Prognostic value of Geriatric-8 for adverse outcomes within 30 days of surgery in older adults with colorectal cancer: A retrospective cohort study

PURPOSE

It is unclear whether the Geriatric-8 (G8) has the accuracy to preselect patients for complete geriatric assessment, and has the ability to predict adverse outcomes in patients with colorectal cancer (CRC). We therefore aimed to determine whether the G8, or other variables present in the medical record, are applicable in predicting 30-day adverse outcomes in older patients undergoing surgery for CRC.

METHODS

We performed a retrospective cohort study involving patients ≥70 years who had surgery for CRC between 2018 and 2020 in a general hospital in the Netherlands. The primary outcome was adverse outcome(s), which is a composite of surgical and non-surgical complications, readmission and mortality, all within 30 days of surgery. The secondary endpoints were the individual components, such as delirium, infection and ileus. We explored potential prognostic factors using multivariable logistic regression analysis. Data were collected from the Dutch ColoRectal Audit (DRCA) and medical records.

RESULTS

The study included 200 patients (mean age 78.9 years: 50% female), with 36.5% having adverse outcomes in the first 30 days of surgery. In neither univariate nor multivariable analysis were G8 scores associated with adverse outcomes. Factors with higher odds of adverse outcomes were male gender, and having cognitive decline or previous delirium.

CONCLUSION

This study confirms that G8 scores have no prognostic value for adverse outcomes, complications and mortality within 30 days of surgery among older adults with CRC. Therefore, the G8 should not be the tool for short-term risk prediction of adverse outcomes in these patients.

Fifteen years' experience with methylphenidate for attention-deficit disorder during pregnancy: Effects on birth weight, Apgar score and congenital malformation rates

BACKGROUND

Methylphenidate (MPD) is increasingly prescribed to fertile women with Attention-Deficit Disorder (AD(H)D), with or without hyperactivity, despite advice for discontinuation during pregnancy. Few studies report on results concerning safety after methylphenidate exposure during pregnancy for the offspring.

AIM

Safety for the offspring of exposure to MPD during pregnancy.

METHODS

This is an observational retrospective cohort study in a population of pregnant women and their offspring, treated with MPD for ADHD in the Psychiatry-Gynaecology-Pediatrics outpatient clinic between 1 January 2005 and 1 June 2020 at Isala hospital. The primary endpoints were birth weight and Apgar score in offspring exposed to MPD during pregnancy, compared to offspring unexposed to MPD. Birth weight was analysed using linear mixed model analysis. Apgar score and (secondary endpoint) neonatal malformations, at 20 week ultrasound, were analysed using basic univariate statistical analysis.

RESULTS

MPD continuation, compared to discontinuation, was associated with higher neonatal birth weight (p = 0.049), but lost statistical significance after incorporating covariates (p = 0.079). There were no significant differences in Apgar scores and congenital malformations between neonates exposed and unexposed to MPD.

CONCLUSIONS

MPD does not seem to affect birth weight, Apgar score and the frequency of neonatal malformations at the 20 week ultrasound.

Advising special population emergency medicine residency applicants: a survey of emergency medicine advisors and residency program leadership

BACKGROUND

The objective of this study was to determine the advising and emergency medicine (EM) residency selection practices for special population applicant groups for whom traditional advice may not apply.

METHODS

A survey was distributed on the Council of Residency Directors in EM and Clerkship Directors in EM Academy listservs. Multiple choice, Likert-type scale, and fill-in-the-blank questions addressed the average EM applicant and special population groups (osteopathic; international medical graduate (IMG); couples; at-risk; re-applicant; dual-accreditation applicant; and military). Percentages and 95% confidence intervals [CI] were calculated.

