication rates. In this article, we provide a comprehensive review of the literature on EUS-GBD and ETP-GBD, delineating instances when clinicians should opt for endoscopic management and highlighting potential risks associated with each approach.

Incidence of Kidney Stones After Bariatric Surgeries: Comparing Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

INTRODUCTION/PURPOSE

The two most common procedures performed to treat obesity are Roux-En-Y gastric bypass (RNYGB) and laparoscopic sleeve gastrectomy (LSG). Due to changes in enteric absorption, bariatric surgery increases rates of nephrolithiasis. As population-based data are limited, we aimed to compare the incidence of kidney stones after RNYGB and LSG.

MATERIALS AND METHODS

We queried Explorys (Cleveland, OH), a database that aggregated data from 26 healthcare systems. We identified patients who were newly diagnosed with nephrolithiasis 3, 6, and 12 months after their RNYGB or LSG. Additionally, a multivariate analysis was conducted to investigate the association of nephrolithiasis with RNYGB as compared to LSG. This analysis adjusted for other risk factors, including age above 65, male gender, Caucasian race, diabetes mellitus, hypertension, primary hyperparathyroidism, gout, and obesity.

RESULTS

From 1999 to 2019, there were 11,480 patients who underwent RNYGB and 22,770 patients who underwent LSG. The incidence of nephrolithiasis in the RNYGB cohort at all three time points was higher than in the LSG cohort (3 months, 7.1% vs. 2.4%; 6 months, 6.6% vs. 2.0%; 1 year, 5.8% vs. 1.4%; P < 0.001). After the multivariate analysis, it was found that, though both RNYGB and LSG were independently associated with the development of nephrolithiasis, the risk of nephrolithiasis was higher in those who underwent RNYGB compared to those who underwent LSG (OR 1.594, 95% CI 1.494 to 1.701, P < 0.001).

CONCLUSION

RNYGB is associated with a higher risk of nephrolithiasis when compared to LSG.

A Unique Management Strategy for Migrated Biliary Stent Causing Duodenal Perforation

Distal stent migration leading to duodenal perforation is an uncommon complication of endoscopic biliary plastic stent placement. We present a case in which a patient with a migrated biliary plastic stent that perforated through the duodenum was managed expectantly until a duodenocolic fistula formed prior to endoscopic removal.

A Spontaneous Melanoma Mouse Model Applicable for a Longitudinal Chemotherapy and Immunotherapy Study

Mouse models that reflect human disorders provide invaluable tools for the translation of basic science discoveries to clinical therapies. However, many of these in vivo therapeutic studies are short term and do not accurately mimic patient conditions. In this study, we used a fully immunocompetent, transgenic mouse model, TGS, in which the spontaneous development of metastatic melanoma is driven by the ectopic expression of a normal neuronal receptor, mGluR1, as a model to assess longitudinal treatment response (up to 8 months) with an inhibitor of glutamatergic signaling, troriluzole, which is a prodrug of riluzole, plus an antibody against PD-1, an immune checkpoint inhibitor. Our results reveal a sex-biased treatment response that led to improved survival in troriluzole and/or anti-PD-1-treated male mice that correlated with differential CD8+ T cells and CD11b+ myeloid cell populations in the tumor-stromal interface, supporting the notion that this model is a responsive and tractable system for evaluating therapeutic regimens for melanoma in an immunocompetent setting.

Herpes Simplex Virus Esophagitis in an Immunocompetent Patient

Esophagitis due to herpes simplex virus (HSV) infection is a rare entity in the immunocompetent population. It is usually seen in immunocompromised hosts, those with human immunodeficiency virus (HIV) infection, malignancies, and patients on immunosuppressive medications. We present a case of a young immunocompetent man with anabolic steroid use who presented with esophagitis symptoms found to be from HSV infection. So far, the use of corticosteroids has been reported as a predisposing factor for HSV esophagitis in immunocompetent hosts in multiple case reports. However, our case suspects that transient immunosuppression with similar medication can cause HSV esophagitis in otherwise immunocompetent hosts.

