Pancreatic metastases in patients with neuroendocrine neoplasms: A multi-centre cohort study.

Pancreatic metastases (PMs) from neuroendocrine neoplasms (NENs) are rare but the increased sensitivity of new diagnostic tools such as 68 Ga-DOTATATE PET/CT has resulted in their increased recognition at initial diagnosis or follow-up. A retrospective analysis of the data of patients from six tertiary referral centres was performed in order to identify the characteristics and the prognostic significance of PMs in patients with NENs. We used a control group of 69 age-, sex- and primary tumour - matched NEN patients from the same cohort with stage IV disease but no PMs. Overall survival (OS) was assessed using the Kaplan-Meier method log-rank analysis was used to assess the impact of various clinical and histopathological variables in OS. We identified 25 patients (11 females) with PMs with a median age at diagnosis of 60 years. The small intestine was the most common primary (80%) with a prevalence of 4.2% PMs (21/506). Fourteen patients presented with synchronous PMs whereas 11 developed metachronous PMs after a median time of 28 months (range: 7-168 months). Grading was available in 24 patients; 16 patients had G1 tumours, four G2, two atypical lung carcinoid, one typical and one atypical thymic carcinoid. Most patients had other concomitant metastases (12 hepatic, 4 lung and 6 bone) while five patients exhibited peritoneal carcinomatosis. Median OS in the PMs group was not reached compared with 212 months in the control group (95% CI: 26-398). The univariate analysis identified no prognostic factors statistically significantly associated with the OS. In conclusion, PMs are encountered with a low prevalence among NEN patients mostly developing in patients with advanced metastatic disease. The presence of PMs does not seem to be associated with a negative prognostic impact in OS.

Comparative effectiveness of a second-line biologic in patients with ulcerative colitis: vedolizumab followed by an anti-TNF versus anti-TNF followed by vedolizumab.

Background: Sequential drug treatment with biological agents in ulcerative colitis (UC) is becoming increasingly complex. There are few studies comparing head-to-head outcomes in second-line treatments. The study assesses whether using anti-tumour necrosis factor (anti-TNF)-α therapy following the α4ß7 integrin blocker vedolizumab (VDZ) or VDZ after an anti-TNF has more favourable clinical outcomes in UC in a real-world outpatient setting. Methods: Patients with UC who were exposed to first-line anti-TNF (adalimumab or infliximab) or VDZ who subsequently switched to the alternate class between May 2013 and August 2020 were identified by reviewing patient databases at 10 hospitals. Data were collected retrospectively using patient records. Baseline demographics, disease activity indices, biochemical markers, endoscopic Mayo score, colectomy rates, treatment persistence and urgent hospital utilisation composite endpoint (UHUC) rates were examined over a 52-week period. Results: Second-line week 52 treatment persistence was higher in the VDZ group (71/81, 89%) versus the anti-TNF group (15/34, 44%; p=0.0001), as were week 52 colectomy-free survival (VDZ: 77/80, 96%, vs anti-TNF: 26/32, 81%; p=0.009), week 52 UHUC survival (VDZ: 68/84, 81%, vs anti-TNF: 20/34, 59%; p=0.002) and week 52 corticosteroid-free clinical remission (CFCR) rates (VDZ: 22/34, 65%, vs anti-TNF: 4/20, 20%; p=0.001). Conclusion: Compared with second-line anti TNF usage, the VDZ second-line cohort had significantly higher 52-week treatment persistence, UHUC survival, higher colectomy-free survival rates and higher week 52 CFCR. These data suggest that VDZ is an effective biologic in UC as a second-line therapy after anti-TNF exposure. It highlights the effect of biological order on clinically important outcomes.

Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions.

The diagnosis of thoracic outlet syndrome (TOS) has long been a controversial and challenging one. Despite common presentations with pain in the neck and upper extremity, there are a host of presenting patterns that can vary within and between the subdivisions of neurogenic, venous, and arterial TOS. Furthermore, there is a plethora of differential diagnoses, from peripheral compressive neuropathies, to intrinsic shoulder pathologies, to pathologies at the cervical spine. Depending on the subdivision of TOS suspected, diagnostic investigations are currently of varying importance, necessitating high dependence on good history taking and clinical examination. Investigations may add weight to a diagnosis suspected on clinical grounds and suggest an optimal management strategy, but in this changing field new developments may alter the role that diagnostic investigations play. In this article, we set out to summarise the diagnostic approach in cases of suspected TOS, including the importance of history taking, clinical examination, and the role of investigations at present, and highlight the developments in this field with respect to all subtypes. In the future, we hope that novel diagnostics may be able to stratify patients according to the exact compressive mechanism and thereby suggest more specific treatments and interventions.

Low-intensity pulsed ultrasound treatment as an alternative to vascular bone graft surgery for a 5-year-long ulnar non-union in a patient with haemochromatosis.