RESULTS

One hundred four surveys were completed. Of respondents involved in the interview process, 2 or more standardized letters of evaluation (SLOEs) were recommended for osteopathic (90.1% [95% CI 84-96]), IMG (82.5% [73-92]), dual-accreditation (46% [19-73]), and average applicants (48.5% [39-58]). Recommendations for numbers of residency applications to submit were 21-30 (50.5% [40.7-60.3]) for the average applicant, 31-40 (41.6% [31.3-51.8]) for osteopathic, and > 50 (50.9% [37.5-64.4]) for IMG. For below-average Step 1 performance, 56.0% [46.3-65.7] were more likely to interview with an average Step 2 score. 88.1% [81.8-94.4] will consider matching an EM-EM couple. The majority were more likely to interview a military applicant with similar competitiveness to a traditional applicant. Respondents felt the best option for re-applicants was to pursue the Supplemental Offer and Acceptance Program (SOAP) for a preliminary residency position.

CONCLUSION

Advising and residency selection practices for special population applicants differ from those of traditional EM applicants. These data serve as an important foundation for advising these distinct applicant groups in ways that were previously only speculative. While respondents agree on many advising recommendations, outliers exist.

Determinants of HbA1c reduction with FreeStyle Libre flash glucose monitoring (FLARE-NL 5)

Aims

To identify factors predicting HbA1c reduction in patients with diabetes mellitus (DM) using FreeStyle Libre Flash Glucose Monitoring (FSL-FGM).

Methods

Data from a 12-month prospective nation-wide FSL registry were used and analysed with multivariable regression. For the present study we included patients with hypoglycaemia unawareness or unexpected hypoglycaemias (n = 566) and persons who did not reach acceptable glycaemic control (HbA1c > 70 mmol/mol (8.5%)) (n = 294). People with other indications for use, such as sensation loss of the fingers or individuals already using FSL-FGM or rtCGM, were excluded (37%).

Results

Eight hundred and sixty persons (55% male with a mean age of 46.7 (±16.4) years) were included. Baseline HbA1c was 65.1 (±14.5) mmol/mol (8.1 ± 1.3%), 75% of the patients had type 1 DM and 37% had microvascular complications. Data concerning HbA1c was present for 482 (56.0%) at 6 months and 423 (49.2%) persons at 12 months. A significant reduction in HbA1c (≥5 mmol/mol (0.5%)) was present in 187 (22%) persons. For these persons, median HbA1c reduction was −9.0 [−13.0, −4.0] mmol/mol (−0.82 [−1.19, −0.37]%) at 6 months and −9.0 [−15.0, −7.0] mmol/mol (−0.82 [−1.37, −0.64]%) at 12 months. In multivariable regression analysis with age, gender and SF-12 physical and mental component scores as covariates, only baseline HbA1c was significant: −0.319 (SE 0.025; p < 0.001; R² = 0.240 for the model). In exploratory analysis among subgroups with different indications for FSL-FGM use (hypoglycaemia unawareness or persistently high HbA1c) and persons with a significant HbA1c decrease over the study period, baseline HbA1c remained the only significant predictor.

Conclusions

Among the variables we analysed in the present study, only high HbA1c at baseline predicts significant HbA1c reduction during FSL-CGM use.

International Medical Graduate Advising Recommendations From the Council of Residency Directors in Emergency Medicine Advising Student Committee

International Medical Graduate (IMG) physicians applying to residency training programs in a country different from where they completed medical school, bring beneficial diversity to a training program, but also face significant challenges matching into an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program. Despite the growing number of IMG applications in Emergency Medicine (EM), there is a paucity of targeted recommendations for IMG applicants. As a result, the Council of Residency Directors (CORD) Advising Students Committee in EM (ASC-EM) created a dedicated IMG Advising Team to create a set of evidence-based advising recommendations based on longitudinal data from the National Residency Match Program (NRMP) and information collected from EM program directors and clerkship directors. IMG applicants should obtain at least two EM standardized letters of evaluation (SLOEs), review IMG matched percentages for programs-of-interest, analyze their objective scores with the previous matched cohorts, and rank at least 12 programs to maximize their chances of matching into EM.

