Gastric IgG4-related disease mimicking a gastrointestinal stromal tumor in a child: A case report.

BACKGROUND: Gastric IgG4-related disease (IgG4-RD) is rarely encountered in clinical practice, and especially more so among pediatric patients. To our knowledge, this is the first report of IgG4-RD presenting as a calcifying gastric mass in a child. We describe how this entity was difficult to differentiate from a gastrointestinal stromal tumor (GIST) imaging-based approaches. Therefore, this case highlights the importance of considering IgG4-RD in the differential diagnosis of gastric tumor before performing surgical resection, especially to distinguish it from malignancy to avoid unnecessary surgery. CASE SUMMARY: The patient suffered from epigastric pain for several days. Panendoscopy and computed tomography scan revealed a submucosal tumor. Differential diagnoses included GIST, leiomyoma, teratoma, and mucinous adenocarcinoma. However, laparoscopic proximal gastrectomy allowed for the definitive diagnosis of IgG4-related stomach disease. CONCLUSION: We emphasize the importance of considering IgG4-RD in the differential diagnosis of gastric submucosal tumors before performing surgical resection.

Post-surgical discharge opioid prescribing, use and handling after introduction of a stewardship program.

SummaryOpioids are often used to provide postsurgical analgesia but may cause harm if used inappropriately. We introduced an opioid stewardship program in three Melbourne hospitals to reduce the inappropriate use of opioids after patient discharge. The program had four pillars: prescriber education, patient education, a standardised quantity of discharge opioids, and general practitioner (GP) communication. Following introduction of the program, we undertook this prospective cohort study. The study aimed to describe post-program discharge opioid prescribing, patient opioid use and handling, and the impact of patient demographics, pain and surgical treatment factors on discharge prescribing. We also evaluated compliance with the program components. We recruited 884 surgical patients from the three hospitals during the ten-week study period. Discharge opioids were dispensed to 604 (74%) patients, with 20% receiving slow-release opioids. Junior medical staff undertook 95% of discharge opioid prescribing, which was guideline-compliant for 78% of patients. Of the patients discharged with opioids, a GP letter was sent for only 17%. Follow-up at two weeks was successful in 423 (70%) patients and in 404 (67%) at three months. At the three-month follow-up, 9.7% of patients reported ongoing opioid use; in preoperatively opioid naïve patients, the incidence was 5.5%. At the two-week follow-up, only 5% reported disposal of excess opioids, increasing to 26% at three months. Ongoing opioid therapy at three months in our study cohort (9.7%; 39/404) was associated with preoperative opioid consumption and higher pain scores at the three-month follow-up. The introduction of the opioid stewardship program resulted in highly guideline-compliant prescribing, but hospital-to-GP communication was uncommon and opioid disposal rates were low. Our findings suggest that opioid stewardship programs can improve postoperative opioid prescribing, use and handling, but the realisation of these gains will require effective program implementation.

Self-Nanoemulsifying Drug Delivery System-Containing the Poorly Absorbed Drug - Valsartan in Post-Bariatric Surgery.

Purpose: Morbid obesity and its related metabolic syndrome are an important health issue. Recently, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) have accounted for the most popular bariatric surgeries. Valsartan (VST) is a common hypertension drug, and nano-carriers can increase its solubility and bioavailability. This study aims to explore the nano-VST formula in bariatric surgery subjects. Methods: High-fat fed animals were used as obese models. Operations were performed according to a standardized protocol. The drug was administrated by gavage, and blood samples were taken by serial tail vein sampling. Caco-2 cells were used for examining cell viability and drug uptake. A self-nano-emusifying drug delivery system (SNEDDS) formula was composed of sefsol-218, RH-40 and propylene glycol by a specified ratio, while high-performance liquid chromatography (HPLC) was used for determining drug concentrations. Results: Post-operatively, subjects that underwent RYGB lost more body weight compared to the SG group. The SNEDDS did not exhibit cytotoxicity after adequate dilution, and the cytotoxicity was not related to VST dose. A better cellular uptake of SNEDDS was observed in vitro. The SNEDDS formula achieved a diameter of 84 nm in distilled water and 140 nm in simulated gastric fluid. In obese animals, the maximum serum concentration (Cmax) of VST was increased 1.68-folds by SNEDDS. In RYGB with SUS, the Cmax was reduced to less than 50% of the obese group. SNEDDS increased the Cmax to 3.5 folds higher than SUS and resulted in 3.28-folds higher AUC0-24 in the RYGB group. Fluorescence imaging also confirmed a stronger signal of SNEDDS in the gastrointestinal mucosa. SNEDDS accumulated a higher drug concentration than suspension alone in the liver of the obese group. Conclusion: SNEDDS could reverse the VST malabsorption in RYGB. Further studies are mandatory to clarify post-SG change of drug absorption.

