Quantitative ultrasound bone measurements: normal values and comparison with bone mineral density by dual X-ray absorptiometry

Normative data for qualitative ultrasound (QUS) measurements: speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness were established in 118 healthy women aged 20-86 years and in 42 healthy men aged 22-76 years. The relations between age, weight, height, and QUS were studied. QUS measurements were negatively correlated with age in both sexes. In women, age was accepted as first factor (R2 = 0.39 for SOS, 0.35 for BUA, and 0.45 for stiffness, P < 0.001); weight was accepted as second factor for BUA (R2 = 0.44, P < 0.001). In men, age was the only significant parameter (R2 = 0.41 for SOS, 0.39 for BUA, 0.43 for stiffness, P < 0.001). QUS measurements of the right and left feet were highly correlated unless unilateral foot pathology such as algodystrophy was present. Significant correlations were found between QUS of the calcaneus and dual X-ray absorptiometry (DXA) of the lumbar spine (R = 0.67, P < 0.01 for SOS; R = 0.57, P < 0.02 for BUA; R = 0.65, P < 0.01 for stiffness).

Differential regulation of Rhizobium etli rpoN2 gene expression during symbiosis and free-living growth

The Rhizobium etli rpoN1 gene, encoding the alternative sigma factor sigma54 (RpoN), was recently characterized and shown to be involved in the assimilation of several nitrogen and carbon sources during free-living aerobic growth (J. Michiels, T. Van Soom, I. D'hooghe, B. Dombrecht, T. Benhassine, P. de Wilde, and J. Vanderleyden, J. Bacteriol. 180:1729-1740, 1998). We identified a second rpoN gene copy in R. etli, rpoN2, encoding a 54.0-kDa protein which displays 59% amino acid identity with the R. etli RpoN1 protein. The rpoN2 gene is cotranscribed with a short open reading frame, orf180, which codes for a protein with a size of 20.1 kDa that is homologous to several prokaryotic and eukaryotic proteins of similar size. In contrast to the R. etli rpoN1 mutant strain, inactivation of the rpoN2 gene did not produce any phenotypic defects during free-living growth. However, symbiotic nitrogen fixation was reduced by approximately 90% in the rpoN2 mutant, whereas wild-type levels of nitrogen fixation were observed in the rpoN1 mutant strain. Nitrogen fixation was completely abolished in the rpoN1 rpoN2 double mutant. Expression of rpoN1 was negatively autoregulated during aerobic growth and was reduced during microaerobiosis and symbiosis. In contrast, rpoN2-gusA and orf180-gusA fusions were not expressed aerobically but were strongly induced at low oxygen tensions or in bacteroids. Expression of rpoN2 and orf180 was abolished in R. etli rpoN1 rpoN2 and nifA mutants under all conditions tested. Under free-living microaerobic conditions, transcription of rpoN2 and orf180 required the RpoN1 protein. In symbiosis, expression of rpoN2 and orf180 occurred independently of the rpoN1 gene, suggesting the existence of an alternative symbiosis-specific mechanism of transcription activation.

Cyclical pamidronate infusions in postmenopausal osteoporosis

OBJECTIVES

Until recently, two bisphosphonates, pamidronate (APD) and etidronate were available for clinical purposes. Contrary to etidronate, pamidronate was not extensively studied in osteoporosis. Therefore, we investigated the effect of cyclic intravenous APD treatment in postmenopausal osteoporosis.

METHODS

Parameters of bone remodelling and lumbar spine bone mineral density (BMDL) were assessed in 36 postmenopausal women with osteoporosis (BMDL t-score < -2.5). They received five courses of APD. Intervals between courses were defined according to the fasting urinary calcium excretion (UCa/Cr, mg/mg creatinine) which was measured before each APD course and every 2 weeks after the first treatment. The patients were retreated when UCa/Cr had reached baseline levels. Serum biochemical parameters and urinary hydroxyproline (UOHPro/Cr, mg/mg) were measured before each APD.