COVID-19: A Driver for Disruptive Innovation of the Emergency Medicine Residency Application Process

The coronavirus disease (COVID-19) pandemic has had a significant impact on undergraduate medical education with limitation of patient care activities and disruption to medical licensing examinations. In an effort to promote both safety and equity, the emergency medicine (EM) community has recommended no away rotations for EM applicants and entirely virtual interviews during this year's residency application cycle. These changes affect the components of the EM residency application most highly regarded by program directors - Standardized Letters of Evaluation from EM rotations, board scores, and interactions during the interview. The Council of Residency Directors in Emergency Medicine Application Process Improvement Committee suggests solutions not only for the upcoming year but also to address longstanding difficulties within the process, encouraging residency programs to leverage these challenges as an opportunity for disruptive innovation.

The Emergency Medicine Group Standardized Letter of Evaluation as a Workplace-based Assessment: The Validity Is in the Detail

Introduction

Interest is growing in specialty-specific assessments of student candidates based on clinical clerkship performance to assist in the selection process for postgraduate training. The most established and extensively used is the emergency medicine (EM) Standardized Letter of Evaluation (SLOE), serving as a substitute for the letter of recommendation. Typically developed by a program’s leadership, the group SLOE strives to provide a unified institutional perspective on performance. The group SLOE lacks guidelines to direct its development raising questions regarding the assessments, processes, and standardization programs employ. This study surveys EM programs to gather validity evidence regarding the inputs and processes involved in developing group SLOEs.

Methods

A structured telephone interview was administered to assess the input data and processes employed by United States EM programs when generating group SLOEs.

Results

With 156/178 (87.6%) of Accreditation Council of Graduate Medical Education-approved programs responding, 146 (93.6%) reported developing group SLOEs. Issues identified in development include the following: (1) 84.9% (124/146) of programs limit the consensus process by not employing rigorous methodology; (2) several stakeholder groups (nurses, patients) do not participate in candidate assessment placing final decisions at risk for construct under-representation; and (3) clinical shift assessments don’t reflect the task-specific expertise of each stakeholder group nor has the validity of each been assessed.

Conclusion

Success of the group SLOE in its role as a summative workplace-based assessment is dependent upon valid input data and appropriate processes. This study of current program practices provides specific recommendations that would strengthen the validity arguments for the group SLOE.

Optimization of pulmonary emphysema quantification on CT scans of COPD patients using hybrid iterative and post processing techniques: correlation with pulmonary function tests

Objectives

The aim of this study was to assess the effect of hybrid iterative reconstruction and post processing on emphysema quantification in low-dose CT scans of COPD patients using pulmonary function tests (PFT) as a reference.

Methods

CT scans of 23 COPD patients diagnosed with GOLD I or higher were reconstructed with iDose⁴ level 1 to 7 in IntelliSpace Portal (ISP) 6 and 7. ISP7 was used with and without specific denoising filter for COPD. The extent of emphysema was measured as percentage of lung voxels with attenuation < − 950 Hounsfield units (%LAA-950). The correlation between %LAA-950 and PFT, age, BMI, pack years, and the Clinical COPD Questionnaire (CCQ) and Medical Research Council dyspnea scale (MRC) was determined.

Results

Denoising significantly reduced %LAA-950 as was demonstrated by lower %LAA-950 in ISP7 with denoising filter and a significant reduction in %LAA-950 with higher iDose⁴ levels. All PFT except forced vital capacity (FVC) were significantly inversely correlated with %LAA-950. There was a trend toward a stronger correlation at higher iDose⁴ levels. %LAA-950 was also significantly correlated with BMI, GOLD class, and CCQ scores.

Conclusions

Our study showed that hybrid iterative reconstruction and use of post processing denoising can optimize the use of emphysema quantification in CT scans as a complimentary diagnostic tool to stage COPD in addition to PFT.

