Quantifying Radiation Doses in Common Endoscopic Retrograde Cholangiopancreatography Scenarios: An Evaluation of Radiation Safety Measures in a Real-World Environment.

Introduction Radiation safety training remains variable among gastroenterologists performing endoscopic retrograde cholangiopancreatography (ERCP). This study sought to ascribe dosimeter readings to various real-world ERCP scenarios to provide data supporting the 3 pillars of radiation safety: distance, time, and shielding. Methods An ERCP fluoroscopy unit was used to generate radiation scatter from 2 differently sized anthropomorphic phantoms. Radiation scatter was measured at various distances from the emitter, with and without a lead apron, and at various frame rates (measured in frames per second, fps) and degrees of fluoroscopy pedal actuation. An image quality phantom was used to assess resolution at various frame rates and air gaps. Results Increasing the distance resulted in a decrease in measured scatter (from 0.75 mR/h at 1.5 ft to 0.15 mR/h at 9 ft with the average phantom and from 50 mR/h at 1.5 ft to 3.06 mR/h at 9 ft with the large phantom). Depressing the fluoroscopy pedal less frequently, or decreasing the frame rate (ie, increasing the time per frame), resulted in a linear decrease in scatter (from 55 mR/h at 8 fps to 24.5 mR/h at 4 fps and 13.60 mR/h at 2 fps). Providing shielding through the presence of a 0.5-mm lead apron reduced scatter (from 4.10 to 0.11 mR/h with the average phantom; from 15.30 mR/h to 0.43 mR/h with the large phantom). However, decreasing the frame rate from 8 fps to 2 fps did not change the number of line pairs identified on the image phantom. A greater air gap increased the number of line pairs resolved. Conclusions Implementing the 3 pillars of radiation safety led to a quantifiable, clinically significant decrease in radiation scatter. The authors hope that these findings spark greater implementation of radiation safety measures among practitioners utilizing fluoroscopy.

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients.

BACKGROUND: Hepatic cirrhosis is associated with greater adverse event rates following surgical procedures and is thought to have a higher risk of complications with interventional procedures in general. However, these same patients often require interventional gastrointestinal procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). While studies examining this scenario exist, the overall body of evidence for adverse event rates associated with ERCP/EUS procedures is more limited. We sought add to the literature by examining the incidence of adverse events after ERCP/EUS procedures in our safety-net hospital population with the hypothesis that severity of cirrhosis correlates with higher adverse event rates. AIM: To examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures. METHODS: We performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies from January 1, 2016 to March 14, 2019 at our safety net hospital. We recorded Child-Pugh and Model for End-stage Liver Disease (MELD-Na) scores at time of procedure, interventions completed, and 30-day post-procedural adverse events. Statistical analyses were done to assess whether Child-Pugh class and MELD-Na score were associated with greater adverse event rates and whether advanced techniques (single-operator cholangioscopy, electrohydraulic lithotripsy/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates. RESULTS: 77 procedures performed on 36 patients were included. The study population consisted primarily of middle-aged Hispanic males. 30-d procedure-related adverse events included gastrointestinal bleeding (7.8%), infection (6.5%), and bile leak (2%). The effect of Child-Pugh class C vs class A and B significantly predicted adverse events (ß = 0.55, P < 0.01). MELD-Na scores also significantly predicted adverse events (ß = 0.037, P < 0.01). Presence of advanced techniques was not associated with higher adverse events (P > 0.05). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, logistic regression showed MELD-Na scores were a significant predictor of adverse events (P < 0.01). The findings held after controlling for age, gender, ethnicity and repeat cases. CONCLUSION: Increasing cirrhosis severity predicted adverse events while the presence of advanced techniques did not. MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.

A pragmatic evidence-based clinical management algorithm for burning mouth syndrome.

