Prevalence and Etiology of Eating Disorders in Polycystic Ovary Syndrome: A Scoping Review

Polycystic ovary syndrome (PCOS) is the most common endocrine-metabolic disorder affecting females across the lifespan. Eating disorders (EDs) are psychiatric conditions that may impact the development of PCOS and comorbidities including obesity, metabolic syndrome, and type 2 diabetes. The aim of this scoping review was to determine the prevalence of EDs and disordered eating, and to review the etiology of EDs in PCOS. The review was conducted using search terms addressing PCOS, EDs, and disordered eating in databases, including PubMed, Scopus, PsycINFO, and CINAHL. Structured interviews, self-administered questionnaires, chart review, or self-reported diagnosis were used to identify EDs in 38 studies included in the review. The prevalence of any ED in those with PCOS ranged from 0% to 62%. Those with PCOS were 3-6-fold more likely to have an ED and higher odds ratios (ORs) of an elevated ED score compared with controls. In those with PCOS, 30% had a higher OR of bulimia nervosa and binge ED was 3-fold higher compared with controls. Studies were limited on anorexia nervosa and other specified feeding or ED (such as night eating syndrome) and these were not reported to be higher in PCOS. To our knowledge, no studies reported on avoidant/restrictive food intake disorder, rumination disorder, or pica in PCOS. Studies showed strong associations between overweight, body dissatisfaction, and disordered eating in PCOS. The etiologic development of EDs in PCOS remains unclear; however, psychological, metabolic, hypothalamic, and genetic factors are implicated. The prevalence of any ED in PCOS varied because of the use of different diagnostic and screening tools. Screening of all individuals with PCOS for EDs is recommended and high-quality studies on the prevalence, pathogenesis of specific EDs, relationship to comorbidities, and effective interventions to treat ED in those with PCOS are needed.

Multidetector computed tomography evaluation of normal thymus and variations with age

Background

Thymus is a T-cell-producing lymphoid organ that appears prominent in the paediatric population and involutes in size with ageing. The gland shows a wide variety of appearances across different age groups. The purpose of the study is to evaluate the computed tomography (CT) appearance of thymus gland in the normal population with a focus on size, CT attenuation and fatty infiltration in different age groups.

Patients and Methods

This is a retrospective study done after taking approval from the Institutional Ethics Committee. Patients undergone CT scans of the thorax were identified from our database. All evaluations were done in non-contrast CT scans. Patients having underlying diseases that may have associated thymic abnormality were excluded. The appearance of thymus and the presence of fatty replacement were assessed. The size of thymus (length and thickness of right limb and left limb) and non-contrast CT Hounsfield unit (HU) value of thymic tissue were measured and compared in various age groups.

Results

Four hundred and fifty patients were included, 262 (58.2%) were male. Mean age was 33.6 ± 17.1 years, range (3 months-80 years). The size of thymus was observed to decrease with increasing age. The mean age of complete fatty replacement in our study was 45 years. Complete fatty replacement was noted in all cases with an age of more than 60 years. The most common shape was arrowhead, and the most common location was pre-aortic and para-aortic location. Non-contrast CT HU value was maximum in infants and gradually decreased with advancing age.

Conclusion

Even normal thymus can show varied appearance on CT which changes with the age of the patient being imaged. A comparison with normative data could help differentiate normal from abnormal glands to avoid unnecessary intervention.

Use of Silicon T-Tube for Subglottic Stenosis and Tracheal Stenosis

Introduction

The management of subglottic and tracheal stenosis is challenging for any ENT surgeon. The treatment choice depends on the site, severity of stenosis, patient symptoms, and surgeon preferences. The various options for the management include endoscopic balloon dilatation, various types of laryngotracheoplasty, resection anastomosis, and insertion of a silicon T-tube. Compared to the above, silicon T-tube stenting is a better alternative, as it is a onetime procedure, easy to perform with fewer chances of complications. Shiann Yann lee technique is a form of laryngotracheoplasty with long-term stenting using silicon T-tube. This article analyzed our silicon T-Tube insertion result in patients with subglottic and tracheal stenosis using this technique.

Materials and Methods

In this retrospective study, we included a total of 21 patients with subglottic and tracheal stenosis who underwent silicon T-Tube insertion. Data regarding the site of stenosis, procedure, complications, and outcome were analyzed.