RESULTS

UCa/Cr decreased during 21-28 days after each course but UCa/Cr measured before APD infusion remained unchanged. UOHPro/Cr significantly fell after the third APD (P = 0.02). Serum calcium was however not modified. Parameters of bone remodelling decreased with time: bone-GLA protein (BGP) started to fall after the first APD (P = 0.0001) and continued to decrease until the fourth APD course, alkaline phosphatase (ALP) significantly decreased after the first APD (P = 0.005); intact PTH significantly increased at the fifth APD (P = 0.02). BMDL significantly increased after 1 year treatment: +2.9% of baseline value.

CONCLUSIONS

Cyclical pamidronate treatment of postmenopausal osteoprosis appeared to be effective in reducing bone turnover assessed by BGP, ALP and OHPro/Cr. This effect is followed by an increase in vertebral BMD.

Study of the influence of the pH media dissolution, degree of polymerization, and degree of swelling of the polymers on the mechanism of release of diltiazem from matrices based on mixtures of chitosan/alginate

The dissolution profiles of formulations based on mixtures of chitosan/alginate depend on the pH. It is possible to distinguish two processes: (a) a fast kinetic drug release up to 180 min, where the pH value changes from 1.17 to 2.21 and the drug released is controlled by the degree of polymerization and the quantity of chitosan in the formulation; (b) a low kinetic drug release between 210 and 480 min, where the pH value changes from 5.52 to 8.72 and the drug release from the matrix is controlled by the interpolymeric complex. In all formulations the order of release, according to Peppas's model in the range of fast kinetic drug release, was between 0.5 and 1.0. The mechanism of release was non-fickian diffusion, which corresponds to a coupling mechanism of diffusion and relaxation of the polymer.

Efficiency of quantitative ultrasound measurements as compared with dual-energy X-ray absorptiometry in the assessment of corticosteroid-induced bone impairment

Bone loss due to corticosteroid treatment differs from that of postmenopausal osteoporosis with regard to bone structure. Corticosteroids affect both horizontal and vertical trabeculae while horizontal trabeculae are damaged in postmenopausal osteoporosis. Dual-energy X-ray absorptiometry (DXA) is the gold standard to evaluate bone loss. The place of quantitative ultrasound (QUS), a technique that could theoretically provide information on bone structure, is not well established in corticosteroid-induced bone impairment. The aim of the study was to determine the usefulness of QUS in the assessment of corticosteroid-induced bone impairment. We hypothesized that the relationship between QUS and DXA could be influenced by changes in bone structure and thus differ with regard to corticosteroid treatment. Seventy-seven women with inflammatory diseases chronically treated with corticosteroids (dose: 7.5-15 mg/day), 29 without corticosteroids and 100 controls were investigated. Bone mineral density at the lumbar spine (BMDL) was measured by DXA and QUS parameters were measured at the calcaneus. Both the QUS parameters (SOS, BUA, Stiffness) and BMDL were significantly lower (by 1.3% for SOS, 5.8% for BUA, 12.7% for Stiffness and 11% for BMDL) in patients treated with corticosteroids compared with patients not taking corticosteroids and with controls (p < 0.001, ANCOVA, with age and height as covariates). Multiple linear regressions of Stiffness, SOS and BUA as dependent variables on age, BMDL, corticosteroid treatment and a computed new variable designed to test the interaction between BMDL and the treatment group showed that Stiffness, SOS and BUA were dependent on age and BMDL (p < 0.001); BUA and Stiffness were dependent on treatment group. Taking into account the age of the patients, a significant difference was observed in the relation between BUA and BMDL according to treatment with corticosteroids. A similar difference was found in the subgroup of patients without fractures. SOS and BUA were strongly correlated but their relation did not differ according to treatment. Thus, QUS is useful in the assessment of corticosteroid-associated bone loss. Furthermore, the observation of a significant difference in the relationship between BUA and BMDL with regard to corticosteroid treatment might support the hypothesis that QUS, especially BUA, could give additional information about bone structure.