Estructura dimensional de la escala ces-d-10 en estudiantes rurales / Dimensional structure of the ces-d-10 scale in rural students

El desempeño psicométrico de los instrumentos de medición en salud suele variar de una población a otra1. A este principio se suma el de la necesidad constante de revisar el conjunto de ítems que miden constructos conceptualmente cambiantes2, como el de episodio depresivo. La intención de este trabajo es mostrar hallazgos de desempeño de la Escala para Depresión del Centro para Estudios Epidemiológicos en Depresión, versión de 10 ítems (CES-D-10)3, en una muestra rural, habitualmente omitida en la mayoría de la investigaciones4,5.

Hallazgos psicométricos de la escala para ideación suicida del centro de estudios epidemiológicos en adolescentes escolarizados de samacá, boyacá, colombia / Psychometric findings of the suicidal ideation scale of the center of epidemiological studies in school enrolled adolescents in samacá, boyacá, colombia

RESUMEN El Centro de Estudios Epidemiológicos (CES) de los Estados Unidos introdujo con la escala para depresión (CES-D) y otra escala para cuantificar en forma rápida ideación suicida (CES-IS) durante las dos semanas más recientes; sin embargo, se conoce poco del rendimiento psicométrico de este instrumento. El objetivo fue verificar el desempeño psicométrico de la CES-IS en adolescentes escolarizados de un municipio de Boyacá, Colombia. Se realizó un estudio de validación con la participación de 363 estudiantes de un municipio de características rurales en edades entre 10 y 17 años (media=13; DE=1,8); 55,4% de los estudiantes de sexo femenino y 44,5% de sexo masculino. Los adolescentes diligenciaron los cuatro ítems de la CES-IS, una versión de diez ítems de la (CES-D-10) y la escala de Rosenberg para autoestima (ERA). Se estimó la consistencia interna (alfa de Cronbach y omega de McDonald), la estructura dimensional (análisis factorial confirmatorio, AFC) y la convergencia con la CES-D-10 (correlación de Spearman, rs). Las puntuaciones en la CES-IS se observaron entre 4 y 20 (M=6,1; DE=3,5; Me=4, RIC=4-7) y en la CES-D entre 11 y 44 (M=23,3; DE=6,8; Me=22; RIC=18-27). La CESIS mostró alfa de Cronbach de 0,86 y omega de McDonald de 0,87, una dimensión que explicó el 71,2% de la varianza, los indicadores de ajuste RMSEA=0,00; IC90% 0,00-0,09; CFI=1,00; TLI=1,00; y SRMR=0,01, correlación convergente de rs=0,59 (p=0,001) con la CES-D-10 y correlación divergente de rs=-0,38(p=0,001) con la ERA. Se concluye que la CES-IS en adolescentes de un municipio de Boyacá presenta alta consistencia interna, una estructura unidimensional y alta convergencia con la CES-D-10 y divergencia con la ERA. Se necesita investigar el rendimiento de este instrumento en adolescentes colombianos con otras características distintivas.