Results

Out of 21 patients, nine patients had subglottic stenosis (42.8%), 8 had cervical tracheal stenosis (38.09%), 3 had thoracic tracheal stenosis (14.28%), and 1 (4.7%) had combined subglottic and cervical tracheal stenosis. Out of 21 patients,7 (33.3%) have undergone successful removal of silicon T-Tube so far, one death due to medical reasons, and 13 patients (61.9%) are still on Silicon tube on regular follow-up. They are comfortable with the tube in situ.

Conclusions

Silicon T-Tube for benign acquired laryngotracheal stenosis with Shiann Yann Lee's technique is effective, safe with less complication, and good acceptability and tolerance by the patient.

Gastric perforation and renal vein thrombosis in acute pancreatitis: a case report

Background

Acute pancreatitis is one of the most common causes of acute abdomen. It is associated with multiple complications. Gastric perforation and isolated renal vein thrombosis are two infrequent complications. We present a case of acute pancreatitis with gastric perforation and isolated renal vein thrombosis in the same patient.

Case presentation

A 28-year-old gentleman with chronic alcohol intake presented with complaints of abdominal pain and not responding to analgesics. Biochemical investigations revealed elevated amylase and lipase level. Contrast-enhanced computed tomography (CECT) showed necrotizing pancreatitis with necrotic collection in the lesser sac. On oral contrast, active contrast extravasation from gastric perforation was picked up. Renal vein and splenic vein thrombosis was observed.

Conclusions

Gastric perforation and renal vein thrombosis are two infrequent complications of acute pancreatitis. High-end radiological suspicion is needed to reduce the associated morbidity and mortality.

Comparative Morphometry of the Sacrum and Its Clinical Implications: A Retrospective Study of Osteometry in Dry Bones and CT Scan Images in Patients Presenting With Lumbosacral Pathologies

Background

Morphometric measurement of the sacrum is crucial due to its active involvement in the instrumentation for lumbar pathologies. From screw placement to stabilization procedures for the spine, the sacrum remains a site of surgical importance. Thus, the purpose of this study was to generate baseline data by comparing two techniques, namely, osteometry in dry bones and CT scan imaging.

Methodology

In this study, 30 dry, fully ossified, disarticulated sacra were studied for osteometry, and 60 CT scan reports of patients with lumbar pathologies were retrospectively evaluated. In both cases, similar parameters were measured. The mean values were determined, the two methods were compared, and statistical analysis was performed.

Results

Among the 30 dry bone samples, 33.3% (10 out of 30) were males, while 55% of the CT scan group were males. Correlation between the different measurements in the CT scan group suggested that the vertebral body maximum width of S1 had a significant positive correlation with the vertebral body height of S1, sacral height, sacral breadth, transverse diameter of auricular surface, and vertical diameter of auricular surface. Statistically significant higher values (P < 0.001) were observed for the vertebral body mid diameter of S1, vertebral body height of S1, pedicle width, and pedicle depth measurements in the dry bone group compared to the CT scan group.

Conclusions

The efficiency of anaesthetic blocks can be increased if the parameters are evaluated beforehand. Moreover, sexual dimorphism of the bone can account for the varied results of the parameters, indicating the necessity to conduct gender-based studies in a wider population.

EMBR-20. ELONGATION CONTROL OF MRNA TRANSLATION DRIVES GROUP 3 MEDULLOBLASTOMA

Medulloblastoma (MB) is the most common pediatric intracranial tumor and leading cause of childhood related cancer deaths. Group 3 affiliation and genetic amplifications of the MYC oncogene are predictors of adverse outcome in MB, underscoring a dire need for novel and more effective therapeutic approaches. The let-7 family of small non-coding RNAs (miRNAs) is known to inhibit tumor progression and regulate metabolism by targeting and degrading several cellular mRNAs, including MYC. Indeed, let-7 miRNAs are frequently repressed in several cancer types, including in MYC-driven MB. We previously reported that the mRNA translation elongation regulator eukaryotic Elongation Factor-2 Kinase (eEF2K) is a pivotal mediator of cancer cell adaptation to nutrient deprivation. In the current work, we identified a potential binding site for let-7 miRNAs on the eEF2K 3’ untranslated region (UTR). In addition, eEF2K mRNA and let-7 miRNA expressions negatively correlate in MB, suggesting a potential regulation of the former by the latter. Let-7 miRNAs transfection decreases eEF2K mRNA and protein levels (by ~40–50%). Down-regulation of luciferase activity by let-7 miRNAs is impaired upon mutation of the let-7 binding site on the eEF2K 3’UTR. Inhibition of eEF2K significantly reduces survival of MYC-amplified MB cell lines under nutrient deprivation, altering their mRNA translation rates. Knockout of eEF2K increases survival of MYC-amplified MB xenografts when mice are kept under calorie restricted diets. We conclude that let-7 miRNAs degrade the eEF2K mRNA by binding to its 3’UTR, indicating that let-7 repression in MYC-driven MB is partially responsible for increased eEF2K levels. Moreover, the let-7-eEF2K axis constitutes a critical mechanism for MYC-driven MB adaptation to acute metabolic stress, representing a promising therapeutic target. Future therapeutic studies will aim to combine eEF2K inhibition with caloric restriction mimetic drugs, as eEF2K activity appears critical under metabolic stress conditions.