Current and Potential Applications of Green Membranes with Nanocellulose

Large-scale applications of nanotechnology have been extensively studied within the last decade. By exploiting certain advantageous properties of nanomaterials, multifunctional products can be manufactured that can contribute to the improvement of everyday life. In recent years, one such material has been nanocellulose. Nanocellulose (NC) is a naturally occurring nanomaterial and a high-performance additive extracted from plant fibers. This sustainable material is characterized by a unique combination of exceptional properties, including high tensile strength, biocompatibility, and electrical conductivity. In recent studies, these unique properties of nanocellulose have been analyzed and applied to processes related to membrane technology. This article provides a review of recent synthesis methods and characterization of nanocellulose-based membranes, followed by a study of their applications on a larger scale. The article reviews successful case studies of the incorporation of nanocellulose in different types of membrane materials, as well as their utilization in water purification, desalination, gas separations/gas barriers, and antimicrobial applications, in an effort to provide an enhanced comprehension of their capabilities in commercial products.

Esophageal Granular Cell Tumor: An Uncommon Cause of Dysphagia

Granular cell tumors (GCTs) are rare, typically benign, solitary neoplasms that can arise throughout the body, with reports of cases in the tongue, esophagus, colon, skin, vulva, and skeletal muscle, among others. Although GCTs are usually asymptomatic, esophageal GCTs can grow large enough to cause dysphagia. When developing the differential diagnosis for dysphagia, a broad consideration includes routine etiologies such as esophageal strictures, eosinophilic esophagitis, carcinoma, webs and rings, achalasia, and motility disorders, but GCTs may not readily come to mind. Due to their scarcity, this case report is presented to raise awareness of esophageal GCTs and emphasize key goals for diagnosing and managing this uncommon yet treatable cause of dysphagia. This case report details the clinical course of a patient presenting with a chief complaint of difficulty swallowing that was found to be caused by a subepithelial esophageal tumor discovered with esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). Histopathological studies paired with immunohistochemical investigations of a tissue biopsy confirmed the etiology of the offending esophageal mass to be a GCT. The patient's dysphagia resolved after endoscopic mucosal resection of the GCT, and follow-up evaluations have remained negative for recurrence. This case highlights the esophageal GCT as an uncommon source of dysphagia and the need for EGD and EUS evaluations of subepithelial esophageal lesions accompanied by histopathological analysis for a definitive diagnosis of GCT.

Gastroplasty with endoscopic myotomy for the treatment of obesity

Video 1Demonstration of the steps of gastroplasty with endoscopic myotomy for the treatment of obesity.

High Burden of Obesity and Low Rates of Weight Loss Pharmacotherapy in Inflammatory Bowel Disease: 10-Year Trend

Background

The prevalence of obesity and inflammatory bowel disease (IBD) has increased in the last decade. There is a paucity of data on the recent trend of obesity and the utilization of anti-obesity pharmacotherapy in IBD. We aimed to use a population-level database to analyze their trends.

Methods

A retrospective analysis of population-level data from 2010 to 2019 was performed among individuals ≥18 years of age using a commercial database, IBM Explorys. The prevalence and trends of obesity, diabetes mellitus type 2 (DM2), essential hypertension, dyslipidemia and/or hyperlipidemia, sleep apnea, and anti-obesity pharmacotherapy were studied. Univariate analysis using chi-square test and trend analysis using the Cochrane Armitage test were performed.

Results

Among 39 717 520 adults, 37.3% of IBD patients have a diagnosis of obesity (Crohn's disease 36.9% vs ulcerative colitis 38.5%, P < .0001). The proportion of IBD adults with obesity and metabolic comorbidities increased from 2010 to 2019: obesity (19.7%-30.1%), DM2 (8.3%-12.5%), hypertension (25.1%-33.9%), hyperlipidemia (22.1%-32.2%), and sleep apnea (4.1%-10.8%). All comparisons were statistically significant (P < .0001). Only 2.8% of eligible adults with obesity were prescribed anti-obesity pharmacotherapy in the last 10 years, with trends increasing from 1.4% to 3.6%, 2010-2019.

Conclusions

With obesity being a harbinger for metabolic syndrome, the increase in obesity in IBD patients was accompanied by a concomitant increase in the diseases associated with obesity in the past decade. However, this alarming rise in obesity was accompanied by a disproportionately small increase in anti-obesity pharmacotherapy similar to general population.

