Eosinophilic esophagitis: search for non-invasive techniques for long-term monitoring

Comment on: Unsedated transnasal esophagoscopy for monitoring therapy in pediatric eosinophilic esophagitis. [Gastrointest Endosc. 2016

Inflammation and Atherosclerosis—Revisited:

Atherogenesis has been traditionally viewed as a metabolic disease representing arterial obstruction by fatty deposits in its wall. Today, it is believed that atherogenesis involves highly specific biochemical and molecular responses with constant interactions between various cellular players. Despite the presence of inflammatory reaction in each and every step of atherosclerosis from its inception to terminal manifestation, the cause–effect relationship of these 2 processes remains unclear. In this article, we have attempted to review the role of inflammation in the development of atherosclerosis and in its major complication—coronary heart disease

Can granulomatosis with polyangiitis be diagnosed earlier in primary care? A case-control study

Background: People with granulomatosis with polyangiitis (GPA) commonly describe long delays before diagnosis. Aim: To study the natural history of GPA prior to diagnosis using primary care data, and determine whether clinical features could be identified to help earlier diagnosis.DesignCase-control study using the Clinical Practice Research Datalink. Methods: We compared primary care activity and clinical features between cases and 10 matched controls. Results: We identified 757 cases and matched 7,546 controls. Compared to controls, cases had more GP consultations and overall healthcare activity in the five years prior to their diagnosis, with a marked increase in the year before diagnosis, and particularly in the last 3 months. However, consultations were mostly for symptoms that were not specifically related to GPA. In the year prior to diagnosis, the most frequent and strongly predictive clinical features of GPA were Ear Nose and Throat (ENT) symptoms (34.5% of cases, odds ratio (OR) 10.5, 95% confidence intervals (CI) 8.6-12.7), and general (constitutional) symptoms (21.5% of cases, OR 9.0, 95% CI 7.1-11.3). In the year before diagnosis a larger number of cases attended secondary care (382, 50.5%) than had records of clinical features of GPA. Conclusions: After discussing our findings, we conclude it would be difficult to identify cases of GPA earlier in primary care. Our results support a need for heightened awareness of this condition among secondary care clinicians, especially those assessing emergency admissions, and in the clinics which were most frequently attended by cases 3-12 months prior to diagnosis

Novel insights into the aetiology of granulomatosis with polyangiitis—a case–control study using the Clinical Practice Research Datalink

Objectives We aimed to provide insights into the aetiology of granulomatosis with polyangiitis (GPA), by conducting a large case–control study using a general population-based, prospectively collected database of healthcare records. Methods We compared all incident cases of GPA in the Clinical Practice Research Datalink 1990–2014, with up to 10 age-, sex- and general practice-matched controls. We identified potential risk factors, recorded numbers of cases and controls exposed to each, and calculated odds ratios (ORs) using conditional logistic regression. Our main analysis excluded data recorded during 1 year before diagnosis, to prevent early symptoms being mistaken for risk factors. Results We identified 757 people with GPA and matched 7546 controls. People with GPA were five times more likely to have a previous diagnosis of bronchiectasis (OR = 5.1, 95% CI: 2.7, 9.4; P 5 years prior to diagnosis. People with GPA were two to three times more likely than controls to have previous diagnoses of autoimmune diseases or chronic renal impairment, and these effects also remained stable >5 years prior to diagnosis. People with GPA were more likely to have a diagnosis of pulmonary fibrosis (OR = 5.7, 95% CI: 1.7, 19.5; P = 0.01) and sinus infections (OR = 2.7, 95% CI: 1.8, 4.2; P < 0.0001) recorded in the 3 years before diagnosis, but not before this. We also found former smoking, some medications and higher socio-economic status significantly, but less strongly, associated. Conclusion We found novel long-term associations between GPA and pre-existing bronchiectasis and autoimmune diseases

Advanced Performance Analysis

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Development and Validation of a Digital (Peek) Near Visual Acuity Test for Clinical Practice, Community-Based Survey, and Research

PURPOSE: Unaddressed near vision impairment (NVI) affects more than 500 million people. Testing near vision is necessary to identify those in need of services. To make such testing readily accessible, we have developed and validated a new smartphone-based near visual acuity (NVA) test: Peek Near Vision (PeekNV). METHODS: Two forms of the PeekNV test were developed: (1) quantitative measurement of NVA, and (2) binary screening test for presence or absence of NVI. The validity study was carried out with 483 participants in Sagarmatha Choudhary Eye Hospital, Lahan, Nepal, using a conventional Tumbling "E" Near Point Vision Chart as the reference standard. Bland-Altman limits of agreement (LoA) were used to evaluate test agreement and test-retest repeatability. NVI screening was assessed using Cohen's kappa coefficient, sensitivity, and specificity. RESULTS: The mean difference between PeekNV and chart NVA results was 0.008 logMAR units (95% confidence interval [CI], -0.005 to 0.021) in right eye data, and the 95% LoA between PeekNV and chart testing were within 0.235 and -0.218 logMAR. As a NVI screening tool, the overall agreement between tests was 92.9% (κ = 0.85). The positive predictive value of PeekNV was 93.2% (95% CI, 89.6% to 96.9%), and the negative predictive value 92.7% (95% CI, 88.9% to 96.4%). PeekNV had a faster NVI screening time (11.6 seconds; 95% CI, 10.5 to 12.6) than the chart (14.9 seconds; 95% CI, 13.5 to 16.2; P < 0.001). CONCLUSIONS: The PeekNV smartphone-based test produces rapid NVA test results, comparable to those of an accepted NV test. TRANSLATIONAL RELEVANCE: PeekNV is a validated, reliable option for NV testing for use with smartphones or digital devices

