Narrow Band Imaging, Magnifying Chromoendoscopy, and Gross Morphological Features for the Optical Diagnosis of T1 Colorectal Cancer and Deep Submucosal Invasion: A Systematic Review and Meta-Analysis

OBJECTIVES

Optical diagnosis of T1 colorectal cancer (CRC) and T1 CRC with deep submucosal invasion is important in guiding the treatment strategy. The use of advanced imaging is not standard clinical practice in Western countries. A systematic review and meta-analysis were conducted comparing the accuracy of narrow band imaging (NBI), magnifying chromoendoscopy (MCE), and gross morphological features (GMF) seen with conventional view for the optical diagnosis of T1 CRC and deep submucosal invasion.

METHODS

A literature search identified studies on the optical diagnosis of T1 CRC and deep invasion using NBI, MCE, or GMF. Pooled estimates (PE) of sensitivity and specificity across studies reporting on NBI or MCE were compared using a random effects bivariate meta-regression approach, and a paired analysis focusing on studies that performed both techniques within the same patient was performed.

RESULTS

Thirty-three studies with 31,568 polyps were included. For the optical diagnosis of T1 CRC, both NBI (4 studies; PE 0.85, 95% confidence interval (CI) 0.75-0.91) and MCE (5 studies; PE 0.90, 95% CI 0.83-0.94) yielded higher sensitivity as compared with GMF (3 studies; range 0.21-0.46). No significant preference for NBI or MCE was found (sensitivity relative risk (RR) 0.93, 95% CI 0.79-1.09, P=0.37; specificity RR 0.98, 95% CI 0.86-1.11, P=0.74). Similarly, for the optical diagnosis of deep invasion, both NBI (13 studies; PE 0.77, 95% CI 0.68-0.84) and MCE (17 studies; PE 0.81, 95% 0.75-0.87) yielded higher sensitivity as compared with GMF (6 studies; range 0.18-0.88), and no significant preference for either NBI or MCE was found (sensitivity RR 0.92, 95% CI 0.76-1.11, P=0.36; specificity RR 1.00, 95% CI 0.96-1.04, P=0.92).

CONCLUSIONS

This review supports the use of advanced imaging techniques in preference to GMF to reduce the risk of performing piecemeal resection for T1 CRCs or unnecessary surgical referral for lesions amendable to endoscopic resection. A preference for either NBI or MCE could not be observed.

Rapid Resolution of Donor-Derived Glomerular Fibrin Thrombi After Deceased Donor Kidney Transplantation

The aim of this study was to determine the clinical and histologic outcomes related to transplanting kidneys from deceased donors with glomerular fibrin thrombi (GFT). We included all cases transplanted between October 2003 and October 2014 that had either a preimplantation biopsy or an immediate postreperfusion biopsy showing GFT. The study cohort included 61 recipients (9.9%) with GFT and 557 in the control group without GFT. Delayed graft function occurred in 49% of the GFT group and 39% in the control group (p = 0.14). Serum creatinine at 1, 4, and 12 months and estimated GFR at 12 months were similar in the two groups. Estimated 1-year graft survival was 93.2% in the GFT group and 95.1% in the control group (p = 0.22 by log-rank). Fifty-two of the 61 patients in the GFT group (85%) had a 1-month protocol biopsy, and only two biopsies (4%) showed residual focal glomerular thrombi. At the 1-year protocol biopsy, the prevalence of moderate to severe interstitial fibrosis and tubular atrophy was 24% in the GFT group and 30% in the control group (p = 0.42). We concluded that GFT resolves rapidly after transplantation and that transplanting selected kidneys from deceased donors with GFT is a safe practice.

[Current Guidelines to Prevent Obesity in Childhood and Adolescence]

BACKGROUND

Current guidelines for the prevention of obesity in childhood and adolescence are presented.

METHODS

A literature search was performed in Medline via PubMed, and appropriate studies were analysed.