Probing the Degree of Coherence through the Full 1D to 3D Crossover

We experimentally study a gas of quantum degenerate ^{87}Rb atoms throughout the full dimensional crossover, from a one-dimensional (1D) system exhibiting phase fluctuations consistent with 1D theory to a three-dimensional (3D) phase-coherent system, thereby smoothly interpolating between these distinct, well-understood regimes. Using a hybrid trapping architecture combining an atom chip with a printed circuit board, we continuously adjust the system's dimensionality over a wide range while measuring the phase fluctuations through the power spectrum of density ripples in time-of-flight expansion. Our measurements confirm that the chemical potential μ controls the departure of the system from 3D and that the fluctuations are dependent on both μ and the temperature T. Through a rigorous study we quantitatively observe how inside the crossover the dependence on T gradually disappears as the system becomes 3D. Throughout the entire crossover the fluctuations are shown to be determined by the relative occupation of 1D axial collective excitations.

Evidence-Based Cognitive Endoscopy Simulators: Do They Exist? A Systematic Search and Evaluation of Existing Platforms

BACKGROUND

The development of guidelines by gastroenterology societies increasingly stresses evidence-based endoscopic practice.

AIMS

We performed a systematic assessment to determine whether endoscopic video teaching platforms incorporate evidence-based educational strategies and methods in order to disseminate guideline-based endoscopic management strategies.

METHODS

Platforms with a video component were systematically identified using the Google search engine, Apple and Android application stores, and searching four major gastroenterology society websites and three known platforms, to identify all relevant platforms. Two video samples from each teaching platform were reviewed independently by two authors and assessed for use of a priori defined principles of evidence-based medicine, as determined by consensus agreement and for the use of simulation.

RESULTS

Fourteen platforms were included in the final analysis, and two videos from each were analyzed. One of the 14 platforms used simulation and incorporated evidence-based medicine principles consistently. Nine of the 14 platforms were not transparent in regard to citation. None of the platforms consistently cited the certainty of evidence or explained how evidence was selected.

CONCLUSIONS

Education of guideline-based endoscopic management strategies using principles of evidence-based medicine is under-utilized in endoscopic videos. In addition, the use of cognitive simulation is absent in this arena. There is a paucity of evidence-based cognitive endoscopy simulators designed for fellows that incorporate systematic evaluation, and efforts should be made to create this platform.

NUT carcinoma of the mandible in a child: case report and systematic review

Nuclear protein of the testis (NUT) carcinoma is a rare, undifferentiated carcinoma that is characterized by NUTM1 gene rearrangements. Patients with NUT carcinoma have an overall survival of approximately 5% at 5 years despite a multimodal treatment approach. This report illustrates the management of mandibular NUT carcinoma in a pediatric patient, complemented by a systematic review of head and neck NUT carcinoma. A 5-year-old female presented with an enlarging jaw mass that was diagnosed as BRD4-NUTM1 carcinoma and was treated with hemimandibulectomy and chemoradiation. She remains disease-free 21 months after completion of therapy. A total of 63 patient cases reported in 34 articles were identified in the review. Only 26.9% (14/52) of tumors were correctly diagnosed initially as NUT carcinoma, whereas 73.1% (38/52) were incorrectly diagnosed as another malignancy; the initial diagnosis was not reported for 11 patients. The mandibular tumor subtype was among the rarest reported (n = 1; 1.6%). Combination therapy, including surgery and chemoradiation, was the most common treatment (55.2%). The patient case presented here is a novel case of pediatric mandibular NUT carcinoma. Due to the poor overall survival of patients with NUT carcinoma, aggressive upfront resection with 2-cm margins followed by adjuvant chemoradiation is advocated.

A Rare Case of Phlegmonous Gastritis in a Previously Healthy Male: A Case Report

Though rare, phlegmonous gastritis (PG) is a serious and life-threatening infection of the gastric submucosa and mucosa. Many factors have been associated with PG, including malignancy, chronic alcohol use, and immunocompromised states. Clinical presentation of PG is often non-specific, and diagnosis is often delayed. Early recognition and starting antibiotics significantly reduce overall mortality. We describe a case of a previously healthy male who presented with moderate abdominal pain and was found to have PG that was treated with an extensive course of antibiotics and total parental nutrition. Contrary to previously described cases in the literature, our patient had no predisposing factors, highlighting the importance of suspecting PG even in the absence of such factors and demonstrating the effectiveness of antibiotics in this disease.