We present the case of a 75-year-old woman with haemochromatosis who developed a 5-year-long right ulnar non-union after a shortening osteotomy to correct a malunited Colles' fracture. Standard surgical treatment for ulnar non-unions was attempted on 19 March 2008 and again on 20 April 2009, but the non-union persisted on 8 May 2012, as confirmed by CT scan. Vascular bone grafting and refixation was then considered, but the patient declined this extensive operation, instead choosing to try non-invasive low-intensity pulsed ultrasound treatment with an Exogen device. Just 4 months later, complete union as confirmed by CT scan was achieved. This is the first case demonstrating the efficacy of ultrasound treatment for long-standing non-unions resistant to surgery in patients with haemochromatosis, a disorder where iron deposition can provide suboptimal circumstances for bone healing. Our finding suggests that low-intensity pulsed ultrasound devices could be used as a first-line treatment for stable non-unions instead of revision surgery.

Treatment for thoracic outlet syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) is one of the most controversial diagnoses in clinical medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence-based management is lacking. This is the first update of a review first published in 2010. OBJECTIVES: To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of TOS a minimum of six months after the intervention. SEARCH METHODS: On 23 June 2014 we searched the Cochrane Neuromuscular Disease Group Trials Specialized Register, CENTRAL, The Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL Plus and AMED. We also searched reference lists of the identified trials. SELECTION CRITERIA: We selected randomized or quasi-randomized studies involving participants with the diagnosis of TOS of any type (neurogenic, vascular, and 'disputed'), without limitations as to language of publication.We accepted studies that examined any intervention aimed at treating TOS.The primary outcome measure was change in pain rating, measured on a validated visual analog or similar scale at least six months after the intervention.The secondary outcomes were change in muscle strength, disability, experiences of paresthesias (numbness and tingling sensations), and adverse effects of the interventions. DATA COLLECTION AND ANALYSIS: Three authors independently selected the trials to be included and extracted data. Authors rated included studies for risk of bias, according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. We identified one study comparing natural progression with an active intervention. We found three randomized controlled trials (RCTs), but only two of them had a follow-up of six months or more, which was the minimum required follow-up for inclusion in the review. The first trial that met our requirements involved 55 participants with the 'disputed type' of TOS and compared transaxillary first rib resection (TFRR) with supraclavicular neuroplasty of the brachial plexus (SNBP). The trial had a high risk of bias. TFRR decreased pain more than SNBP. There were no adverse effects in either group. The second trial that met these requirements analyzed 37 people with TOS of any type, comparing treatment with a botulinum toxin (BTX) injection into the scalene muscles with a saline placebo injection. This trial had a low risk of bias. There was no significant effect of treatment with the BTX injection over placebo in terms of pain relief or improvements in disability, but it did significantly improve paresthesias at six months' follow-up. There were no adverse events of the BTX treatment above saline injection. AUTHORS' CONCLUSIONS: This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty, but no randomized evidence that either is better than no treatment. There is moderate evidence to suggest that treatment with BTX injections yielded no great improvements over placebo injections of saline. There is no evidence from RCTs for the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures, and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Steroid injection for shoulder pain causes prolonged increased glucose level in type 1 diabetics.

Shoulder pain is very common in diabetic patients and often treated with steroid injections, with subsequent increases in blood glucose levels or the need for additional insulin being questioned. We report a case of significant and prolonged elevation of blood glucose levels and resultant insulin requirement in a type 1 diabetic man after a single 40 mg injection of triamcinolone for shoulder pain. Within 48 h, the shoulder pain as assessed by a visual analogue scale (0-10) was reduced to zero, but the elevated insulin requirements continued for 4 weeks after the injection. This finding suggests that steroid injections for shoulder pain in diabetics may not always be as safe as previously thought. We propose that medical practitioners advise their patients to monitor their glucose levels more carefully after such injections and that caution is exercised when considering administrating these injections to those who have poorly controlled blood glucose levels preinjection to avoid ketoacidosis.

What is the better treatment for single digit dupuytren's contracture: surgical release or collagenase clostridium histolyticum (Xiapex) injection?

UNLABELLED: The purpose of this study was to compare the initial and final outcome range of motion in the MCP-J and PIP-J of single digit Dupuytren's Contracture treated with either open surgical excision or manipulation after collagenase clostridium histolyticum (CCH; Xiapex) injection. MATERIAL: Ten patients in either group. The range of motion measurements were statistically compared using the student t-test with a p-value of 0.05. There was no statistical difference in the pre-treatment status of the total active range of movement (TAM) between the two groups. RESULTS: Open surgical release achieved a statistically better initial outcome in combined total passive range of movement than the xiapex group (p = 0.0047), but at the final outcome the better TAM measurement at the MCP-J after surgery was not statistically significant. However, the total active range of movement was statistically better at the PIP-J level in the xiapex group (p = 0.01) and the MCP-J and PIP-J combined total active range of movement was statistically better in the xiapex group (p = 0.0258). CONCLUSION: Surgery achieved better initial outcome at both MCP-J and PIP-J levels, and at discharge, only extension in the MCP-J level was statistically better after open excision. However the final outcome was statistically better at the PIP-J level in extension (p = 0.006) and total active movement (TAM) (p = 0.008) after treatment with collagenase clostridium histolyticum. Further studies are required to assess the long-term differences between the two groups and to investigate the outcomes for patients with multi-digit involvement.