ABSTRACT The Center for Epidemiological Studies (CES) of the United States introduced, along with the Depression Scale (CES-D) and another scale to rapidly quantify suicidal ideation (CED-IS) during the two most recent weeks. However, little is known about the psychometric performance of this instrument. The objective of this study was to verify the psychometric performance of the CES-IS in school enrolled adolescents from a small town in Boyacá, Colombia. A validation study was carried out with the participation of 363 students between 10 and 17 years of age (mean=13, SD=1.8); 55.4% female students and 44.5% male students. The adolescents completed the four items of the CES-IS, a ten-item version of the CES-D-10 and the Rosenberg Self-esteem Scale (RSS). Internal consistency (Cronbach alpha and McDonald omega), dimensional structure (confirmatory factorial analysis, AFC) and convergence with CES-D-10 (Spearman correlation, rs) were estimated. The CES-IS scores were observed between 4 and 20 (M=6.1, SD=3.5, Me=4, IQR=4-7) and the CES-D between 11 and 44 (M=23.3, SD=6.8, Me=22, IQR=18-27). The CES-IS showed Cronbach alpha of 0.86 and McDonald's omega of 0.87, a dimension that explained 71.2% of the variance, the adjustment indicators RMSEA=0.00, 90%CI 0.00-0.09; CFI=1.00, TLI=1.00 and SRMR = 0.01, convergent correlation of rs=0.59 (p=0.001) with the CES-D-10 and divergent correlation of rs=-0.38 (p=0.001) with the RSS. It is concluded that the CES-IS among adolescents of a small town in Boyacá, Colombia, has high internal consistency, a onedimensional structure and high convergence with CES-D-10 and divergence with the RSS. It is necessary to investigate the performance of this instrument in Colombian adolescents with other distinctive characteristics.

Clinical presentations and molecular studies of invasive renal epithelioid angiomyolipoma.

PURPOSE: Epithelioid angiomyolipoma (EAML) is a rare variant of renal angiomyolipoma with malignant potential, and the cytogenetic and clinical behavior of EAML remains a challenging issue. METHODS: We retrospectively analyze the clinical courses of five EAML, the use of everolimus on metastatic EAML, and next-generation sequencing (NGS) and polymerase chain reaction (PCR) studies to investigate the gene mutation of TSC and the impact of PI3K/Akt/mTOR signaling pathway in metastatic EAML. RESULTS: The mean age was 37.8 years, mean tumor size was 13 cm, all patients received radical nephrectomy, one stage IV patient received neoadjuvant mTOR inhibitor management, and one patient with high mitotic activity developed metastasis 1 year after nephrectomy. NGS assay showed a frameshift gene mutation of TSC2 in chromosome 16. PCR array for the mRNA alterations in PI3K/Akt/mTOR signaling pathway of EAML showed high expression of PIP3, AKT, TSC1, mTOR, PDK1, P70, 4E-BP1 and elF4E. CONCLUSION: EAML of the kidney is a specific type of renal AML with malignant potentials, where around 22% of the patients present with invasion or metastasis. Higher mitotic activities indicate a greater metastatic potential, with radical nephrectomy as the treatment of choice, and mTOR inhibitors such as everolimus either as neoadjuvant or adjuvant targeted therapy can lead to a better clinical outcome. NGS to explore the mTOR signaling pathway may help us to better understand the pathogenesis and progression of EAML.

The psychological profile of women presenting to a multidisciplinary clinic for chronic pelvic pain: high levels of psychological dysfunction and implications for practice.

OBJECTIVE: Chronic pelvic pain (CPP) is widely acknowledged as a common problem with significant consequences for those diagnosed with this condition. There is a lack of studies with good sample size that provide a comprehensive psychological profile of women presenting to specialist chronic pain clinics. Therefore, the objective of this study was to describe the psychological profile of a representative sample of women presenting with CPP at a tertiary referral center. DESIGN: This was a cross-sectional study. Women were asked to complete a questionnaire assessing symptoms of anxiety and depression, pain severity and interference, pain self-efficacy and catastrophizing beliefs, and sexual functioning. METHODS: One-hundred and seventy-five women with CPP were recruited when they attended their initial assessment at a specialist CPP clinic of the Royal Women's Hospital, a public hospital in Melbourne, Australia. RESULTS: Over 75% of the participants had experienced pain for longer than 2 years. Fifty-three percent of women experienced either moderate or severe anxiety, and 26.7% experienced moderate-to-severe depression. There were strong correlations between depressive symptoms and pain interference, pain catastrophizing and self-efficacy beliefs. CONCLUSION: Our findings confirm previous evidence for high levels of psychological distress and functional impairment associated with this condition, and extend these findings by including measures that are highly relevant to treatment planning, such as thinking styles and pain self-efficacy. Therefore, treatment of this complex condition needs to be holistic, and a multidisciplinary approach is likely to be the best way to achieve this.