POLYPHARMACY, FRAILTY, AND DISABILITY-FREE SURVIVAL IN COMMUNITY-DWELLING HEALTHY OLDER INDIVIDUALS

BACKGROUND

Polypharmacy and frailty are two common geriatric syndromes. We examined the association between polypharmacy and frailty and if, together, they predicted disability-free survival (DFS), defined as time to the first event of dementia, persistent physical disability or death.

METHODS

We included 19,114 participants from the "ASPirin in Reducing Events in the Elderly" (ASPREE) clinical trial. Polypharmacy was defined as regular, concomitant use of five or more prescription medications. Frailty was assessed using a modified Fried phenotype and a deficit accumulation frailty index (FI) of 66 items. The association between polypharmacy and frailty was assessed by multinomial logistic regression. In addition, Cox regression was used to determine the association between polypharmacy-exposed frailty and DFS.

RESULTS

Individuals with polypharmacy (vs. < 5 medications) were 55% more likely to be pre-frail (Relative Risk Ratio or RRR: 1.55; 95%Confidence Interval or CI:1.44, 1.68) and three times more likely to be frail (RRR: 3.34; 95%CI: 2.64, 4.22) according to Fried phenotype. Frail individuals had a two-fold reduction in their survival free of dementia/disability (Hazard ratio or HR: 2.16; 95%CI: 1.56, 2.99), whereas frail individuals with polypharmacy had a four-fold reduction (HR: 4.24; 95%CI: 3.28, 5.47). Effect sizes were more prominent when frailty was assessed using the FI than when assessed by Fried phenotype.

CONCLUSION

Polypharmacy was significantly associated with pre-frailty/frailty. Polypharmacy-exposed pre-frailty/frailty increased the risk of death, dementia or physical disability among older adults. Addressing polypharmacy in older people could ameliorate the impact of frailty on individuals’ functional status, cognition and survival.

AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity

BACKGROUND & AIMS

Pharmacological management of obesity improves outcomes and decreases the risk of obesity-related complications. This American Gastroenterological Association guideline is intended to support practitioners in decisions about pharmacological interventions for overweight and obesity.

METHODS

A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, and conduct an evidence synthesis of the following agents: semaglutide 2.4 mg, liraglutide 3.0 mg, phentermine-topiramate extended-release (ER), naltrexone-bupropion ER, orlistat, phentermine, diethylpropion, and Gelesis100 oral superabsorbent hydrogel. The guideline panel used the evidence-to-decision framework to develop recommendations for the pharmacological management of obesity and provided implementation considerations for clinical practice.

RESULTS

The guideline panel made 9 recommendations. The panel strongly recommended the use of pharmacotherapy in addition to lifestyle intervention in adults with overweight and obesity (body mass index ≥30 kg/m2, or ≥27 kg/m2 with weight-related complications) who have an inadequate response to lifestyle interventions. The panel suggested the use of semaglutide 2.4 mg, liraglutide 3.0 mg, phentermine-topiramate ER, and naltrexone-bupropion ER (based on moderate certainty evidence), and phentermine and diethylpropion (based on low certainty evidence), for long-term management of overweight and obesity. The guideline panel suggested against the use of orlistat. The panel identified the use of Gelesis100 oral superabsorbent hydrogel as a knowledge gap.

CONCLUSIONS

In adults with overweight and obesity who have an inadequate response to lifestyle interventions alone, long-term pharmacological therapy is recommended, with multiple effective and safe treatment options.