BACKGROUND: Burning mouth syndrome is a poorly understood disease process with no current standard of treatment. The goal of this article is to provide an evidence-based, practical, clinical algorithm as a guideline for the treatment of burning mouth syndrome. MATERIAL AND METHODS: Using available evidence and clinical experience, a multi-step management algorithm was developed. A retrospective cohort study was then performed, following STROBE statement guidelines, comparing outcomes of patients who were managed using the algorithm and those who were managed without. RESULTS: Forty-seven patients were included in the study, with 21 (45%) managed using the algorithm and 26 (55%) managed without. The mean age overall was 60.4 ±16.5 years, and most patients (39, 83%) were female. Cohorts showed no statistical difference in age, sex, overall follow-up time, dysgeusia, geographic tongue, or psychiatric disorder; xerostomia, however, was significantly different, skewed toward the algorithm group. Significantly more non-algorithm patients did not continue care (69% vs. 29%, p=0.001). The odds ratio of not continuing care for the non-algorithm group compared to the algorithm group was 5.6 [1.6, 19.8]. Improvement in pain was significantly more likely in the algorithm group (p=0.001), with an odds ratio of 27.5 [3.1, 242.0]. CONCLUSIONS: We present a basic clinical management algorithm for burning mouth syndrome which may increase the likelihood of pain improvement and patient follow-up. Key words:Burning mouth syndrome, burning tongue, glossodynia, oral pain, oral burning, therapy, treatment.

Sialodochoplasty Stents: Cost Analysis and Outcomes.

PURPOSE: We reviewed a patient cohort receiving sialodochoplasty with or without salivary stent placement. We propose the Firlit-Kluge pediatric urinary catheter (Cook Medical, Bloomington, IN) as an advantageous alternative stent because of our duct patency results with stenting, considering the advantages and disadvantages of specific stents. We also provide a simple cost summary of commonly used stents. MATERIALS AND METHODS: A retrospective review of a case series of patients undergoing sialodochoplasty or salivary duct surgery from 2012 to 2015 was undertaken at a tertiary care center. The indications, duct reconstruction results, and complications were analyzed, and a comparative cost analysis was performed. RESULTS: Of 25 patients, 16 were stented with Firlit-Kluge catheters, 2 with CORFLO ULTRA feeding tubes (Corpak Medsystems, Buffalo, NY), 1 with an Introcan Safety intravenous (IV) catheter (B. Braun Medical Inc, Melsungen, Germany), and 6 were not stented. All 16 Firlit-Kluge-stented patients had successful duct reconstruction with a patent duct orifice draining saliva on the last follow-up visit, and only 1 stent dislodged early. All patients stented with feeding tubes or the IV catheter experienced discomfort or early dislodgement of the stent. Comparing the Firlit-Kluge stent to commercially available salivary stents, the cost savings in the Firlit-Kluge stent group was $2,480.16 compared with the cost of the Walvekar and Schaitkin stents (Hood Laboratories, Pembroke, MA) and $880.15 to $1,120.00 compared with Ad-Tech-Med stents (Lublin, Poland). However, the cost of the Firlit-Kluge stent exceeded the costs of the Braun IV catheter, Bard infant urinary catheter (Bard Medical Division, CR Bard, Louisville, CO), and CORFLO ULTRA stent by $60.48, $24.64, and $258.72, respectively. CONCLUSIONS: The Firlit-Kluge urinary catheter incurs considerable cost savings compared with commercial stents, and its silicone makeup and ball flange enhances comfort and prevents dislodgment by aiding in suture placement.

Thyroglossal Duct Papillary Thyroid Carcinoma and Synchronous Lingual Thyroid Atypia.

Thyroglossal duct and lingual thyroid ectopic lesions are exceedingly rare synchronous findings. Papillary thyroid carcinoma of these ectopic thyroid sites is well understood but still a rare finding. This case points to some management nuances in regard to ectopic thyroid screening with imaging and also shows the effectiveness of minimally invasive transoral robotic surgery for lingual thyroid.

Multiple functional therapeutic effects of the estrogen receptor ß agonist indazole-Cl in a mouse model of multiple sclerosis.

Currently available immunomodulatory therapies do not stop the pathogenesis underlying multiple sclerosis (MS) and are only partially effective in preventing the onset of permanent disability in patients with MS. Identifying a drug that stimulates endogenous remyelination and/or minimizes axonal degeneration would reduce the rate and degree of disease progression. Here, the effects of the highly selective estrogen receptor (ER) ß agonist indazole chloride (Ind-Cl) on functional remyelination in chronic experimental autoimmune encephalomyelitis (EAE) mice were investigated by assessing pathologic, functional, and behavioral consequences of both prophylactic and therapeutic (peak EAE) treatment with Ind-Cl. Peripheral cytokines from autoantigen-stimulated splenocytes were measured, and central nervous system infiltration by immune cells, axon health, and myelination were assessed by immunohistochemistry and electron microscopy. Therapeutic Ind-Cl improved clinical disease and rotorod performance and also decreased peripheral Th1 cytokines and reactive astrocytes, activated microglia, and T cells in brains of EAE mice. Increased callosal myelination and mature oligodendrocytes correlated with improved callosal conduction and refractoriness. Therapeutic Ind-Cl-induced remyelination was independent of its effects on the immune system, as Ind-Cl increased remyelination within the cuprizone diet-induced demyelinating model. We conclude that Ind-Cl is a refined pharmacologic agent capable of stimulating functionally relevant endogenous myelination, with important implications for progressive MS treatment.