Evaluation of Adhesion Protocol for Titanium Base Abutments to Different Ceramic and Hybrid Materials

Scientific evidence regarding conditioning of different ceramic and hybrid materials and their bonding on titanium abutments is lacking. Titanium disks (Tritan) (N=450, n=15) were randomly cemented onto five different ceramic and hybrid materials, namely 1. Zenostar T, 2. Lava Ultimate, 3. IPS e.max CAD, 4. Vita Enamic multicolor and 5. G-ceram using three different cements, Panavia 21, TheraCem and Multilink hybrid abutment. Half of all specimens were thermocycled (5000 cycles, 5-55°C), while the other half were kept dry. Macro shear bond testing was conducted using a universal testing machine. Failure types were classified using a digital microscope. Data was statistically analyzed with three-way ANOVA and Tukey HSD post hoc tests. Both the ceramic (P⟨0.0001) and cement type(P⟨0.0001) significantly affected the shear bond strength(MPa), while thermocycling did not (P⟩0.05). The incidence of cohesive (50.34%) and adhesive failures (49.66%) were not significantly different. As for implant superstructures, when ceramics are bonded to titanium bases, the ceramic and cement type both have an impact on the bond strengths along with the conditioning and bonding protocols for each substrate. An equal affinity of the cements tested to the ceramic, hybrid materials and to titanium can be assumed. Combination of zirconia and TheraCem can be recommended for clinical use.

Abstract B27: A link between small noncoding RNAs and mRNA translation elongation: The let7-eEF2K axis in pediatric tumor adaptation to nutrient deprivation

Background: Medulloblastoma (MB) and neuroblastoma (NB) are the most common pediatric solid cancers and the leading cause of childhood cancer-related deaths. Genetic amplifications of the MYC and MYCN oncogenes are the strongest independent predictor of adverse outcomes in MB and NB, underscoring a dire need to improve therapeutic approaches. Tumors continually weather stress from acute microenvironmental changes, including limited nutrient availability. The let-7 family of small noncoding RNAs (miRNAs) inhibits tumor progression and regulates metabolism by selectively targeting and degrading mRNAs, including MYC and MYCN. Indeed, let-7 miRNAs are frequently repressed in several cancers, including in MYC-driven MB and NB. We previously reported that the mRNA translation elongation regulator eukaryotic eEF2K is a pivotal mediator of cancer cell adaptation to nutrient deprivation. Our preliminary data indicate that the eEF2K 3´ untranslated region (UTR) harbors a potential binding site for let-7 miRNAs. In addition, eEF2K mRNA and let-7 miRNA expressions negatively correlate in MB and NB. We therefore hypothesized that let-7 downregulation induces eEF2K expression, thereby supporting MYC-driven MB and NB adaptation to nutrient deprivation and tumor progression.

Methods: Effects of eEF2K pharmacologic and genetic inhibition on MB and NB cell death were evaluated in vitro by flow cytometry, while cellular mRNA translation rates were studied by polysome fractionation and Click chemistry. The ability of let-7 to degrade eEF2K mRNA was assessed by let-7 miRNAs transfection into MB cells, followed by RT-PCR and Western blotting for eEF2K. Binding of let-7 to the eEF2K 3´UTR was validated by luciferase reporter assay. Finally, NB xenograft mouse models confirmed in vitro observations.