Spatial Relationship of Maxillary Posterior Teeth with Maxillary Sinus Floor in Sagittal, Coronal and Axial Planes by Using Cone-Beam Computed Tomography in a Subpopulation of Central India

Inadvertent perforation of the root apex during endodontic procedure in maxillary posterior teeth may unnecessarily invite the complications of sinusitis or inflammatory responses. This becomes even more important when performing endodontic surgical procedures. Thus, it is mandatory to have the precise knowledge of anatomic structures which are in close proximity to the apex of roots and its variations among different geographic area. This retrospective observational study was performed in the Central India to assess the spatial relationships between the maxillary second pre-molar (sPM), maxillary first molar (M1), maxillary second molar (M2) with the maxillary sinus floor using cone beam computed tomography (CBCT) in all three axial, sagittal and coronal sections from year 2016 to 2021. Three hundred and sixty teeth were examined through sixty full volumes CBCT scans of the patients in between year 2016-2021 in Indore, (MP, India). The Distances (D) between the examined roots and the sinus floor, were evaluated using CBCT in all three sections, and grouped in 7 classes. To simplify, Class 1 and 2 were grouped as Negative Configuration where apices are protruding into sinus floor, Class 3 as Zero and Class 4-7 as Positive configuration. The data were analyzed statistically using SPSS system. The prevalence of class 1 and 2 (negative configuration) was the highest for the Palatal of M1 (16.67%) followed by Distobuccal of M1 (13.34%). The prevalence of class 3 that is Zero configuration was the highest for the Mesiobuccal of M2 (63.33%). The results suggested all the three teeth roots showed closed proximity with sinus floor, closest relationship with the sinus floor was seen in palatal of M1 in this study.

10-Year Trend of Abdominal Magnetic Resonance Imaging Compared With Abdominal Computed Tomography Scans in Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) frequently undergo multiple computed tomography (CT) examinations. With the widespread availability of magnetic resonance imaging (MRI), it is unclear whether the use of CTs in IBD has declined. We aimed to analyze the trends of CT and MRI use in a large cohort of IBD patients in a 10-year period.

METHODS

We retrospectively analyzed adults ≥18 years of age using a de-identified database, IBM Explorys. Patients with ≥1 CT of the abdomen (± pelvis) or MRI of the abdomen (± pelvis) at least 30 days after the diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were included. We examined the factors associated with patients undergoing multiple CTs (≥5 CTs of the abdomen) and performed a trend analysis from 2010 to 2019.

RESULTS

Among 176 110 CD and 143 460 UC patients, those with ≥1 CT of the abdomen annually increased from 2010 to 2019 with mean annual percentage change of +3.6% for CD and +4.9% for UC. Similarly, annual percentage change for patients with ≥1 MRI (CD: +15.6%; UC: +22.8%) showed a rising trend. There was a 3.8% increase in CD patients receiving ≥5 CTs of the abdomen annually compared with a 2.4% increase among UC patients in the 10-year period. Age ≥50 years, men, African Americans, public insurance payors, body mass index ≥30kg/m2, and smoking history were associated with ≥5 CTs.

CONCLUSIONS

There is a considerable increase in the number of CT scans performed in IBD patients. Further studies can explore factors influencing the use of CT and MRI of the abdomen in IBD patients.

Patient-Derived Antibody Data Yields Development of Broadly Cross-Protective Monoclonal Antibody against ST258 Carbapenem-Resistant Klebsiella pneumoniae

The most pressing challenge for the development of anti-capsular antibodies is maximizing coverage against the heterogenous capsular polysaccharide (CPS) of carbapenem-resistant Klebsiella pneumoniae (CR-Kp). So far, only CR-Kp with wzi154 CPS has been successfully targeted by antibodies. Here, we present murine antibody 24D11, which was developed by vaccinating mice with purified wzi50-type CPS. Cross-reactivity and protective efficacy of MAb 24D11 were confirmed against CR-Kp that express the 3 most prevalent CPS types (wzi29, wzi154, wzi50) using both in vitro and in vivo infection models. 24D11 induced complement-mediated and independent opsonophagocytosis in macrophages as well as killing of all CR-Kp strains in whole blood cells derived from healthy donors. In a murine intratracheal infection model, 24D11 reduced lung burden and dissemination of CR-Kp strains when administered 4 h pre- or postinfection. The protective efficacy of 24D11 remained effective in neutropenic mice. This is the first antibody which exhibits cross-protective efficacy against clade 1 and 2 ST258 CR-Kp strains. It overcomes a major barrier to successfully target wzi29, a major CPS expressed by ST258 CR-Kp. The finding that 24D11 also exhibits potent protective efficacy against wzi154 CR-Kp strains highlights its high potential as a lead agent for the development of broadly active immunotherapy. IMPORTANCE Here, we present in vitro and in vivo data for the wzi50 CPS-specific monoclonal antibody MAb 24D11, demonstrating its cross-protective efficacy against three prominent win types (wzi29, wzi154, and wzi50) of the carbapenem-resistant clonal group CG258. In a murine pulmonary infection model, MAb 24D11 reduced bacterial lung burden and dissemination to other organs even if administered 4 h postinfection. Its protective efficacy was also observed in neutropenic mice, which highlights its potential value in clinical settings where oncology patients with CG258 infections may also be neutropenic.

