Risk stratification system for evaluation of complex polyps can predict outcomes of endoscopic mucosal resection.

BACKGROUND: Apart from size, little is known about what makes a colonic polyp difficult to endoscopically remove. OBJECTIVE: The aim of this study was to evaluate polyp complexity by using a novel classification system and to assess how this affects success at endoscopic resection. DESIGN: This prospective cohort study was conducted at a tertiary referral center in the United Kingdom. INTERVENTIONS: Data were collected on patients referred for endoscopic resection of polyps >2 cm in size. Lesions were classified on the basis of size, morphology, site, and ease of access with the use of a novel scoring system (size/morphology/site/access). Endoscopic resection was performed to resect the lesions. Patients were followed up endoscopically to assess clinical outcomes. MAIN OUTCOME MEASURES: The primary outcomes measured were the endoscopic cure and complication rate by size/morphology/site/access grade and the cost savings of endoscopic resection over surgery. RESULTS: Endoscopic resection was performed on 220 patients (135 male) with 220 polyps, mean size of 43 mm (range, 20 mm-150 mm). Thirty-seven percent were classified as size/morphology/site/access 2 or 3; 63% were classified as the most challenging size/morphology/site/access level 4. Complete endoscopic clearance was achieved in 90% of cases with the first endoscopic resection attempt, improving to 96% with further endoscopic resection attempts. There were complications in 18 of 220 (8.1%) of cases. Complications were independent of lesion size and location but were affected by size/morphology/site/access grade (p = 0.018). Probability of clearance at first endoscopic resection attempt was affected by lesion complexity. Size/morphology/site/access 2 and 3 = 97.5 vs SMSA 4 = 87.5% (p = 0.009). Probability of cancer was not affected by size/morphology/site/access grade. For the whole cohort, endoscopic resection represented a cost saving of £726,288 ($1,123,858.05) over that of surgery. LIMITATIONS: The main limitation of this study is that it is a single-center, single-endoscopist series. CONCLUSIONS: The size/morphology/site/access scoring system is easy to use and provides valuable information on the lesion complexity and success and complication rates of endoscopic resection. This can be used for service planning, training endoscopists, and providing prognostic information for patients.

Mobile Cardiac Acoustic Monitoring System to Evaluate Left Ventricular Systolic Function in Pacemaker Patients.

The mobile cardiac acoustic monitoring system is a promising tool to enable detection and assist the diagnosis of left ventricular systolic dysfunction (LVSD). The objective of the study was to evaluate the diagnostic value of electromechanical activation time (EMAT), an important cardiac acoustic biomarker, in quantifying LVSD among left bundle branch pacing (LBBP) and right ventricular apical pacing (RVAP) patients using a mobile acoustic cardiography monitoring system. In this prospective single-center observational study, pacemaker-dependent patients were consecutively enrolled. EMAT, the time from the start of the pacing QRS wave to first heart sound (S1) peak; left ventricular systolic time (LVST), the time from S1 peak to S2 peak; and ECG were recorded simultaneously by the mobile cardiac acoustic monitoring system. LVEF was measured by echocardiography. A logistic regression model was applied to evaluate the association between EMAT and reduced EF (LVEF < 50%). A total of 105 pacemaker-dependent patients participated. The RVAP group (n = 58) displayed a significantly higher EMAT than the LBBP group (n = 47) (150.95 ± 19.46 vs. 108.23 ± 12.26 ms, p < 0.001). Pearson correlation analysis revealed a statistically significant negative correlation between EMAT and LVEF (p < 0.001). Survival analysis showed the sensitivity and specificity of detecting LVEF to be < 50% when EMAT ≥ 151 ms were 96.00% and 96.97% in the RVAP group. In LBBP patients, the sensitivity and specificity of using EMAT ≥ 110 ms as the cutoff value for the detection of LVEF < 50% were 75.00% and 100.00%. There was no significant difference in LVST with or without LVSD in the RVAP group (p = 0.823) and LBBP group (p = 0.086). Compared to LVST, EMAT was more helpful to identify LVSD in pacemaker-dependent patients. The cutoff point of EMAT for diagnosing LVEF < 50% differed regarding the pacing type. Therefore, the mobile cardiac acoustic monitoring system can be used to identify the progress of LVSD in pacemaker patients.