Evaluation of quantitative ultrasound and dual X-Ray absorptiometry measurements in women with and without fractures

Dual X-ray absorptiometry (DXA) is considered a gold standard for bone measurements in the assessment of osteoporosis. Other techniques such as quantitative ultrasound (QUS) are promising to detect patients with osteoporosis-related fractures and to predict fracture risk. In this cross-sectional retrospective study, we analyzed the behavior of QUS and DXA measurements alone and in combination with regard to the presence of fractures in 320 women, 147 with nontraumatic fractures. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and a third parameter derived from SOS and BUA called stiffness were measured at the calcaneus using an Achilles device (Lunar, Madison, WI). Lumbar (BMDL) and hip (BMDH( bone mineral density were measured by DXA (Hologic QDR 1000, Waltham, MA). Mean SOS, BUA, stiffness, and BMDL and BMDH were significantly lower in women with fractures compared with women without fractures. Logistic regression adjusted for age identified stiffness as the parameter most strongly associated with the presence of fracture: its sensitivity was 54% and specificity 70%. Hip BMD was second, with a sensitivity of 54% and a specificity of 69%. Combining QUS and DXA measurements did not improve the specificity nor the sensitivity. There was no difference in the odds ratios with regard to the technique that was chosen for bone assessment. In conclusion, these results suggest that low QUS measurements are associated with the presence of fractures in a way similar to DXA. In our study, the combination of QUS and DXA did not improve the discrimination of women with fractures.

Study on some hepatic functions and prevalence of hepatitis B surface antigenaemia in Egyptian children with schistosomal hepatic fibrosis

Several different hepatic parenchymal lesions, including chronic hepatitis and cirrhosis, have been increasingly reported in children with schistosomal hepatic fibrosis (SHF) despite the known mesenchymal nature of the disease. The prevalence of persistent hepatitis (B) surface (HBs) antigenaemia and some hepatic functions have been determined in 52 children with SHF as well as in 100 age-matched healthy children. High prevalence of chronic HBs antigenaemia (58 per cent) has been demonstrated in children with SHF, but only in 2 per cent of the normal children. This denotes that children with SHF represent a dangerous reservoir for hepatitis B infection to the community. Serum alanine transferase (ALT) was higher than normal in 58 per cent of HBS seropositive patients and in none of the seronegative patients. This points to the risk of continual hepatic parenchymal injury to the HBs seropositive patients with schistosomiasis.

Risk factors for malignant progression of intraductal papillary mucinous neoplasms

BACKGROUND

Intraductal papillary mucinous neoplasms of the pancreas are increasingly diagnosed. Due to their malignant potential, greater understanding of their nature is required.

AIMS

Define risk factors for malignancy in intraductal papillary mucinous neoplasms.

METHODS

An international, multicentre study was performed in Europe and the United States. Clinical databases were reviewed for patients with intraductal papillary mucinous neoplasms diagnosis.

RESULTS

Of 1126 patients, 84 were diagnosed with invasive carcinoma/high-grade dysplasia and were compared to the rest of the cohort. Multivariate logistic analysis showed a statistically significant association between cancer/high-grade dysplasia and the variables smoking history (OR 1.9, 95% CI [1.1-3.1]), body mass index (OR 1.1, 95% CI [1-1.1]), symptoms (OR 3.4, 95% CI [1.9-6]), jaundice (OR 0.1, 95% CI [0-0.3]), and steatorrhea (OR 0.3, 95% CI [0.1-0.8]). Univariate analysis showed no association between malignancy and the cyst number/location (p=0.3 and p=0.5, respectively) although a strong association was shown for cyst size (p<0.001). The presence and size of nodules (p<0.01) and main duct involvement (p<0.001) were also strongly related with malignancy.

CONCLUSION

The presence of jaundice and steatorrhea, smoking, high body mass index, and imaging features such as cyst size, main duct involvement, and the presence and size of mural nodules are associated with high-grade neoplasia in intraductal papillary mucinous neoplasms.

Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events

BACKGROUND

The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy.

METHODS

Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data.

RESULTS

Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically.

CONCLUSION

Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.

Prevalence and outcomes of cystic lesion of the pancreas in immunosuppressed patients with solid organ transplantation

BACKGROUND

Solid organ transplant recipients have an increased risk of cancer due to immunosuppressive therapy. Pancreatic cystic lesions are increasingly being detected, some with malignant potential. We aimed to determine the prevalence of these lesions and describe their clinical course in these patients.

METHODS

We identified the presence of pancreatic cystic lesions in a retrospective cohort of 3188 consecutive solid organ transplant recipients from 2000 to 2013 and compared lesion characteristics at initial and follow-up imaging, when available.

RESULTS

Lesion prevalence was 11.4% (365/3188), and increased with age. Median diameter of the largest lesions was 7mm (range: 1-31mm). We noted worrisome features in two patients (0.54%) at the time of cyst diagnosis. Of 155 patients who underwent follow-up imaging, the cysts size remained stable in 80%, increased in 16%, and decreased in 4%. Two patients (1.3%) developed features concerning for cancer. One underwent pancreatic surgery, and pathology confirmed the presence of high-grade dysplasia. The other continued with conservative management due to multiple comorbidities.

CONCLUSIONS

Pancreatic cystic lesions are common in solid organ transplant recipients. In lesions without high-risk features, the development of features worrisome for cancer is rare. These lesions can be managed conservatively, and their presence should not affect transplant eligibility.

Thermal ablation of pancreatic cyst with a prototype endoscopic ultrasound capable radiofrequency needle device: A pilot feasibility study

BACKGROUND AND OBJECTIVES

Pancreatic cysts are evaluated by endoscopic ultrasound and fine needle aspiration (EUS). The only accepted treatment is pancreatectomy, which is associated with morbidity and mortality. This study evaluated the optimal thermal dosimetry of a novel radiofrequency ablation device using a standard electrosurgical unit in ex vivo cyst models.

METHODS

A modified EUS 22-gauge monopolar needle prototype with a tip electrode connected to a standard electrosurgical unit (Erbe USA, Marietta, GA, USA) was used to induce a subboiling point temperature. A cyst model was created using 2-cm sections of porcine small intestine ligated and filled with saline. After ablation, the cyst models were prepared for pathological evaluation. The epithelial layers were measured in at least two different sites with a micrometer and compared with the corresponding control sample.

RESULTS

Thirty-two cyst models were ablated with maximum temperatures of 50°C, 60°C, 90°C, and 97°C in 8, 11, 11, and 2 cysts, respectively. Longer ablation times were required to induce higher temperatures. A trend in the reduction in thickness of the measured layers was observed after exposure to higher temperatures. A temperature over 50°C was required for the ablation of the muscularis, submucosa, and villi, and over 60°C was required to ablate the mucosal crypts.

CONCLUSIONS

In a preclinical model, a novel radiofrequency EUS-capable needle connected to a standard electrosurgical unit using standard low-voltage coagulation provided ablation in a temperature-dependent fashion with a threshold of at least 60°C and a safe cyst margin below 97°C. This potentially will allow low-cost, convenient cyst ablation.

Intraductal papillary mucinous neoplasms and mucinous cystadenomas: current status and recommendations

The real prevalence of pancreatic cystic lesions remains unknown. The malignant potential of some of these lesions remains a cause for significant concern. Thus, it is mandatory to develop a strategy to clearly discriminate those cysts with a potential for malignant transformation from those that do not carry any significant risk. Intraductal papillary mucinous neoplasms and mucinous cystadenomas are mucinous cystic neoplasms with a known malignant potential that have gained greater recognition in recent years. However, despite the numerous studies that have been carried out, their differential diagnosis among other cysts subtypes and their therapeutic approach continue to be a challenge for clinicians. This review contains a critical approach of the current recommendations and management strategies regarding intraductal papillary mucinous neoplasms and mucinous cystadenomas, as well as highlighting the limitations exposed in current guidelines.