107 A Rare Presentation of a Giant, Multi-Compartmental Lipoma of the Hand Causing Median Nerve Compression

Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body. However, giant lipomas of the hand, defined as greater than 5cm in diameter, are rare. They have the potential to invade and cause a multitude of symptoms due to the compression and proximity of underlying structures.

We describe a case of a 64-year-old woman who presents with a swelling of the left thenar eminence, associated with numbness and tingling in all fingers.

MRI and nerve conduction studies confirmed the diagnosis of a lipoma causing median nerve compression. The patient underwent elective surgical excision using a volar approach, with good postoperative recovery. The excised lesion, measuring 12x7x2.4cm, is the largest giant lipoma of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsal sub-aponeurotic space and carpal tunnel.

Space occupying lesions, such as giant lipomas of the hand, are a rare but important secondary cause of compression neuropathies of the upper extremity and must be suspected when these neuropathies present with atypical symptomatology. Any patient presenting with a soft-tissue lesion of the hand demonstrating rapid growth, pain or large size must be thoroughly investigated to rule out malignancy. MRI forms an essential part of the workup in such cases due to its high diagnostic accuracy. Malignant transformation of giant lipomas of the hand is extremely rare, and such lesions can be removed by en bloc marginal resection with excellent postoperative results.

709 Two-Layer Biodegradable Temporizing Matrix Reconstruction of Abdominal Wall Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive dermal sarcoma. The management is generally surgical, with wide local excision (WLE) forming the mainstay of treatment. Large abdominal wall defects are most aesthetically reconstructed using pedicled or free flaps; however, these require tumour-free surgical margins, and can cause donor site morbidity. We describe an alternative, aesthetic, and low-morbidity technique for abdominal wall reconstruction following WLE of DFSP, using 2 layers of a novel synthetic dermal matrix (NovoSorb® BTM).

25-year-old women presented with a large DFSP involving the right anterior-abdominal wall. After WLE with 3cm margins, BTM was implanted to the large sub-fascial abdominal wall defect. At 6 weeks, after histological confirmation of tumour-free margins, a second layer of BTM was applied to improve the significant contour deformity of the wound bed. After complete integration by 7 weeks, a split-thickness skin graft was harvested from the right thigh and fixed to the new dermis.

At 14-days postoperatively, the skin graft had fully taken, and donor site healed. By 8 weeks, the scar had started to mature with no obvious contour defect or contracture. Overall, the patient was satisfied with the functional and aesthetic outcome.

To our knowledge, a two-layer reconstruction using an artificial dermal matrix has never been described for abdominal wall reconstruction. We found that double-layer BTM is able to restore the inherent thickness and pliability of skin in complex abdominal wall reconstruction following WLE of DFSP and offers improved durability and cosmesis compared to skin grafting or indeed single layer skin substitutes alone.

Components of interprofessional education programs in neonatal medicine: A focused BEME review: BEME Guide No. 73

BACKGROUND

Care delivery in neonatology is dependent on an interprofessional team. Collaborative learning and education amongst professionals can lead to successful management of critically ill patients. This focused BEME review synthesized the components, outcomes, and impact of such interprofessional education (IPE) programs in neonatal medicine.

METHODS

The authors systematically searched four online databases and hand-searched MedEdPublish up to 10 September 2020. Two authors independently screened titles, abstracts, full-texts, performed data extraction and risk of bias assessment related to study methodology and reporting. Discrepancies were resolved by a third author. We reported our findings based on BEME guidance and the STORIES (STructured apprOach to the Reporting in health education of Evidence Synthesis) statement.