Results: Inhibition of eEF2K significantly reduces survival of MYC/MYCN-amplified NB and MB cell lines under nutrient deprivation, altering their mRNA translation rates. Let-7 miRNAs transfection decreases eEF2K mRNA and protein levels by 40-50%. Downregulation of luciferase activity by let-7 miRNAs is impaired upon mutation of the let-7 binding site on the eEF2K 3´UTR. eEF2K knockdown decreases growth twofold in MYCN-amplified NB xenografts in mice under calorie-restriction diets.

Conclusions: Let-7 miRNAs degrade the eEF2K mRNA by binding to its 3´UTR, indicating that let-7 repression in MYC-driven NB and MB is partially responsible for increased eEF2K levels. Moreover, the let-7-eEF2K axis constitutes a critical mechanism for MYC-driven MB and NB adaptation to acute metabolic stress, representing a promising therapeutic target. Future therapeutic studies will aim to combine eEF2K inhibition with caloric restriction mimetic drugs, as eEF2K activity appears critical under metabolic stress conditions.

Citation Format: Alberto Delaidelli, Gian Luca Negri, Xue Qi Wang, Simran Sidhu, Brian Cho, Gabriel Leprivier, Volker Hovestadt, Stefan Pfister, Michael Taylor, Marcel Kool, Poul Sorensen. A link between small noncoding RNAs and mRNA translation elongation: The let7-eEF2K axis in pediatric tumor adaptation to nutrient deprivation [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr B27.

Abstract 3660: A link between miRNAs and mRNA translation elongation: The let7-eEF2K axis in MYC-driven pediatric tumors adaptation to nutrient deprivation

BACKGROUND/OBJECTIVES: MYC family proteins are implicated in many human cancers, but their therapeutic targeting has proven challenging. MYCN and MYC amplification in childhood neuroblastoma (NB) and medulloblastoma (MB) are associated with aggressive disease and high mortality, underscoring a dire need for novel therapies. Let-7 microRNAs (miRNAs) inhibit tumor progression and regulate metabolism by degrading several mRNAs, including MYC. Let-7 miRNAs are therefore frequently repressed in cancer, including MYC-driven NB and MB. We previously reported that the mRNA translation elongation regulator eukaryotic Elongation Factor-2 Kinase (eEF2K) is a pivotal mediator of cancer cells adaptation to nutrient deprivation (ND). Publicly available transcriptomic database analyses indicate that eEF2K expression significantly correlate with MYCN and MYC expression in multiple tumor cohorts. Our preliminary data also indicate that the eEF2K 3’ untranslated region (UTR) harbors a potential binding site for let-7 miRNAs. In addition, eEF2K mRNA and let-7 miRNA expression negatively correlates in NB and MB, suggesting a potential regulation of the former by the latter. We therefore hypothesized that let-7 down-regulation induces eEF2K expression, thereby supporting MYC-driven NB and MB adaptation to ND and tumor progression.

METHODS: Immunohistochemistry for eEF2K substrate (p-eEF2) was performed on NB and MB tissue microarrays to link results with MYC expression and outcome. Effects of eEF2K pharmacological and genetic inhibition on NB and MB cell survival were evaluated in vitro by MTT assay and PI staining. The ability of let-7 to degrade eEF2K mRNA was assessed by let-7 miRNAs transfection into MB cells, followed by RT-PCR and Western Blotting for eEF2K. Binding of let-7 to the eEF2K 3’UTR was validated by luciferase reporter assay. Finally, NB xenograft mouse models were used to confirm in vitro observations.

RESULTS: High eEF2K activity is linked to MYC over-expression and reduced survival in NB and MB (p&lt;0.05). Pharmacological and genetic inhibition of eEF2K significantly reduces survival of MYC/MYCN-amplified NB and MB cell lines under ND. Let-7 miRNAs transfection decreases eEF2K mRNA and protein levels (by ~40-50%), and down-regulation of luciferase activity by let-7 miRNAs is impaired upon mutation of the let-7 binding site on the eEF2K 3’UTR. Knockdown of eEF2K determines a twofold growth decrease of MYCN-amplified NB xenografts when mice are kept under caloric restriction diet.

CONCLUSIONS: Let-7 miRNAs degrade eEF2K mRNA by binding to its 3'UTR, indicating that let-7 repression in MYC-driven NB and MB is partially responsible for eEF2K increased levels and activity. Moreover, the let-7-eEF2K axis represents a critical mechanism for MYC-driven NB and MB adaptation to ND, constituting a promising therapeutic target.