An Individualized Low-Intensity Walking Clinic Leads to Improvement in Frailty Characteristics in Older Veterans

BACKGROUND

Sedentary lifestyle leads to worse health outcomes with aging, including frailty. Older adults can benefit from regular physical activity, but exercise promotion in the clinical setting is challenging.

OBJECTIVES

The objective of this clinical demonstration project was to implement a Geriatric Walking Clinic for older adults and determine whether this clinical program can lead to improvements in characteristics of frailty.

DESIGN

This was a clinical demonstration project/quality improvement project.

SETTING

Outpatient geriatrics clinic at the South Texas Veterans Health Care System (STVHCS).

PARTICIPANTS

Older Veterans, aged ≥60 years.

INTERVENTION

A 6-week structured walking program, delivered by a registered nurse and geriatrician. Patients received a pedometer and a comprehensive safety evaluation at an initial face-to-face visit. They were subsequently followed with weekly phone calls and participated in a final face-to-face follow-up visit at 6 weeks.

MEASUREMENTS

Grip strength (handheld dynamometer), gait speed (10-ft walk), Timed Up and Go (TUG), and body mass index (BMI) were assessed at baseline and follow-up. Frailty status for gait speed was assessed using Fried criteria.

RESULTS

One hundred eighty five patients completed the program (mean age: 68.4 ±7 years, 88% male). Improvements from baseline to follow-up were observed in average steps/day, gait speed, TUG, and BMI. Improvement in gait speed (1.13 ±0.20 vs. 1.24 ± 0.23 meter/second, p<0.0001) resulted in reduced odds of meeting frailty criteria for slow gait at follow-up compared to the baseline examination (odds ratio = 0.31, 95% confidence interval: 0.13-0.72, p = 0.01).

CONCLUSIONS

Our findings demonstrate that a short duration, low-intensity walking intervention improves gait speed and TUG. This new clinical model may be useful for the promotion of physical activity, and for the prevention or amelioration of frailty characteristics in older adults.

5032Evaluation of the EAPCI OCT criteria for optimization of angioplasty in the DOCTORS study population

Background

The recent expert consensus of the EAPCI suggested OCT criteria for the optimization of PCT after stent implantation. Using the data from the randomized, controlled DOCTORS study, we aimed to analyze the proportion of OCT criteria that were met immediately after stent implantation, and to evaluate the changes made to the revascularization strategy in order to optimize the procedure.

Methods

The DOCTORS study population consisted of patients admitted for non ST elevation myocardial infarction (NSTEMI) and presenting an indication for PCI with stent implantation of the target lesion. In the 120 patients randomized to the OCT-guided group, OCT was performed after initial coronary angiography and repeated immediately after stent implantation. The operator was required to evaluate quantitative measures of the reference diameter and reference area of the vessel and the length of the lesion based on the OCT images acquired before PCI. All OCT images were analyzed in a centralized core laboratory by 2 independent operators blinded to the angiographic findings. Post-PCI optimization targets to be achieved following stent implantation included optimal stent expansion (minimal stent area (MSA)/average reference lumen >80%), avoidance of landing zone in plaque burden >50% or lipid rich tissue; avoidance of large malapposition regions (axial distance <0.4 mm and <1 mm length), no extensive irregular tissue protrusion, and limited dissections (<60°, flap limited to intima, <2 mm length).

Results

Among the 120 patients who had an OCT run performed immediately after stent implantation, 50 patients (42%) had stent under-expansion, 59 (49%) had landing zone in plaque burden >50% or lipid rich tissue, 27 (22.5%) had stent malapposition, 25 (20.8%) had extensive irregular tissue protrusion and 45 (37.5%) had extensive edge dissection. Only 2 patients (1.7%) fullfiled all criteria of post-PCI optimization immediately after stent implantation, while no criterion was reached in 15 patients (12.5%). Post-stent overdilation was performed in all patients with stent underexpansion, and in 22/27 patients (81.5%) with stent malapposition. Additional stent implantation was performed in 32 patients (24 for landing zone in plaque burden >50% and 8 for extensive adventitial edge dissection). Overall, the use of OCT led the operator to optimize the procedural strategy in 60 patients (50%).