RESULTS

Programs to prevent childhood obesity were to date mainly school-based. Effects were limited to date. Analyses tailored to different age groups show that prevention programs have the best effects in younger children (< 12 years). Evidence based recommendations for preschool- and early school age imply the need for interventions addressing parents and teachers alike. During adolescence, school-based interventions were most effective when adolescents were directly addressed. To date, obesity prevention programs have mainly focused on behavior oriented prevention. Recommendations for condition oriented prevention have been suggested by the German Alliance of Non-communicable Diseases and include one hour of physical activity at school, promotion of healthy food choices by taxing unhealthy foods, mandatory quality standards for meals at kindergarten and schools as well as a ban on unhealthy food advertisement addressing children.

CONCLUSION

Behavior oriented prevention programs showed hardly any or only limited effects in the long term. Certain risk groups for the development of obesity are not reached effectively by available programs. Due to the heterogeneity of available studies, universally valid conclusions cannot be drawn. The combination with condition oriented prevention, which has to counteract on an obesogenic environment, is crucial for sustainable success of future obesity prevention programs.

Transplanting Kidneys from Deceased Donors With Severe Acute Kidney Injury

Our aim was to determine outcomes with transplanting kidneys from deceased donors with acute kidney injury, defined as a donor with terminal serum creatinine ≥2.0 mg/dL, or a donor requiring acute renal replacement therapy. We included all patients who received deceased donor kidney transplant from June 2004 to October 2013. There were 162 AKI donor transplant recipients (21% of deceased donor transplants): 139 in the standard criteria donor (SCD) and 23 in the expanded criteria donor (ECD) cohort. 71% of the AKI donors had stage 3 (severe AKI), based on acute kidney injury network (AKIN) staging. Protocol biopsies were done at 1, 4, and 12 months posttransplant. One and four month formalin-fixed paraffin embedded (FFPE) biopsies from 48 patients (24 AKI donors, 24 non-AKI) underwent global gene expression profiling using DNA microarrays (96 arrays). DGF was more common in the AKI group but eGFR, graft survival at 1 year and proportion with IF/TA>2 at 1 year were similar for the two groups. At 1 month, there were 898 differentially expressed genes in the AKI group (p-value <0.005; FDR <10%), but by 4 months there were no differences. Transplanting selected kidneys from deceased donors with AKI is safe and has excellent outcomes.

Joint analysis of BICEP2/keck array and Planck Data

We report the results of a joint analysis of data from BICEP2/Keck Array and Planck. BICEP2 and Keck Array have observed the same approximately 400  deg^{2} patch of sky centered on RA 0 h, Dec. -57.5°. The combined maps reach a depth of 57 nK deg in Stokes Q and U in a band centered at 150 GHz. Planck has observed the full sky in polarization at seven frequencies from 30 to 353 GHz, but much less deeply in any given region (1.2  μK deg in Q and U at 143 GHz). We detect 150×353 cross-correlation in B modes at high significance. We fit the single- and cross-frequency power spectra at frequencies ≥150  GHz to a lensed-ΛCDM model that includes dust and a possible contribution from inflationary gravitational waves (as parametrized by the tensor-to-scalar ratio r), using a prior on the frequency spectral behavior of polarized dust emission from previous Planck analysis of other regions of the sky. We find strong evidence for dust and no statistically significant evidence for tensor modes. We probe various model variations and extensions, including adding a synchrotron component in combination with lower frequency data, and find that these make little difference to the r constraint. Finally, we present an alternative analysis which is similar to a map-based cleaning of the dust contribution, and show that this gives similar constraints. The final result is expressed as a likelihood curve for r, and yields an upper limit r_{0.05}<0.12 at 95% confidence. Marginalizing over dust and r, lensing B modes are detected at 7.0σ significance.