Citation Format: Alberto Delaidelli, Gian Luca Negri, Brian Cho, Simran Sidhu, Stefan Pfister, Michael Taylor, Gabriel Leprivier, Marcel Kool, Poul Soresnsen. A link between miRNAs and mRNA translation elongation: The let7-eEF2K axis in MYC-driven pediatric tumors adaptation to nutrient deprivation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3660.

Folliculin regulates mTORC1/2 and WNT pathways in early human pluripotency

To reveal how cells exit human pluripotency, we designed a CRISPR-Cas9 screen exploiting the metabolic and epigenetic differences between naïve and primed pluripotent cells. We identify the tumor suppressor, Folliculin(FLCN) as a critical gene required for the exit from human pluripotency. Here we show that FLCN Knock-out (KO) hESCs maintain the naïve pluripotent state but cannot exit the state since the critical transcription factor TFE3 remains active in the nucleus. TFE3 targets up-regulated in FLCN KO exit assay are members of Wnt pathway and ESRRB. Treatment of FLCN KO hESC with a Wnt inhibitor, but not ESRRB/FLCN double mutant, rescues the cells, allowing the exit from the naïve state. Using co-immunoprecipitation and mass spectrometry analysis we identify unique FLCN binding partners. The interactions of FLCN with components of the mTOR pathway (mTORC1 and mTORC2) reveal a mechanism of FLCN function during exit from naïve pluripotency.

The pathways involved in exit from pluripotency in human embryonic stem cells are poorly understood. Here, the authors performed a CRISPR-based screen to identify genes that promote exit from naïve pluripotency and find a role for folliculin (FLCN) by regulating the mTOR and Wnt pathways.

Dosing modifications to increase tolerability of gemcitabine and nab-paclitaxel in treatment of pancreatic cancer in the elderly

441

Background: Gemcitabine and nab-paclitaxel has been reported to prolong survival in patients with metastatic pancreatic cancer. This drug combination was studied in such patients in the MPACT trial with an average age of enrolled patients being 63. Pancreatic cancer, however, is a disease of the aging with a median age at diagnosis of 70. Reductions in dosing by 20% or more in one or both components and has been shown to improve the tolerability of this regimen, thereby increasing treatment exposure. Our study aims to examine the efficacy and tolerability of this drug combination in an elderly population and how this is affected by schedule and dosing modifications. Methods: A retrospective chart review was performed of 83 patients over the age of 70 with a median age of 79 who received this drug combination as first-line treatment for pancreatic adenocarcinoma at a single institution. Overall survival and progression-free survival were assessed as well as schedule modification, dose reduction, and rates of adverse events. Results: For patients with metastatic or non-metastatic disease, the mean overall survival and progression-free survival were found to be 10.57 months and 6.63 months, respectively. When only patients with metastatic disease are analyzed, these values were found to be 9.26 months and 6.05 months, respectively, which are similar to those observed in the MPACT trial. The most common adverse events of grade 3 or greater were fatigue in 34.9% of patients and hematologic adverse events including neutropenia in 27.7% and leukopenia in 25.3% of patients. Dose reductions were commonly used to mitigate adverse events. Reductions in either one or both drugs by at least 20% occurred in 84.3% of patients. Conclusions: Gemcitabine and nab-paclitaxel in treatment of pancreatic cancer is well tolerated in an elderly population with similar rates of adverse effects when compared with previous studies, though this population experienced a significantly higher rate of fatigue. Dose reductions were used frequently in this population to improve tolerability, which may have contributed to the observed increase in overall survival in this population.

A Rare Case of Medullary Carcinoma of the Ileum

Medullary carcinoma of the small intestine is an exceedingly rare tumor. These tumors account for less than 0.04% of all colorectal cancers and only one case to date has been reported in the ileum. Although the clinical manifestations can be consistent with signs of intestinal obstruction, often times they are discovered incidentally in an asymptomatic patient. Major contributing risk factors to the development include long standing inflammation such as Crohn's disease, and other chronic inflammatory illnesses. Tumor markers and imaging can aid in the diagnosis, however biopsy is needed for definitive diagnosis. Despite the fact that the development of these tumors in the ileum is rare, further enhancement of awareness can aid in the appropriate early detection and appropriate treatment modalities.