Conclusion

The proportion of suboptimal results as evaluated by OCT and based on the EAPCI criteria immediately after stent implantation was very high in the DOCTORS study, even though the choice of stent in these patients was based on pre-PCI OCT data. The post-PCI OCT findings led to a change of strategy to optimize the procedure in 50% of patients. It remains to be determined through a larger prospective study whether this optimization of PCI strategy is associated with a clinical benefit in the long term.

Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry

INTRODUCTION

Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality.

METHODS

This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022.

RESULTS

We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality.

DISCUSSION

EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.

Predictors of Malignancy in Patients With Indeterminate Biliary Strictures and Atypical Biliary Cytology: Results From Retrospective Cohort Study

Background

Atypical cellular features are commonly encountered in patients with indeterminate biliary strictures, which are nondiagnostic of malignancy yet cannot rule it out. This study aims to identify clinical features that could discriminate patients with indeterminate biliary strictures and atypical biliary cytology who may harbor underlying malignancy.

Methods

All patients with an indeterminate biliary stricture and an atypical brush cytology obtained during endoscopic brushings were identified in a large tertiary-care center. Demographical information, clinical data and the final pathological diagnosis were collected. The study cohort was divided based on the final diagnosis into benign and malignant groups. Descriptive and multivariable analyses were performed.

Results

A total of 151 patients were included in the analysis. Of these, 62.9% were males with mean age of 61.7 ± 16.4 years. Overall, there was an almost equal distribution of patients in the benign and malignant groups. Older age (≥65 years), jaundice, weight loss, intrahepatic biliary and pancreatic duct dilation, double-duct sign and presence of a mass were associated with malignancy in the univariate analysis. However, only older age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00 to 1.03), jaundice (OR 3.33, 95% CI 1.11 to 9.98) and presence of a mass (OR 12.10, 95% CI 4.94 to 29.67) were significantly associated with malignancy in the multivariate analysis. High CA19-9 was associated with malignancy only in patients with primary sclerosing cholangitis.

Conclusion

In patients with indeterminate biliary stricture and atypical brush cytology, older age, jaundice and presence of a mass are significant predictors of malignancy. Patients with such characteristics need prompt evaluation to rule out underlying malignancy.

Endoscopic retrograde cholangiopancreatography training conditions, results from a pan-European survey: Between vision and reality

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) still has a relatively high complication rate, underscoring the importance of high-quality training. Despite existing guidelines, real-world data on training conditions remain limited. This pan-European survey aims to systematically explore the perceptions surrounding ERCP training.

METHODS

A survey was distributed through the friends of United European Gastroenterology (UEG) Young Talent Group network to physicians working in a UEG member or associated states who regularly performed ERCPs.

RESULTS

Of 1035 respondents from 35 countries, 649 were eligible for analysis: 228 trainees, 225 trainers, and 196 individuals who regularly performed ERCP but were neither trainees nor trainers. The mean age was 43 years, with 72.1% identifying as male, 27.6% as female, and 0.3% as non-binary. The majority (80.1%) agreed that a structured training regimen is desirable. However, only 13.7% of trainees and 28.4% of trainers reported having such a structured program in their institutions. Most respondents (79.7%) supported the concept of concentrating training in centers meeting specific quality metrics, with 64.1% suggesting a threshold of 200 annual ERCPs as a prerequisite. This threshold revealed that 36.4% of trainees pursued training in lower-volume centers performing <200 ERCPs annually. As many as 70.1% of trainees performed <50 annual ERCPs, whereas only 5.0% of trainers performed <50 ERCPs annually. A low individual trainee caseload (<50 ERCPs annually) was more common in lower-volume centers than in higher-volume centers (82.9% vs. 63.4%).