Colorectal endoscopic submucosal dissection for elderly patients at least 80 years of age.

BACKGROUND: Endoscopic submucosal dissection (ESD) has been used recently for successful en bloc resection of even large lesions, although no consensus appears in medical literature concerning its application to elderly patients. This prospective cohort study aimed to evaluate the efficacy and safety of colorectal ESD for patients 80 years of age or older. METHODS: Colorectal ESD procedure findings were compared with clinical outcomes, including associated complications and mortalities, for two age groups totaling 196 consecutive patients with 202 colorectal lesions. Of the 196 patients, 31 patients (16%) were 80 years of age or older (group E), and 165 patients (84%) were younger than 80 years (group Y). RESULTS: The median ages were 82 years in group E and 68 years in group Y. The frequency of chronic concomitant diseases was significantly higher in group E (65%) than in group Y (27%) (p = 0.003). No significant pressure decrease or need for oxygenation was observed in either group. In addition, groups E and Y did not differ significantly in terms of mean lesion sizes (40.9 vs. 39.7 mm) en bloc resection rates (84% vs. 93%), curative rates (78% vs. 84%), median procedure times (65 vs. 70 min), or associated complications (no perforation or delayed bleeding cases [0%] vs. 5 perforations [3%]) The median postprocedure hospitalization period was 3 days in both groups. Except for 10 cases requiring subsequent lymph node dissection surgery, follow-up colonoscopy examinations showed no recurrences or ESD-related mortalities in either group. CONCLUSION: Colorectal ESD is a safe and effective treatment for elderly patients (age ≥ 80 years) despite a significantly higher frequency of chronic concomitant diseases than among younger patients.

Acetic acid spray is an effective tool for the endoscopic detection of neoplasia in patients with Barrett's esophagus.

BACKGROUND & AIMS: Diagnosis of Barrett's neoplasia requires collection of large numbers of random biopsy samples; the process is time consuming and can miss early-stage cancers. We evaluated the role of acetic acid chromoendoscopy in identifying Barrett's neoplasia. METHODS: Data were collected from patients with Barrett's esophagus examined at a tertiary referral center, between July 2005 and November 2008 using Fujinon gastroscopes and EPX 4400 processor (n = 190). All procedures were performed by a single experienced endoscopist. Patients were examined with white light gastroscopy and visible abnormalities were identified. Acetic acid (2.5%) dye spray was used to identify potentially neoplastic areas and biopsy samples were collected from these, followed by quadrantic biopsies at 2 cm intervals of the remaining Barrett's mucosa. The chromoendoscopic diagnosis was compared with the ultimate histological diagnosis to evaluate the sensitivity of acetic acid chromoendoscopy. RESULTS: Acetic acid chromoendoscopy had a sensitivity of 95.5% and specificity of 80% for the detection of neoplasia. There was a correlation between lesions predicted to be neoplasias by acetic acid and those diagnosed by histological analysis (r = 0.98). There was a significant improvement in the detection of neoplasia using acetic acid compared with white light endoscopy (P = .001). CONCLUSIONS: Analysis of this large series showed that acetic acid-assisted evaluation of Barrett's esophagus detects neoplasia better than white light endoscopy, with sensitivity and specificity equal to that of histological analysis.

Peptide analysis of mammalian decomposition fluid in relation to the post-mortem interval.