Suture repair of simple transverse olecranon fractures and chevron olecranon osteotomy

Tension band wiring of simple transverse olecranon fractures results in a high reoperation rate due to hardware problems. A technique using high-strength braided polyester and polyethylene suture through a bone tunnel has been piloted. This technique is suitable for simple transverse olecranon fractures or olecranon osteotomy with stability of the ulnohumeral articulation. A transverse drill hole was made in the ulna with a 2.5-mm drill. Fracture fixation was achieved using 2 braided synthetic sutures passed through the bone tunnel and grasping the insertion of the triceps tendon. The outcome measures used were Oxford Elbow score and QuickDASH score. Ten consecutive patients with a mean age of 47 years (range, 18 to 88 y) were included. The mean follow-up was 19 months (range, 14 to 30 mo). All fractures were clinically and radiographically united by 6 weeks. One malunion occurred. The mean Oxford score was 41 (20 to 48). The mean QuickDASH Score was 9 (0 to 20). This technique provides a safe and reliable alternative to conventional tension band wiring with no reoperations required in a pilot series.</p

Comprehensive validation of halcyon 2.0 plans and the implementation of patient specific QA with multiple detector platforms

PURPOSE: To perform a comprehensive validation of plans generated on a preconfigured Halcyon 2.0 with preloaded beam model, including evaluations of new features and implementing the patient specific quality assurance (PSQA) process with multiple detectors. METHODS: A total of 56 plans were generated in Eclipse V15.6 (Varian Medical System) with a preconfigured Halcyon treatment machine. Ten plans were developed via the AAPM TG-119 test suite with both IMRT and VMAT techniques. 34 clinically treated plans using C-arm LINAC from 24 patients were replanned on Halcyon using IMRT or VMAT techniques for a variety of sites including: brain, head and neck, lung, breast, abdomen, and pelvis. Six of those plans were breast VMAT plans utilizing the extended treatment field technique available with Halcyon 2.0. The dynamically flattened beam (DFB), another new feature on Halcyon 2.0, was also used for an AP/PA spine and four field box pelvis, as well as ten 3D breast plans. All 56 plans were measured with an ion chamber (IC), film, portal dosimetry (PD), ArcCHECK, and Delta4. Tolerance and action limits were calculated and compared to the recommendations of TG-218. RESULTS: TG-119 IC and film confidence limits met those set by the task group, except for IMRT target point dose. Forty-four of 46 clinical plans were within 3% for IC measurements. Average gamma passing rates with 3% dose difference and 2mm distance-to-agreement for IMRT/VMAT plans were: Film - 96.8%, PD - 99.9%, ArcCHECK - 99.1%, and Delta4 - 99.2%. Calculated action limits were: Film - 86.3%, PD - 98.4%, ArcCHECK - 96.1%, and Delta4 - 95.7%. Extended treatment field technique was fully validated and 3D plans with DFB had similar results to IMRT/VMAT plans. CONCLUSION: Halcyon plan deliveries were verified with multiple measurement devices. New features of Halcyon 2.0 were also validated. Traditional PSQA techniques and process specific tolerance and action limits were successfully implemented

Younger age is a risk factor for regrowth and recurrence of nonfunctioning pituitary macroadenomas: results from a single Australian centre

Objective: The natural history of nonfunctioning pituitary macroadenomas (NFPMA) after surgical resection is variable, with guidelines unable to define the duration of radiological follow-up. In this first Australian series, we identify risk factors for regrowth/recurrence of NFPMA to assist with guiding recommendations for long-term follow-up. Design: Retrospective analysis of all radiotherapy-naïve cases with NFPMA resected between 1995 and 2013. Patients: One hundred and twenty-three cases had both ≥2 postoperative scans and ≥12-month follow-up. Measurements: Regrowth was defined as any sustained increase in diameter of residual adenoma or recurrence as any new adenoma occurring post complete resection on serial pituitary MRI. Results: Median follow-up time was 48\ua0months (interquartile range [IQR]: 31-86). Overall regrowth/recurrence occurred in 29% (36/123). Regrowth occurred in 40% (30/76) at a median time of 44.5\ua0months (IQR 22-80) compared to recurrence of 12.5% (6/48; P=.003), occurring at a median time of 48\ua0months (IQR 12-96; P=.7). Further treatment was required in 66.7% and 56.7%, respectively (=1.0). Risk factors for regrowth/recurrence by multivariate analysis were presence of residual disease and younger age at presentation. The longest time for regrowth was 168\ua0months (14\ua0years) and recurrence 156\ua0months (13\ua0years). Conclusions: Presence of postoperative residual adenoma and younger age at presentation are the main predictors of regrowth/recurrence in NFPMA. Long-term serial imaging is required to detect regrowth and recurrence in younger patients and those with residual disease. Most regrowth/recurrences will occur within 10\ua0years of follow-up