CONCLUSIONS

The first pan-European survey investigating ERCP training conditions reveals strong support for structured training and the concentration of training efforts within centers meeting specific quality metrics. Furthermore, this survey exposes the low availability of structured training programs with many trainees practicing at lower-volume centers and 71% of all trainees having little hands-on exposure. These data should motivate to standardize ERCP training conditions further and ultimately improve patient care throughout Europe.

Règle pédiatrique RC (Radiologique Chimique) : un outil pour optimiser la prise en charge préhospitalière de victimes pédiatriques d’un évènement chimique ou radiologique

En cas d’évènement impliquant des agents chimique ou radiologique, la prise en charge de nombreuses victimes pédiatriques incomberait principalement à des primo-intervenants non spécialisés en pédiatrie ou à des pédiatres peu au fait des modalités de prise en charge en milieu de type NRBC. Pour tenter de pallier cette problématique, nous avons développé un outil s’inspirant de la règle de Broselow pour déterminer le poids des enfants pris en charge et les posologies des thérapeutiques à utiliser en cas d’intoxication par des agents neurotoxiques organophosphorés ou par des agents cyanés. Les modalités de préparation (reconstitution, dilution) des différentes thérapeutiques sont mentionnées sur l’outil pour faciliter l’action des primointervenants. L’outil incorpore également une aide diagnostique s’appuyant sur les différents toxidromes des intoxications chimiques pour orienter les primo-intervenants ainsi que le rappel de quelques actes réflexes (décontamination d’urgence, déshabillage des victimes) à avoir dans un tel contexte qu’il soit radiologique ou chimique. La pertinence de l’outil proposé doit être évaluée lors d’exercices simulant la prise en charge de victimes pédiatriques d’un événement chimique ou radiologique afin de valider son intérêt et d’identifier les modifications ou évolutions nécessaires.

Plastic pigtail vs lumen-apposing metal stents for drainage of walled-off necrosis (PROMETHEUS study): an open-label, multicenter randomized trial

BACKGROUND

Lumen-apposing metal stents (LAMS) have displaced double-pigtail plastic stents (DPS) as the standard treatment for walled-off necrosis (WON),β but evidence for exclusively using LAMS is limited. We aimed to assess whether the theoretical benefit of LAMS was superior to DPS.

METHODS

This multicenter, open-label, randomized trial was carried out in 9 tertiary hospitals. Between June 2017, and Oct 2020, we screened 99 patients with symptomatic WON, of whom 64 were enrolled and randomly assigned to the DPS group (n = 31) or the LAMS group (n = 33). The primary outcome was short-term (4-weeks) clinical success determined by the reduction of collection. Secondary endpoints included long-term clinical success, hospitalization, procedure duration, recurrence, safety, and costs. Analyses were by intention-to-treat.

CLINICALTRIALS

gov, NCT03100578.

RESULTS

A similar clinical success rate in the short term (RR, 1.41; 95% CI 0.88-2.25; p = 0.218) and in the long term (RR, 1.2; 95% CI 0.92-1.58; p = 0.291) was observed between both groups. Procedure duration was significantly shorter in the LAMS group (35 vs. 45-min, p = 0.003). The hospital admission after the index procedure (median difference, - 10 [95% CI - 17.5, - 1]; p = 0.077) and global hospitalization (median difference - 4 [95% CI - 33, 25.51]; p = 0.82) were similar between both groups. Reported stent-related adverse events were similar for the two groups (36 vs.45% in LAMS vs. DPS), except for de novo fever, which was significantly 26% lower in LAMS (RR, 0.26 [0.08-0.83], p = 0.015).

CONCLUSIONS

The clinical superiority of LAMS over DPS for WON therapy was not proved, with similar clinical success, hospital stay and similar safety profile between both groups, yet a significant reduction in procedure time was observed.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT03100578.