We report the results of a semi-quantitative peptide analysis of decomposition fluid under field-based conditions in the absence of a soil matrix. Sixteen domestic pig (Sus scrofa domesticus) cadavers were used to model human decomposition in trials conducted in the summer and winter months in Western Australia. Physical characteristics were recorded and targeted peptide components of decomposition fluid were analysed using high performance liquid chromatography-triple quadrupole mass spectrometry. Principal component analysis identified 29 peptides, originating from haemoglobin subunits alpha and beta, creatine kinase, beta-enolase and lactate dehydrogenase, that contributed to differences in the mean peak areas of samples collected during the early period of decomposition (days 6-12 and day 2 in winter and summer, respectively) and during the later period (days 24-34 and days 8-10 in winter and summer, respectively). Fold changes for 8 peptides between these periods were significantly different. Three peptides derived from haemoglobin subunit beta, one from beta-enolase and two from lactate dehydrogenase displayed consistent trends, in that a notable increase in mean peak area was followed by a marked decrease in both the summer and winter samples. When temperature was accounted for, these trends occurred at different time points in summer and winter, indicating that factors other than temperature had impacted the rate of degradation of the proteins involved. The single peptides derived from haemoglobin subunit alpha and creatine kinase displayed consistent increases in mean peak area for the summer samples, suggesting that temperature played the most significant role in their degradation. Further analyses revealed that 7 peptides (one originating from haemoglobin subunit alpha, three from haemoglobin subunit beta and three from lactate dehydrogenase) displayed consistent trends that could be correlated with total body score and with the early stages of decomposition. The consistent trends (mean peak area versus time) for peptides derived from several proteins during decomposition trials conducted under different temperature regimes further emphasised the potential of peptide analysis in time since death estimation.

The impact of environmental factors on the production of peptides in mammalian decomposition fluid in relation to the estimation of post-mortem interval: A summer/winter comparison in Western Australia.

We report the peptide content of decomposition fluid produced under field-based conditions and in the absence of a soil matrix. Sixteen domestic pig (Sus scrofa domesticus) cadavers were used to model human decomposition in trials conducted in the summer and winter months in Western Australia. Physical characteristics were recorded and the peptide components of decomposition fluid were analysed using high performance liquid chromatography-time of flight mass spectrometry. A range of peptides was consistently detected in both summer and winter. Thirty seven peptides were common to both trials; 22 originating from haemoglobin subunit beta, 1 from haemoglobin subunit alpha, 4 from beta-enolase, and 2 from creatine kinase. In agreement with our previous findings, 13 peptides occurred consistently, regardless of trial conditions. Degradation patterns for haemoglobin subunits alpha and beta in summer and winter were similar when expressed in ADD and when adjusted for differences in temperature. The consistent identification of several protein-specific peptides generated during decomposition trials conducted under different temperature and rainfall regimes suggests that quantitative peptide analysis may be useful in estimating time since death.

Examination of the temporal variation of peptide content in decomposition fluid under controlled conditions using pigs as human substitutes.

We report the preliminary observations of the peptide content of decomposition fluid produced under controlled laboratory conditions and in the absence of a soil matrix. Four domestic pig (Sus scrofa domesticus) cadavers were used to model human decomposition over a four-week trial period; physical characteristics were recorded and the peptide components of decomposition fluid was analysed using high performance liquid chromatography-time of flight mass spectrometry. Preliminary data analysis indicated that a range of peptides were consistently detected across the course of the trial period and 27 of these were common to all four cadavers; 22 originating from haemoglobin. The peptides associated with haemoglobin subunit alpha and beta displayed a breakdown pattern that remained consistent for all cadavers for the duration of the trial. Though identification of peptides during decomposition has potential for estimating the time since death, quantification of selected peptides is likely to be essential to identify time-dependent trends.

Menthol Cough Drops: Cause for Concern?

BACKGROUND: Over-the-counter (OTC) cough remedies are lightly regulated and their potential side effects may go unrecognized. During 2015, over 282 million cough drops were sold in the United States. A Wisconsin community clinician (RM) made clinical observations suggesting that excessive use of OTC cough drops may exacerbate rather than benefit coughs. The goal of this project was to assess whether menthol in cough drops is related to worse cough symptoms. METHODS: From April 2016 through May 2017, 5 Wisconsin primary care clinics invited adolescent and adult outpatients seeking medical care for an acute or subacute cough to take a voluntary, anonymous, 10-question cough drop use survey that included age, sex, smoking status, cough severity, cough duration, and cough drop use (including type and amount). RESULTS: Of the 548 surveys collected and analyzed, 363 (66.2%) reported using cough drops. Cough drop use was significantly associated with longer duration of cough at presentation (P < .001) but not with overall cough severity (P = .09). Of cough drop users, 269 (90%) reported consuming drops with menthol. Univariate analysis found no statistically significant differences between the menthol and nonmenthol groups for either severity (P = .65) or duration (P = .17). However, significant independent associations were found between cough severity and 1) average menthol dose per cough drop (R = 0.19; P = .007), 2) number of cough drops consumed daily (R = 0.2; P = .002) and 3) total amount of menthol consumed per day (R = 0.21; P = .001) that remained significant (P = .003) after controlling for age, sex, smoking status, season, and clinic site. CONCLUSIONS: Cough severity in some individuals may be negatively influenced by the amount of menthol consumed via cough drops. Clinicians should include cough drop use in history taking of patients with persisting cough illnesses. Further research into potential mechanisms is warranted.