Sorafenib induced hepatic encephalopathy

A 60 year old male, known case of Hepatitis C related cirrhosis was diagnosed with exophytic Hepatocellular carcinoma (size 2.1 x 2.2 cm), Barcelona Clinic Liver Cancer Stage A, on routine surveillance. He refused liver Transplant and underwent laparoscopic segmental resection. Thereafter patient was started on Tablet Sorafenib 400mg twice daily to prevent recurrence of Hepatocellular carcinoma. On 18st post-operative day, patient presented with Hepatic encephalopathy. Routine investigations and MRI Brain were normal; Venous ammonia was high. Sorafenib was discontinued, and neurological symptoms resolved within 24 hours. The ammonia level decreased from 112 to 30 μmol/L. Hepatic encephalopathy recurred 14 days after Sorafenib reintroduction at a dose of 400 mg / day. It resolved within 24 hours of withdrawal of Sorafenib. Sorafenib induced recurrent acute overt Hepatic encephalopathy with biochemical corroboration is reported here.

Treatment of chronic hepatitis C genotype 3 with Sofosbuvir-based therpy: a real-life study

BACKGROUND AND AIMS

Recently, Sofosbuvir was launched in India at affordable cost. We conducted a real-life study to determine the efficacy and safety of Sofosbuvir plus Ribavirin, with and without peginterferon-alfa 2a, in patients with chronic hepatitis C (CHC) genotype 3, the commonest genotype in South Asia.

METHODS

This study included data of CHC patients from 11 sites in northern India between March 2015 and December 2015 (n = 1203). Patients with CHC genotype 3 (n = 931), who were treated with either Sofosbuvir 400 mg plus weight-based Ribavirin, daily ×24 weeks (n = 432) (dual therapy), or Peginterferon-α2a 180 mcg weekly, Sofosbuvir 400 mg plus weight-based Ribavirin, daily ×12 weeks (n = 499) (triple therapy) were included for analysis. Primary outcome was the proportion of patients achieving sustained viral response at 12 weeks post-therapy.

RESULTS

The overall SVR rates were 91 and 92% in the dual and triple therapy arms, respectively. The SVR rates in treatment experienced were 67 and 74% versus 93 and 96% in naïve patients, on the dual and triple therapy arms, respectively. The SVR rates of cirrhotics were 73 and 75% on the dual and triple treatment arms, respectively. The SVR rates were low in the experienced cirrhotic patients: 44% (dual therapy) and 58% (triple therapy). Common adverse events were fatigue, headache, and myalgia.

CONCLUSION

Both dual and triple therapy regimes resulted in SVR rates of >95% in CHC genotype 3 who were naive non-cirrhotics. However, the SVR rates were low in treatment-experienced cirrhotics.

New paradigms in management of alcoholic hepatitis: a review

Severe alcoholic hepatitis (SAH) is defined by modified Maddrey discriminant function ≥32 or Model for End-Stage Liver Disease (MELD) >21 and/or hepatic encephalopathy. It has a 3-month mortality rate ≥30-70 %. Patients with severe alcoholic hepatitis need combined, i.e., static (MELD score) and dynamic (Lille's score), prognostication. Systemic inflammation and poor regeneration are hallmarks of SAH, rather than intrahepatic inflammation. SAH is characterized by dysregulated and uncontrolled systemic inflammatory response followed by weak compensatory antiinflammatory response that leads to increased susceptibility to infection and multiple organ failure. Massive necrosis of hepatocytes exceeds the proliferative capacity of hepatocytes. Liver progenitor cells proliferate to form narrow ductules which radiate out into the damaged liver parenchyma. Corticosteroids have been the standard-of-care therapy, albeit controversial. However, the recent Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial revealed that prednisolone was not associated with a significant reduction in 28-day mortality, with no improvement in outcomes at 90 days or 1 year. A paradigm shift from antiinflammatory therapy such as corticosteroids to liver regeneration treatment, e.g., granulocyte-colony stimulating factor, molecular targeted treatments, and fecal microbiota transplantation, for severe alcoholic hepatitis is taking place. Liver transplantation should be offered to select patients with severe alcoholic hepatitis who are nonresponsive to medical treatment.

The quality of radiographs accompanying endodontic referrals to a health authority clinic

AIM

To assess the quality of radiographs accompanying endodontic referrals, from general dental practitioners, to a health authority clinic.