Increasing Resident Wellness Through a Novel Retreat Curriculum

Background Because of their arduous schedules, residents are susceptible to burnout, fatigue, and depression. In 2015, the Accreditation Council for Graduate Medical Education (ACGME) launched a campaign to foster physician wellness, in response to the suicides of three residents during the previous year. The campaign calls for strategies to developing resiliency, identify problems, and promote well-being. One of the suggested methods to promote well-being was a residency retreat. Objective To implement a novel retreat curriculum that emphasizes team building between residents and faculty, with which residents expressed high satisfaction. Methods We created an "Amazing Race" style retreat involving five activity stations set up in a neighborhood park in which 25 of our 34 residents participated. These stations implemented team building, faculty-resident bonding and resident-resident bonding. An anonymous survey was administered to the 25 participating emergency medicine (EM) residents after the retreat, of whom 21 returned the survey. The survey consisted of questions to assess the resident's perception of the team building activities, their satisfaction with each of the five activity stations and overall retreat satisfaction. Results Of the 25 residents who participated in the retreat, 21 (84%) returned the post-retreat survey (one participant returned a survey leaving the ranking questions incomplete). This low-cost event received high satisfaction ratings in regard to team-building, resident bonding, and faculty-resident bonding. Conclusions This novel retreat proved to be a low-cost and easily implemented activity with which the residents expressed high levels of satisfaction.

Low-dose CT imaging of a total hip arthroplasty phantom using model-based iterative reconstruction and orthopedic metal artifact reduction

OBJECTIVE

To compare quantitative measures of image quality, in terms of CT number accuracy, noise, signal-to-noise-ratios (SNRs), and contrast-to-noise ratios (CNRs), at different dose levels with filtered-back-projection (FBP), iterative reconstruction (IR), and model-based iterative reconstruction (MBIR) alone and in combination with orthopedic metal artifact reduction (O-MAR) in a total hip arthroplasty (THA) phantom.

MATERIALS AND METHODS

Scans were acquired from high- to low-dose (CTDI_vol: 40.0, 32.0, 24.0, 16.0, 8.0, and 4.0 mGy) at 120- and 140- kVp. Images were reconstructed using FBP, IR (iDose⁴ level 2, 4, and 6) and MBIR (IMR, level 1, 2, and 3) with and without O-MAR. CT number accuracy in Hounsfield Units (HU), noise or standard deviation, SNRs, and CNRs were analyzed.

RESULTS

The IMR technique showed lower noise levels (p < 0.01), higher SNRs (p < 0.001) and CNRs (p < 0.001) compared with FBP and iDose⁴ in all acquisitions from high- to low-dose with constant CT numbers. O-MAR reduced noise (p < 0.01) and improved SNRs (p < 0.01) and CNRs (p < 0.001) while improving CT number accuracy only at a low dose. At the low dose of 4.0 mGy, IMR level 1, 2, and 3 showed 83%, 89%, and 95% lower noise values, a factor 6.0, 9.2, and 17.9 higher SNRs, and 5.7, 8.8, and 18.2 higher CNRs compared with FBP respectively.

CONCLUSIONS

Based on quantitative analysis of CT number accuracy, noise values, SNRs, and CNRs, we conclude that the combined use of IMR and O-MAR enables a reduction in radiation dose of 83% compared with FBP and iDose⁴ in the CT imaging of a THA phantom.

Evolution of the Model of the Clinical Practice of Emergency Medicine: 1979 to Present

The Model of the Clinical Practice of Emergency Medicine (the EM Model) is a three-dimensional representation of the clinical practice of emergency medicine. It is a product of successful collaboration involving the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), the Emergency Medicine Residents' Association (EMRA), the Council of Emergency Medicine Residency Directors (CORD), the Residency Review Committee for Emergency Medicine (RRC-EM), and the American Academy of Emergency Medicine (AAEM). In 2017, the most recent update and revision of the EM Model will be published. This document will represent the culmination of nearly 40 years of evolution, from a simple listing of presenting patient complaints, clinical symptoms, and disease states into a three-dimensional representation of the clinical practice of emergency medicine. These dimensions include conditions and components, physician tasks, and patient acuity. In addition, over the years, two other documents have been developed, the Knowledge, Skills, and Abilities (KSAs) and the Emergency Medicine Milestones. Both serve as related and complementary educational and assessment tools. This article will review the development of the EM Model from its inception in 1979 to today.