Valuing the adult health effects of air pollution in Chinese cities.

China's ongoing economic growth is accompanied by a large amount of air pollution that exacts significant health and economic costs on its people. Following up on some earlier work focusing upon general mortality and child-specific health effects, this article uses a larger data set, covering more than 90 Chinese cities, along with a set of China-based epidemiological functions, to estimate some of the adult health benefits of reducing urban air pollution. Projecting future air pollution based upon current conditions, it calculates the averted mortality and morbidity effects that would result from the cleanup of particulates, sulfur dioxide, and nitrogen dioxide. The inclusion of nitrogen dioxide in our analysis is particularly important because it is a growing problem and has not been included in most of the more widely known studies that examine Chinese air pollution. Finally, the economic valuation of these pollution-related health effects is developed, using a number of recent, China-based valuation studies.

A molecular dynamics study of the atomic structure of (CaO)x(SiO2)1-x glasses.

The local atomic environment of Ca in (CaO)x(SiO2)1-x glasses is of interest because of the role of Ca in soda-lime glass, the application of calcium silicate glasses as biomaterials, and the previous experimental measurement of the Ca-Ca correlation in CaSiO(3) glass. Molecular dynamics has been used to obtain models of (CaO)x(SiO2)1-x glasses with x = 0, 0.1, 0.2, 0.3, 0.4, and 0.5, and with approximately 1000 atoms and size approximately 25 A. As expected, the models contain a tetrahedral silica network, the connectivity of which decreases as x increases. In the glass-forming region, i.e., x = 0.4 and 0.5, Ca has a mixture of 6- and 7-fold coordination. Bridging oxygen makes an important contribution to the coordination of Ca, with most bridging oxygens coordinated to 2 Si plus 1 Ca. The x = 0.5 model is in reasonable agreement with previous experimental studies, and does not substantiate the previous theory of cation ordering, which predicted Ca arranged in sheets. In the phase-separated region, i.e., x = 0.1 and 0.2, there is marked clustering of Ca.

Blowing in the wind: the impact of China's Pearl River Delta on Hong Kong's air quality.

The local versus regional nature of Hong Kong's air pollution remains an unresolved issue with important policy implications. Specifically, the potential benefits of different air quality improvement efforts will vary dramatically, depending upon the nature of the pollution. This multi-disciplinary paper attempts to resolve the issue, using a time series, cross-sectional panel of pollution data from Hong Kong and southern China, along with weather variables from Hong Kong. An econometrically-based structural model of Hong Kong pollution levels is constructed, and Granger causality tests are conducted. Then, using results from the structural model, the health impacts on Hong Kong residents of reductions in mainland China's pollution are estimated and valued in economic terms. Results indicate that for the pollutants PM(10) and NO(2) causality runs in both directions, highlighting the regional nature of the air pollution problem. However, the potential health benefits resulting from reductions in southern China's pollution are relatively small. In US dollar terms, the averted mortality benefits of a large China-focused clean up are approximately $40 million, but the benefits of a more modest Hong Kong-focused effort are nearly $200 million. The resulting policy implication is that Hong Kong's primary pollution control efforts should lie at the local level.

Toward a strategy of patient-centered access to primary care.