METHODS

A total of 200 conventional film and digital radiographs accompanying referrals were assessed and rated as 'excellent', 'diagnostically acceptable' or 'unacceptable' according to the National Radiographic Protection Board (NRPB) guidelines. Statistical analyses of the results included inter- and intra-observer agreement to achieve a kappa score and the chi-squared test.

RESULTS

Out of the 200 radiographs assessed, 38 (19%) were conventional film and 162 (81%) were digital. Of the conventional film radiographs, 55% were rated 'excellent' and 37% were 'diagnostically acceptable', whilst 27% of digital radiographs were rated 'excellent' and 40% were 'diagnostically acceptable'. In the 'unacceptable' category, 33% were digital and 8% were conventional film radiographs (p <0.001).

CONCLUSIONS

The quality of digital radiographs was significantly lower compared with conventional film radiographs. The percentage of 'unacceptable' digital radiographs was above the target according to the NRPB guidelines. Hence, there is a need for improvement in quality to avoid repeat radiographs and unnecessary ionising radiation exposure. Instead of hard, printed copies, digital radiographs accompanying referrals should, within the parameters of information governance, be supplied electronically so that they may be optimised, if necessary, for better diagnostic value.

The 5-year outcome of patients having incomplete colonoscopy

AIM

Incomplete colonoscopy indicated for the detection of neoplasia occurs in 2-23% of patients, but there is little information on the long-term outcome of such patients.

METHOD

All patients who underwent colonoscopy over 5 years at the Royal Liverpool University Hospital with a follow-up of up to 5 years were identified.

RESULTS

The risk of colorectal cancer (CRC) was 2.9% (312/10 580) for all patients undergoing colonoscopy. For a failed colonoscopy, the risk was five-fold higher [14.3% (99/693)]. The mean age of the patients was 61 years and 58% were female. Following incomplete colonoscopy the risk of finding additional CRC, advanced colonic neoplasia and extracolonic neoplasia on subsequent investigation was 6.2%, 3.2% and 1.9%. The diagnostic yield on subsequent investigation for CRC or colonic polyps was 7% for repeat colonoscopy, 13.4% for computed tomography colonography, 10.3% for standard computed tomography and 1.8% for barium enema. In the 363 patients who were not offered a subsequent investigation, there was no further instance of CRC or CRC-related mortality over a 36-month period.

CONCLUSION

Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.

The local anaesthetic effect of a dental laser prior to cavity preparation: a pilot volunteer study

OBJECTIVES

It has been suggested that laser preconditioning can produce dental anaesthesia. This study aimed to assess the response of the dental pulp to laser preconditioning.

METHODS

The effects of laser preconditioning, sham laser (negative control), and composite curing light (positive control) on the response of the dental pulp to electric pulp testing was investigated in this double-blind crossover trial with six volunteers. The Er,Cr:YSGG laser or curing light was shone on a premolar tooth in a sweeping motion for 30 seconds (in the sham treatment, the laser was not activated) in blindfolded volunteers subjected to a consistent aural stimulus. Treatment method at each visit was randomized and performed by a researcher not involved in pulp testing. Teeth were pulp tested twice initially by another member of the research team to get baseline readings, immediately following the treatment, and thereafter every two minutes for 10 minutes. Results were analyzed using analysis of variance and an independent-sample t-test.

RESULTS

There were no significant differences in pulpal response between treatments (p>0.05).

CONCLUSION

Laser preconditioning did not affect pulpal response as measured by an electronic pulp tester. Laser preconditioning did not result in any pain or noticeable symptoms for both teeth and soft tissues.

Long-term outcome after parathyroidectomy for lithium-induced hyperparathyroidism

BACKGROUND

The accepted management of lithium-associated hyperparathyroidism (LiHPT) is open four-gland parathyroid exploration (OPTX). This approach has recently been the subject of controversy. A recent study has shown very high long-term recurrence rates after OPTX, whereas some have promoted unilateral focused parathyroidectomy as appropriate management. The aim was to evaluate long-term outcomes after surgery for LiHPT and to assess the accuracy of preoperative imaging.

METHODS

This was a retrospective cohort study that comprised all patients undergoing initial surgery for LiHPT between 1990 and 2013. The cumulative recurrence rate was calculated by the Kaplan-Meier method. The sensitivity and specificity of sestamibi scintigraphy and ultrasound imaging for identification of single-gland versus multigland disease was investigated using intraoperative assessment as reference.