Therapeutic laquinimod treatment decreases inflammation, initiates axon remyelination, and improves motor deficit in a mouse model of multiple sclerosis.

BACKGROUND: Therapeutic strategies that induce effective neuroprotection and enhance intrinsic repair mechanisms are central goals for future treatment of multiple sclerosis (MS), as well as other diseases. Laquinimod (LQ) is an orally administered, central nervous system (CNS)-active immunomodulator with demonstrated efficacy in MS clinical trials and a favorable safety and tolerability profile. AIMS: We aimed to explore the pathological, functional, and behavioral consequences of prophylactic and therapeutic (after presentation of peak clinical disease) LQ treatment in the chronic experimental autoimmune encephalomyelitis (EAE) mouse model of MS. MATERIALS AND METHODS: Active EAE-induced 8-week-old C57BL/6 mice were treated with 5 or 25 mg/kg/day LQ via oral gavage beginning on EAE post-immunization day 0, 8, or 21. Clinical scores and rotorod motor performance were assessed throughout the disease course. Immune analysis of autoantigen-stimulated splenocytes, electrophysiological conduction of callosal axons, and immunohistochemistry of white matter-rich corpus callosum and spinal cord were performed. RESULTS: Prophylactic and therapeutic treatment with LQ significantly decreased mean clinical disease scores, inhibited Th1 cytokine production, and decreased the CNS inflammatory response. LQ-induced improvement in axon myelination and integrity during EAE was functional, as evidenced by significant recovery of callosal axon conduction and axon refractoriness and pronounced improvement in rotorod motor performance. These improvements correlate with LQ-induced attenuation of EAE-induced demyelination and axon damage, and improved myelinated axon numbers. DISCUSSION: Even when initiated at peak disease, LQ treatment has beneficial effects within the chronic EAE mouse model. In addition to its immunomodulatory effects, the positive effects of LQ treatment on oligodendrocyte numbers and myelin density are indicative of significant, functional neuroprotective and neurorestorative effects. CONCLUSIONS: Our results support a potential neuroprotective, in addition to immunomodulatory, effect of LQ treatment in inhibiting ongoing MS/EAE disease progression.

Estrogen receptor (ER) ß expression in oligodendrocytes is required for attenuation of clinical disease by an ERß ligand.

Treatment of experimental autoimmune encephalomyelitis (EAE) mice with the estrogen receptor (ER) ß ligand diarylpropionitrile (DPN) has been shown to have neuroprotective effects via stimulation of endogenous myelination. The direct cellular mechanisms underlying the effects of this ERß ligand on the central nervous system are uncertain because different cell types in both the peripheral immune system and central nervous system express ERs. ERß is the target molecule of DPN because DPN treatment fails to decrease EAE clinical symptoms in global ERß-null mice. Here we investigated the potential role of ERß expression in cells of oligodendrocyte (OL) lineage in ERß ligand-mediated neuroprotection. To this end, we selectively deleted ERß in OLs using the well-characterized Cre-loxP system for conditional gene knockout (CKO) in mice. The effects of this ERß CKO on ERß ligand-mediated neuroprotective effects in chronic EAE mice were investigated. ERß CKO in OLs prevented DPN-induced decrease in EAE clinical disease. DPN treatment during EAE did not attenuate demyelination, only partially improved axon conduction, and did not activate the phosphatidylinositol 3-kinase/serine-threonine-specific protein kinase/mammalian target of rapamycin signaling pathway in ERß CKO mice. However, DPN treatment significantly increased brain-derived neurotrophic factor levels in ERß CKO mice. These findings demonstrate that signaling through ERß in OLs is essential for the beneficial myelination effects of the ERß ligand DPN in chronic EAE mice. Further, these findings have important implications for neuroprotective therapies that directly target OL survival and myelination.