Patient-centered access (PCA) to primary care services is rapidly becoming an imperative for efficiently delivering high-quality health care to patients. To enhance their PCA-related efforts, some medical practices and health systems have begun to use various tactics, including team-based care, satellite clinics, same-day and group appointments, greater use of physician assistants and nurse practitioners, and remote access to health services. However, few organizations are addressing the PCA imperative comprehensively by integrating these various tactics to develop an overall PCA management strategy. Successful integration means taking into account the changing competitive and reimbursement landscape in primary care, conducting an evidence-based assessment of the barriers and benefits of PCA implementation, and attending to the particular needs of the institution engaged in this important effort. This article provides a blueprint for creating a multifaceted but coordinated PCA strategy-one aimed squarely at making patient access a centerpiece of how health care is delivered. The case of a Wisconsin-based health system is used as an illustrative example of how other institutions might begin to conceive their fledgling PCA strategies without proposing it as a one-size-fits-all model.

Polymorphism in postinsulin receptor signaling pathway is not associated with polycystic ovary syndrome.

OBJECTIVE: To investigate polymorphisms in postinsulin receptor signaling. To investigate PIK3R1, SLC2A4, SLC2A4RG, and MEF2A to determine whether these genes are associated with susceptibility to polycystic ovary syndrome (PCOS) or key phenotypic features of insulin resistance in subjects with PCOS. DESIGN: Case-control study. SETTING: Participants with PCOS were recruited from a clinical practice database, and controls from the general community. PATIENT(S): One hundred seventy-three patients with PCOS conforming to the National Institutes of Health (NIH) diagnostic criteria, all of Caucasian descent; 107 normally ovulating women of white descent from the general community. INTERVENTION(S): Drawing of blood for DNA extraction. MAIN OUTCOME MEASURE(S): Frequency of PIK3R1, SLC2A4, SLC2A4RG, and MEF2A polymorphisms in case and control subjects. RESULT(S): No significant difference between the frequency of the polymorphisms in case and control women was identified. No single nucleotide polymorphism studied in any of these four genes was associated with the PCOS phenotype. CONCLUSION(S): Polymorphisms in the PIK3R1, SLC2A4, SLC2A4RG, and MEF2A genes are not associated with key PCOS phenotypes.

Polymorphism in HSD17B6 is associated with key features of polycystic ovary syndrome.

OBJECTIVE: To investigate polymorphisms in androgen metabolism regulators that are implicated in the etiology of polycystic ovary syndrome (PCOS) in vitro; to investigate HSD17B6 and GATA6 to determine whether these genes are associated with susceptibility to PCOS or key phenotypic features of patients with PCOS. DESIGN: Case-control association study. SETTING: Participants with PCOS were recruited from a clinical-practice database, and controls, from the general community. PATIENT(S): One hundred seventy-three patients with PCOS and who were of Caucasian descent and conformed to the National Institutes of Health (NIH) diagnostic criteria; 107 normally ovulating women of Caucasian descent from the general community. INTERVENTION(S): Drawing of blood for DNA extraction. MAIN OUTCOME MEASURE(S): Frequency of HSD17B6 and GATA6 polymorphisms in cases and controls. Association of single-nucleotide polymorphisms from HSD17B6 in subjects with PCOS with key phenotypes of PCOS: androgen status, insulin resistance, and body mass index. RESULT(S): Allele distribution for the single-nucleotide polymorphism rs898611 in HSD17B6 was significantly different between PCOS and control subjects (P=.03). Presence of the polymorphic allele was associated with reduced fasting glucose-insulin ratio (P=.02) and increased homeostasis model assessment (P<.01) and body mass index (P<.001) as well as with reduced T (P=.03) in the PCOS group. No association was seen between GATA6 and any of the variables studied. CONCLUSION(S): These data suggest that polymorphisms in the HSD17B6 gene are associated with PCOS and key clinical phenotypes of the disorder.

Scanning electron microscopy of epithelial surfaces of the sea anemone Acontiophorum niveum (Phylum Cnidaria): Class anthozoa.

Epithelium of the sea anemone Acontiophorum niveum is modified into four general arrangements of microappendages: (1) uniform microvilli covering pedal disc and column, (2) an interspersion of microvilli, ciliary cones, and kinocilia on tentacles, (3) flagella among an understory of microvilli from the oral disc, actinopharynx, filaments, and acontia, and (4) sparse flagella among irregular microvilli from endoderm. These arrangements are similar to those described previously in the epithelia of other anthozoans.