Performance of the FreeStyle Libre Flash glucose monitoring system in patients with type 1 and 2 diabetes mellitus

OBJECTIVE

To evaluate the performance of the FreeStyle Libre Flash continuous glucose monitoring (FSL-CGM) system against established central laboratory methods.

RESEARCH DESIGN AND METHODS

20 subjects (8 type 1 diabetes mellitus, 12 type 2 diabetes mellitus) were analyzed. FSL-CGM sensor measurements (inserted in arm and abdomen) were compared with capillary blood glucose results analyzed with StatStrip as semigold standard. The glucose response after a standardized oral glucose load was measured by FSL-CGM and capillary samples analyzed by perchloric acid hexokinase (PCA-HK) method, StatStrip and FSL test strip (FSLC), and a commonly used CGM system (iPro2).

RESULTS

FSL-CGM arm sensor readings showed 85.5% of paired readings falling within Clarke Error Grid (ISO 15197:2013) zone A when compared with StatStrip. For FSL-CGM abdomen and FSLC, these percentages were 64% and 98%, respectively. The overall correlation of FSL-CGM in the arm and the StatStrip indicates a performance with lower results with the FSL-CGM in the arm than expected based on the StatStrip in the lower glucose ranges, and higher results than expected in the higher ranges. Following a standardized glucose load, a slower rise in glucose level was observed for FSL-CGM arm as compared with PCA-HK, StatStrip, FSLC, and iPro2 during the first 45-60 min after glucose load ingestion.

CONCLUSIONS

Certain matters need attention while using the FSL-CGM in daily life including the observed lower values in the lower ranges, and the underestimation of the effect of a meal on glucose response. These effects of such deviations can partly be overcome by optimizing the available user instructions.

TRIAL REGISTRATION NUMBER

TC5348; results.

Adapting Gel Wax into an Ultrasound-Guided Pericardiocentesis Model at Low Cost

Cardiac tamponade is a life-threatening emergency for which pericardiocentesis may be required. Real-time bedside ultrasound has obviated the need for routine blind procedures in cardiac arrest, and the number of pericardiocenteses being performed has declined. Despite this fact, pericardiocentesis remains an essential skill in emergency medicine. While commercially available training models exist, cost, durability, and lack of anatomical landmarks limit their usefulness. We sought to create a pericardiocentesis model that is realistic, simple to build, reusable, and cost efficient. We constructed the model using a red dye-filled ping pong ball (simulating the right ventricle) and a 250cc normal saline bag (simulating the effusion) encased in an artificial rib cage and held in place by gel wax. The inner saline bag was connected to a 1L saline bag outside of the main assembly to act as a fluid reservoir for repeat uses. The entire construction process takes approximately 16–20 hours, most of which is attributed to cooling of the gel wax. Actual construction time is approximately four hours at a cost of less than $200. The model was introduced to emergency medicine residents and medical students during a procedure simulation lab and compared to a model previously described by dell’Orto.1 The learners performed ultrasound-guided pericardiocentesis using both models. Learners who completed a survey comparing realism of the two models felt our model was more realistic than the previously described model. On a scale of 1–9, with 9 being very realistic, the previous model was rated a 4.5. Our model was rated a 7.8. There was also a marked improvement in the perceived recognition of the pericardium, the heart, and the pericardial sac. Additionally, 100% of the students were successful at performing the procedure using our model. In simulation, our model provided both palpable and ultrasound landmarks and held up to several months of repeated use. It was less expensive than commercial models ($200 vs up to $16,500) while being more realistic in simulation than other described “do-it-yourself models.” This model can be easily replicated to teach the necessary skill of pericardiocentesis.