RESULTS

We included 17 studies on IPE in neonatal medicine. Most studies were from North America with varying learners, objectives, instruction, and observed outcomes. Learners represented nurses, respiratory therapists, neonatal nurse practitioners, patient care technicians, parents, early interventionists, physicians, and medical trainees amongst others. Risk of bias assessment in reporting revealed poor reporting of resources and instructor training. Bias assessment for study methodology noted moderate quality evidence with validity evidence as the weakest domain. IPE instruction strategies included simulation with debriefing, didactics, and online instruction. Most studies reported level 1 Kirkpatrick outcomes (76%) and few reported level 3 or 4 outcomes (23%). Challenges include buy-in from leadership and the negative influence of hierarchy amongst learners.

CONCLUSIONS

This review highlights IPE program components within neonatal medicine and exemplary practices including a multimodal instructional approach, asynchronous instruction, an emphasis on teamwork, and elimination of hierarchy amongst learners. We identified a lack of reporting on program development and instructor training. Future work should address long term knowledge and skill retention and impact on patient outcomes and organizations.

Multivisceral Transplant in a Patient With Portopulmonary Hypertension: A Case Report

Portopulmonary hypertension, a type of pulmonary arterial hypertension in the setting of cirrhotic or noncirrhotic portal hypertension, is associated with elevated morbidity and mortality during and after transplantation. Uncontrolled portopulmonary hypertension may prevent or delay listing for transplant candidates, and the prognosis without treatment and ultimately transplant is extremely poor. We present a 29-year-old White woman, who had a post-liver transplant at infancy due to biliary atresia. Later on, she developed extensive portal vein thrombosis and portopulmonary hypertension and underwent a multivisceral transplant (liver, stomach, pancreaticoduodenal complex, and small and large intestine). Preoperative mean pulmonary artery pressure was <30 mm Hg with a pulmonary vascular resistance of <300 dynes^.s/cm⁵ on oral sildenafil and intravenous epoprostenol. Intraoperatively, management required comprehensive transfusion protocols, a careful balance between correcting blood loss and preventing thrombosis. Intravenous epoprostenol, sildenafil, milrinone, and inhaled nitric oxide were used to reduce elevated mean pulmonary artery pressure and right ventricular strain associated with vascular clamping, reperfusion, and massive fluid shifts. Nitric oxide and epoprostenol use unleashed antiplatelet effects on a patient already susceptible to coagulopathy. A multimodal and multidisciplinary approach continued throughout the surgery and in the postoperative period, which led to a successful outcome.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Hypercalcemia with methotrexate pneumonitis: A rare, important and intriguing adverse event

Methotrexate leading to hypercalcaemia is a rarely reported adverse event. We present three elderly patients with inflammatory arthritis who developed hypercalcemia probably due to methotrexate-induced granulomatous pneumonitis. All patients presented with worsening non-productive cough with dyspnea, nausea, loss of appetite, and confusion. Their clinical and radiologic features were consistent with methotrexate-induced pneumonitis. On evaluation, all patients concurrently had hypercalcemia with normal 25OH D3, and low PTH with markedly elevated levels of 1,25OH D3 seen in two patients. In all three patients, hypercalcemia and pneumonia responded to hydration, corticosteroids, and methotrexate withdrawal. There was no relapse of symptoms on long term follow-up. In these three patients with inflammatory arthritis, methotrexate-induced pneumonitis led to symptomatic hypercalcemia. Unless hypercalcemia is looked for and treated in this setting, the morbidity can be high.

1005 HEALTH-RELATED QUALITY OF LIFE AND FUTURE RISK OF HEALTH OUTCOMES AMONG OLDER ADULTS LIVING IN AUSTRALIA AND THE UNITED STATES

Introduction

Poor health-related quality of life (HRQoL) is associated with higher morbidity and mortality in patient populations. However, whether HRQoL is associated with health outcomes among community-dwelling older people requires further investigation. This study aimed to examine whether HRQoL predicts cognitive decline, dementia, cardiovascular disease (CVD), and mortality in community-dwelling older people living in Australia and the United States.

Method

A cohort of 19,106 individuals from the ASPirin in Reducing Events in the Elderly (ASPREE) study, aged 65–98 years, initially free of dementia or CVD, and who completed the HRQoL 12-item short form (SF-12, version-2) at baseline (2010–2014), were followed until June 2017. The physical (PCS) and mental component scores (MCS) of SF-12 were generated using standardized norm-based method.