Evidence of inappropriate cardiovascular risk assessment in middle-age women based on recommended cut-points for waist circumference

BACKGROUND AND AIMS

Diverse waist circumference thresholds for assessment of metabolic and cardiovascular risk in Caucasians are recommended by different health professional organizations. We aimed to determine optimal sex-specific thresholds for anthropometric measures showing the strongest association with cardiovascular risk factors in a cohort of middle-aged Germans.

METHODS AND RESULTS

Statistical analyses are based on data from 426 mothers and 267 fathers of participants of the Ulm Birth Cohort Study undergoing a clinical follow-up examination in 2008 (median age 41 years) using logistic regression analyses. The prevalence of many cardiometabolic risk factors was significantly higher in men than in women; hypertension: 45%/17% (p < 0.0001), apolipoprotein ratio B/A1 > 0.72: 35%/9% (<0.0001), hyperglycemia: 11%/14% (p = 0.3), which is in contrast to the predicted cardiovascular risk of 52%/70% and 24%/36% based on thresholds for waist circumference proposed by International Diabetes Federation and American Heart Association, respectively. We determined optimal thresholds for waist circumference between 90 and 95 cm for men and women. Using a threshold of 92 cm the prevalence of abdominal obesity was 59% in men and 24% in women, which was in agreement with the higher prevalence of overweight and obesity in men than in women (Body Mass Index (BMI) > 25: 64%/35%). The prediction of cardiometabolic risk factors by waist circumference and waist-to-height ratio did not outperform the prediction by BMI. In contrast to BMI, waist circumference was correlated with body height independent of sex.

CONCLUSION

Currently proposed thresholds for waist circumference spuriously overestimate the cardiovascular risk in women, but not in men in a German population.

Resolution of long-standing necrobiosis lipoidica diabeticorum (NLD) lesion after restoration of euglycemia following successful pancreas after kidney (PAK) transplantation: a case report

Necrobiosis lipoidica diabeticorum (NLD) is an inflammatory skin disorder of unknown cause which can be seen in patients with diabetes mellitus. Various treatments, including immunosuppressive agents have been tried, without consistent efficacy. NLD is generally thought not to correlate well with tight diabetic control. Pancreas transplantation is the only widely and clinically used treatment that restores euglycemia in type I diabetic recipients. We report a case of resolution of NLD that had been unchanged for decades before pancreas after kidney transplantation. Another unique aspect of our case was that immunosuppression was discounted as a confounding factor, because the patient had been exposed to the same antirejection regimen for 3 years preceding the pancreas transplantation.

Rapid improvement of hepatic steatosis after initiation of leptin substitution in a leptin-deficient girl

BACKGROUND

Leptin deficiency is associated with severe obesity and metabolic disturbances. Increased liver fat content has been reported in only one case beforehand, even though hepatic steatosis is a typical comorbidity of common obesity. It is also frequent in patients with lipodystrophy where it resolves under leptin therapy.

SUBJECT AND METHODS

In 2010, we reported a leptin-deficient patient with a novel homozygous mutation in the leptin gene and severe hepatic steatosis. We have now studied serum changes and changes in liver fat content during the substitution with recombinant methionyl human leptin.

RESULTS

After 23 weeks of leptin substitution, elevated transaminases, total cholesterol and low-density lipoprotein levels normalized. After 62 weeks, homeostasis model assessment of insulin resistance improved from 10.7 to 6.0 and body fat mass dropped from 50.2 to 37.8%. Liver fat content was drastically reduced from 49.7 to 9.4%. The first changes in liver fat content were detectable after 3 days of therapy.

CONCLUSION

Our patient showed a remarkable reduction of liver fat content during the treatment with recombinant methionyl human leptin. These changes occurred rapidly after initiation of the substitution, which implies that leptin has a direct effect on hepatic lipid metabolism in humans as it is seen in rodents.