Mammalian Bites In The Emergency Department: Recommendations For Wound Closure, Antibiotics, And Postexposure Prophylaxis

Half of all Americans will experience a mammalian bite at some time in their life, and the cost of caring for these injuries has reached $160 million annually. Emergency clinicians must consider many factors when making decisions regarding care of these injuries: risk of infection, cost of antibiotics, time of wound healing, cosmetic and functional result, and risk of other injuries or diseases. Knowledge of the current literature and practice guidelines facilitates care for these injuries in the most cost-effective and clinically sound manner. This systematic review provides best-practice recommendations based on the best available evidence.

An Emergency Department Presentation of Erythema Ab Igne Caused by Repeated Heater Exposure

Erythema ab igne is a rare, reticular erythematous hyperpigmentation resulting from repeated thermal injury. We describe our assessment of a 22-year-old woman with bilateral shin discoloration of 3 weeks' duration. Upon questioning, she revealed that she had been standing near a portable heater for extended periods. She was advised to avoid further exposure to the heat source. By the time of a follow-up clinic visit, the discoloration had resolved. Patients with hyperpigmented patches should be questioned about heat exposure. Erythema ab igne can progress to serious dermatologic conditions, but if the cause is eliminated, it usually resolves without medical intervention.

Abstract P3-13-04: Radioactive seed localization in non-palpable breast cancer compared to wire-guided localization and radio-guided occult lesion localization: Results of a comparative study

Introduction Almost 25% of women diagnosed with breast cancer have a non-palpable tumor. In breast-conserving therapy, it is important to have oncologic clear margins while excising minimal healthy tissue with good cosmetic outcome. The three most used techniques for non-palpable tumor localization pre-operative are radioactive seed localization (RSL), wire-guided localization (WGL), and radio-guided occult lesion localization (ROLL). Besides the advantage of tumor localization, each technique has its own disadvantages. When RSL is used, the major concern is safe handling of the seeds because of the used radioactive material. In case of WGL, the ideal skin incision and accurate positioning of the wire do not always match. The tip of the wire is non-palpable during surgery, which increases the risk of positive margins and increases the risk of enlarging resection volume resulting in poor cosmetic outcome. Moreover, the wire can get displaced or can be transsected during surgery. Disadvantages of ROLL include diffuse spread of the radioactive tracer in the breast tissue, which can result in higher excision volumes and problems with the concurrent sentinel node procedure. Thus far, no study has been performed comparing these three techniques. Therefore, this study analyzed the outcomes of RSL, WGL, and ROLL in non-palpable breast cancer in a single institution.

Methods Women diagnosed with ductal carcinoma in situ or non-palpable invasive breast carcinoma (stadium I or II) and were operated from January 2011 to December 2013 were retrospectively included in this study (N=278). In all included women in this study, RSL (n=71), WGL (n=78) or ROLL (n=132) was performed for intra-operative tumour localization. Outcome measures were weight of the resected specimen, oncological margins, re-excision and recurrence of disease.

Results In total 278 lumpectomies were performed in 272 patients. Mean resection volumes were not significant higher in RSL (mean 97.8 cm3), compared to WGL (mean 80.9 cm3) and ROLL (mean 84.8cm3). RSL was associated with significant less tumor-positive margins (n=55, 96.5%) compared to the WGL (n=55, 73.3%) and ROLL (n=111, 84.1%). Also, RSL was associated with significant lower re-excision rates (n=1, 1.4%) as compared to WGL (n=12, 15.4%) and ROLL (n=14, 10.6%). In only one patient with ROLL, recurrence of disease was seen. The median follow-up of all patients was 27 months (9 – 44).

Conclusion This study revealed that RSL is an effective technique for excision of non-palpable breast cancer and is associated with fewer tumor-positive margins and therefore lower re-excision rates.