Results

Over a median of 4.7 years, there were 2,412 cognitive declines, 574 dementia, 922 incident CVD events, and 1,052 deaths. Using Cox proportional-hazard regression adjusted for a range of covariates, every 10-unit increase in PCS was associated with a 6% lower risk of cognitive decline, a 14% lower risk of incident CVD, and 17% lower risk of all-cause mortality, but was not associated with incident dementia. In contrast, higher MCS was only associated with a 12% and 15% lower risk of cognitive decline and dementia, respectively. Findings did not differ by sex.

Conclusion

Our study provides some of the first evidence that HRQoL can be used in combination with clinical data to identify the future risks of health outcomes among older individuals living in the community. Our findings support the decision of the Australian Commission on Safety and Quality in Health Care to incorporate the SF-12 into the annual Patient-Reported Outcome Measures (PROMs assessment.

Meet EBE: The Development of an Evidence-Based Endoscopy Simulator

BACKGROUND AND AIMS

In the digital era of evidence-based medicine, there is a paucity of video endoscopy teaching platforms that use evidence-based medicine principles, or that allow for cognitive simulation of endoscopic management strategies. We created a guideline-based teaching platform for fellows that incorporates these features, and tested it.

METHODS

A pilot video module with embedded questions was drafted, and after incorporation of feedback from several attending gastroenterologists, an additional 2 modules were created. The embedded questions were designed to simulate cognitive management decisions as if the viewer were doing the endoscopy procedure in the video. A narrator explained the evidence behind the task being performed, and its certainty based on endoscopic guidelines. Quizzes and surveys were developed and administered to a sample of attendings and fellows who completed the video modules to test efficacy, usability, and likeability.

RESULTS

Three video modules, named evidence-based endoscopy (EBE), incorporating low fidelity simulation, and utilizing evidence-based medicine principles, were created. Eight fellows and 10 attendings completed the video modules and all quizzes and surveys. Mean test scores improved from before to after completing the video modules (56% to 92%; mean difference = -35%; 95% confidence interval, 27%-47%). Surveys indicated that the product was viewed favorably by participants, and that there is a strong desire for this type of educational product.

CONCLUSIONS

The EBE simulator is a unique, desirable, and effective educational platform based on evidence-based medicine principles that fills a gap in available tools for endoscopy education. Further studies are needed to assess whether EBE can aid in long-term knowledge retention and increase adherence to guideline recommendations.

Is being a victim of bullying or cyberbullying in secondary school associated with subsequent risk-taking behavior in adolescence? A longitudinal study in secondary schools

INTRODUCTION

Neurobiological and social changes in adolescence can make victims of bullying more susceptible to subsequent impulsive behavior. With the high prevalence of bullying in schools and rise in cyberbullying in the United Kingdom, it is important that the health impacts of bullying victimization, including on risk-taking, are understood. Our study aims to investigate whether bullying/cyberbullying victimization is associated with subsequent health risk-taking behavior in adolescence. Risk-taking behavior includes electronic cigarette and cigarette smoking, alcohol consumption, illicit drug use, early sexual debut, weapon carrying, damaging property, and setting fire.

METHODS

A secondary quantitative analysis of data from 3337, English, secondary school students in the control arm of the INCLUSIVE trial, constituting an observational cohort. Bullying victimization was measured at baseline (age 11/12 years) using the gatehouse bullying scale and a separate question on cyberbullying victimization. Logistic regression was used to test for an association between bullying/cyberbullying victimization at baseline and risk-taking behavior at 36 months, adjusting for baseline risk-taking behavior and other potential confounders, and accounting for school clustering.

RESULTS

There was strong evidence (p ≤ .02) for a positive dose-responsive association between being bullied at baseline and nearly all risk-taking behavior at follow-up. Although there was no evidence for an association between being bullied at baseline and weapon carrying (p = .102), there was evidence for a positive association between being cyberbullied at baseline and weapon carrying (p = .036).

CONCLUSIONS

It is plausible that bullying/cyberbullying victimization increases the likelihood of subsequent risk-taking behavior in adolescence. Policy options should focus on implementing evidence-based antibullying school interventions.