Lack of efficacy of monepantel against Teladorsagia circumcincta and Trichostrongylus colubriformis

After reports of the apparent failure of monepantel to reduce the egg counts of goats on a farm in the lower North Island of New Zealand, faecal egg count reduction tests were conducted in goats and lambs resident on the property, and a confirmatory, slaughter study was conducted using 12 sheep, sourced elsewhere, that were grazed on the farm for approximately 5 weeks. In the egg count reduction test in goats, 8 animals were given monepantel at 3.9 mg/kg (just over 1.5× the sheep dose rate of 2.5mg/kg), whilst four received 7.7 mg/kg (just over 3× the sheep dose). In the egg count reduction test in sheep, 15 lambs were treated with 3.0mg/kg of monepantel. For the confirmatory study, the sheep were housed indoors for 2 weeks before half were treated with 2.9 mg/kg monepantel and the animals were killed for worm counts 9 days later. There was no evidence of efficacy in either egg count reduction test, or in the goats, the two dose rates used appeared equally ineffective. Likewise, there were no significant reductions in egg counts or worm burdens in the slaughter study. Monepantel was ineffective against at least two gastrointestinal nematode species, Teladorsagia circumcincta and Trichostrongylus colubriformis. These findings represent the first report from the field of resistance having developed to the anthelmintic monepantel with severe resistance developing in more than one species after being administered on 17 separate occasions to different stock classes and in less than 2 years of the product first being used on the farm in question.

Intracellular drug concentrations and transporters: measurement, modeling, and implications for the liver

Intracellular concentrations of drugs and metabolites are often important determinants of efficacy, toxicity, and drug interactions. Hepatic drug distribution can be affected by many factors, including physicochemical properties, uptake/efflux transporters, protein binding, organelle sequestration, and metabolism. This white paper highlights determinants of hepatocyte drug/metabolite concentrations and provides an update on model systems, methods, and modeling/simulation approaches used to quantitatively assess hepatocellular concentrations of molecules. The critical scientific gaps and future research directions in this field are discussed.

Leptin substitution results in the induction of menstrual cycles in an adolescent with leptin deficiency and hypogonadotropic hypogonadism

BACKGROUND

Leptin deficiency leads to midluteal-phase defect or reduced testicular volume in adults, despite normal gonadotropin levels. All children documented to date with leptin deficiency were prepubertal with physiologically low gonadotropins prior to therapy. A direct effect of leptin on pubertal development in a leptin-naive adolescent has not yet been shown.

METHODS

In 2010, we reported the first connatal leptin-deficient adolescent girl with clinically and chemically proven hypogonadotropic hypogonadism. In this study, we evaluated the effect of recombinant methionyl human leptin substitution.

RESULTS

Initially, the patient had prepubertal basal and stimulated luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, low growth hormone and insulin-like growth factor 1 (IGF1) levels and no pulsatile secretion of LH and FSH. After 11 weeks of therapy, basal and stimulated LH and FSH levels rose to pubertal values and nocturnal pulsatility was initiated. After 76 weeks of therapy, menstruation occurred at the age of 16.3 years. Pulsatile nocturnal growth hormone secretion, stimulated growth hormone secretion and IGF1 values also normalized.

CONCLUSION

We describe here the first adolescent with hypogonadotropic hypogonadism due to connatal leptin deficiency. Leptin substitution led to a rapid induction of gonadotropin secretion and menarche. These data are further proof of the concept that leptin is needed for a timely maturation of the hypothalamic/pituitary/gonadal axis.

Complete Barrett's excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture

BACKGROUND AND STUDY AIMS

Complete Barrett's excision (CBE) of short-segment Barrett's high grade dysplasia (HGD) and early esophageal adenocarcinoma by stepwise endoscopic resection is a precise staging tool, detects covert synchronous disease, and may produce a sustained treatment response. Esophageal stricture is the most commonly reported complication of CBE although risk factors have not yet been clearly defined.