Citation Format: Theunissen CIJM, Noorda EM, Rust EAZ, Bandel C, Ooster- van den Berg JGv, Edens MA, Jager PL, Francken AB. Radioactive seed localization in non-palpable breast cancer compared to wire-guided localization and radio-guided occult lesion localization: Results of a comparative study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-04.

Inhibition of Mitogen-activated Protein Kinase (MAPK)-interacting Kinase (MNK) Preferentially Affects Translation of mRNAs Containing Both a 5'-Terminal Cap and Hairpin

The MAPK-interacting kinases 1 and 2 (MNK1 and MNK2) are activated by extracellular signal-regulated kinases 1 and 2 (ERK1/2) or p38 in response to cellular stress and extracellular stimuli that include growth factors, cytokines, and hormones. Modulation of MNK activity affects translation of mRNAs involved in the cell cycle, cancer progression, and cell survival. However, the mechanism by which MNK selectively affects translation of these mRNAs is not understood. MNK binds eukaryotic translation initiation factor 4G (eIF4G) and phosphorylates the cap-binding protein eIF4E. Using a cell-free translation system from rabbit reticulocytes programmed with mRNAs containing different 5'-ends, we show that an MNK inhibitor, CGP57380, affects translation of only those mRNAs that contain both a cap and a hairpin in the 5'-UTR. Similarly, a C-terminal fragment of human eIF4G-1, eIF4G(1357-1600), which prevents binding of MNK to intact eIF4G, reduces eIF4E phosphorylation and inhibits translation of only capped and hairpin-containing mRNAs. Analysis of proteins bound to m(7)GTP-Sepharose reveals that both CGP and eIF4G(1357-1600) decrease binding of eIF4E to eIF4G. These data suggest that MNK stimulates translation only of mRNAs containing both a cap and 5'-terminal RNA duplex via eIF4E phosphorylation, thereby enhancing the coupled cap-binding and RNA-unwinding activities of eIF4F.

Non-alcoholic fatty liver disease is associated with cardiovascular disease risk markers

Recognition of the link between non-alcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD) has boosted research in this area. The main objective of this paper is to review the literature on NAFLD in the context of CVD, focussing on underlying mechanisms and treatment. Besides excessive fatty acid influx, etiologic factors may include components of the metabolic syndrome, cytokines and mitochondrial dysfunction. NAFLD is associated with both hepatic and systemic insulin resistance. In the case of NAFLD, the liver overproduces several atherogenic factors, notably inflammatory cytokines, glucose, lipoproteins and coagulation factors, and factors increasing blood pressure. Intervention studies on diet and laparoscopic surgery revealed improvements of hepatic fat content and CVD risk profile. Pharmacological approaches with potential benefit have been developed as well, but effects are often confounded by weight change. NAFLD is associated with an increased CVD risk profile (and hepatic risk). In order to improve CVD risk profile, prevention and treatment of NAFLD seem advisable. However, well-designed intervention studies, randomized clinical trials and long-term follow-up studies are scarce.

Successful treatment of respiratory dysfunction in cystinosis by nocturnal non-invasive positive pressure ventilation

Cystinosis is a rare metabolic disorder characterized by lysosomal cystine accumulation leading to multi-organ damage, with kidneys being clinically first affected. Longer survival of cystinosis patients due to successful renal replacement therapy, revealed previously unknown extra-renal symptoms of cystinosis, generally appearing after the first decade. Respiratory insufficiency caused by overall respiratory muscle myopathy is a severely invalidating and sometimes a life-threatening complication of cystinosis. We report a successful treatment of hypoventilation, due to diaphragm myopathy in a cystinosis patient, by nocturnal non-invasive positive pressure ventilation (NIPPV). After initiation of NIPPV the clinical condition of the patient improved and blood-gasses normalized, indicating that this treatment modality should be considered in cystinosis patients with severe respiratory insufficiency.