RESULTS

Of 48 patients, 45 had OPTX and three underwent focused parathyroidectomy. Multiglandular disease was documented in 27 patients and 21 had a single adenoma. The median follow-up was 5·9 (range 0·3-22) years and 16 patients died during follow-up. The 10-year cumulative recurrence rate was 16 (95 per cent confidence interval 2 to 29) per cent. No permanent complications occurred after primary surgery for LiHPT. Twenty-four patients had at least one preoperative ultrasound or sestamibi scan. For concordant sestamibi scintigraphy and ultrasound imaging, the sensitivity and specificity for identifying single-gland versus multigland disease was five of nine and five of eight respectively.

CONCLUSION

Surgery provided a safe and effective management option for patients with LiHPT in this series, with a long-term cure rate of well over 80 per cent.

Overexpression of miR-210 is associated with SDH-related pheochromocytomas, paragangliomas, and gastrointestinal stromal tumours

miR-210 is a key regulator of response to hypoxia. Pheochromocytomas (PCs) and paragangliomas (PGLs) with germline SDHx or VHL mutations have pseudohypoxic gene expression signatures. We hypothesised that PC/PGLs containing SDHx or VHL mutations, and succinate dehydrogenase (SDH)-deficient gastrointestinal stromal tumours (GISTs), would overexpress miR-210 relative to non-SDH or -VHL-mutated counterparts. miR-210 was analysed by quantitative PCR in i) 39 PC/PGLs, according to genotype (one SDHA, five SDHB, seven VHL, three NF1, seven RET, 15 sporadic, one unknown) and pathology (18 benign, eight atypical, 11 malignant, two unknown); ii) 18 GISTs, according to SDHB immunoreactivity (nine SDH-deficient and nine SDH-proficient) and iii) two novel SDHB-mutant neurosphere cell lines. miR-210 was higher in SDHx- or VHL-mutated PC/PGLs (7.6-fold) compared with tumours without SDHx or VHL mutations (P=0.0016). miR-210 was higher in malignant than in unequivocally benign PC/PGLs (P=0.05), but significance was lost when benign and atypical tumours were combined (P=0.08). In multivariate analysis, elevated miR-210 was significantly associated with SDHx or VHL mutation, but not with malignancy. In GISTs, miR-210 was higher in SDH-deficient (median 2.58) compared with SDH-proficient tumours (median 0.60; P=0.0078). miR-210 was higher in patient-derived neurosphere cell lines containing SDHB mutations (6.5-fold increase) compared with normal controls, in normoxic conditions (P<0.01). Furthermore, siRNA-knockdown of SDHB in HEK293 cells increased miR-210 by 2.7-fold (P=0.001) under normoxia. Overall, our results suggest that SDH deficiency in PC, PGL and GISTs induces miR-210 expression and substantiates the role of aberrant hypoxic-type cellular responses in the development of these tumours.

The number of benign moles excised for each malignant melanoma: the number needed to treat

BACKGROUND

The ratio of benign moles excised for each malignant melanoma (MM) diagnosed, i.e. the number needed to treat (NNT), may be a useful indicator of diagnostic accuracy and the efficient use of healthcare resources, and may have personal implications for the patient.

AIM

To assess the NNT for a group of consultant dermatologists serving a population of 600,000, and to compare this with similar studies from other countries.

METHODS

This was a retrospective analysis of data on pigmented lesions excised over a 5-year period (2005-2009). The lesions were divided into three groups: benign naevi (BN), dysplastic naevi (DN) and MM. The NNT ratio was calculated as (BN + DN + MM)/MM.

RESULTS

In total, 4691 lesions were examined. The overall mean NNT was 6.3, with a range of 4.9-11.3 for each of nine consultant dermatologists. The mean NNT was 7.6 for female and 4.8 for male patients. There were more patients with BN (n = 3534; 75%) than with DN (n = 407; 9%) or MM (n = 750; 16%). The gender representation was similar in the DN and MM groups, but had a disproportionately female bias in the BN group (67% female, 33% male patients). Overall, there were more female patients in all three groups [2962 female patients (63%) and 1729 male patients (37%)].

CONCLUSIONS

The NNT of 6.3 in this study compares favourably with NNT ratios from studies of dermatologists from other countries. This study may encourage other countries and individual doctors to assess their NNT ratios, as it may be an important indicator of the efficient use of resources and the avoidance of unnecessary surgery for patients.