PATIENTS AND METHODS

Data were recorded prospectively on patients with limited co-morbidity and age ≤ 80 years undergoing CBE for histologically proven HGD or esophageal adenocarcinoma within ≤ C3M5 segments. Endoscopic resection was performed by standardized protocol every 6 - 8 weeks until CBE was achieved. Esophageal dilation was performed when patients reported dysphagia. Dysphagia scores were recorded at scheduled endoscopic surveillance or by telephone interview.

RESULTS

By intention-to-treat analysis, complete eradication of neoplasia and intestinal metaplasia was achieved in 95 % and 82 %, respectively, in 77 patients undergoing a median of 2 resection sessions (interquartile range [IQR] 1 - 3). Esophageal dilation was required in 33 % (median 3 dilations, IQR 1 - 3.5) at median follow-up of 20 months (IQR 6 - 40). Independent risk factors for dilation requirement were the number of mucosal resections at the index procedure (odds ratio [OR] 1.3 per resection, 95 % confidence interval [CI] 1.0 - 1.9; P = 0.043) and maximal extent of the Barrett's segment (OR 2.2 per cm, 95 %CI 1.2 - 3.9; P = 0.009).

CONCLUSIONS

Although CBE is highly effective in the treatment of Barrett's HGD and esophageal adenocarcinoma, the risk of post-CBE dysphagia increases with the maximal extent of the Barrett's segment and the number of mucosal resections at the index procedure. These data could be used to inform treatment decisions and identify those patients who may benefit from prophylactic therapies such as dilation.

Constraints on the fundamental string coupling from B-mode experiments

We study signatures of cosmic superstring networks containing strings of multiple tensions and Y junctions, on the cosmic microwave background (CMB) temperature and polarization spectra. Focusing on the crucial role of the string coupling constant g(s), we show that the number density and energy density of the scaling network are dominated by different types of string in the g(s) ~ 1 and g(s) ≪ 1 limits. This can lead to an observable shift in the position of the B-mode peak--a distinct signal leading to a direct constraint on g(s). We forecast the joint bounds on g(s) and the fundamental string tension μ(F) from upcoming and future CMB polarization experiments, as well as the signal to noise in detecting the difference between B-mode signals in the limiting cases of large and small g(s). We show that such a detectable shift is within reach of planned experiments.

Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions

BACKGROUND AND STUDY AIMS

Endoscopic mucosal resection (EMR) for large colonic laterally spreading tumors (LSTs) is a safe, efficacious, and cost-effective treatment. The most common serious complication is delayed bleeding, which reduces these advantages, but consensus guidelines for large-polyp EMR do not exist.

PATIENTS AND METHODS

Data from two large prospective intention-to-treat studies of EMR for colonic LSTs 20 mm or greater in size were analyzed. Data collection was comprehensive, and included patient and lesion characteristics. EMR technique and cessation of anticoagulant and antiplatelet therapy was standardized. Clinically significant delayed bleeding was defined as that requiring hospital admission.

RESULTS

EMR was performed on 302 lesions in 288 patients. There was clinically significant delayed bleeding in 21 cases (7 %). Ten underwent colonoscopy. One required angiography. One required surgery after perforation following hemostatic clip placement. There were no deaths. Risk factors for bleeding on multivariate analysis were right colon location [adjusted odds ratio (OR) 4.4, P = 0.01], use of aspirin (OR 6.3, P = 0.005), and age (OR per decade of age 1.70). All bleeds occurred before aspirin was restarted. Patient characteristics, including ASA grade and co-morbidity type, were not predictive. Despite requiring more complex EMR, larger lesion size ( P = 0.2), multiple excisions rather than en bloc resection ( P = 0.1), polyp morphology ( P = 0.2), and previous attempts ( P = 0.5), were not associated with increased risk.

CONCLUSIONS

Proximal lesion location is a highly significant risk for clinically significant delayed bleeding following colonic EMR, and this knowledge could form the basis of a targeted therapeutic trial. Recent aspirin use also increases bleeding risk--specific consensus guidelines in this area are required for colonic EMR.