Present Guidelines Research Articles

The Value of a Tooth for Alveolar Ridge Management; Strategies to Manage Ankylosed Maxillary Anterior Teeth in Young Patients.

In the young and growing patient, tooth ankylosis impedes alveolar growth and presents a serious dilemma regarding the best treatment approach. Two common treatment approaches, extraction of the ankylosed tooth or a "wait and see" will result in a compromised alveolar ridge that can affect future prosthetic rehabilitation. The purpose of this article is to discuss five treatment strategies that can be utilized in the management of tooth ankylosis in the growing patient: (1) extraction, (2) decoronation or root submergence, (3) socket shield (partial extraction), (4) segmental osteotomy and (5) replacement with tooth autotransplantation. It is important to understand the biologic sequelae of ankylosis and the value of the tooth for alveolar ridge management. Strategies will be discussed with an emphasis on alveolar ridge management using a natural tooth and root. With an interdisciplinary team, treatment options can then be developed, to achieve more favorable long-term outcomes. An understanding of each of these procedures and the proper time for implementation will help the clinician achieve the most optimal long-term outcomes for these growing patients. There are several treatment options for traumatized ankylosed incisors in growing patients. This article will describe the details of these treatment strategies, emphasize the value of the tooth for ridge management and present guidelines about selecting the most optimal strategy based on age, rate of growth, condition of the traumatized tooth, and the definitive prosthetic plan.

Cardiovascular disease in waitlisted hemodialyzed patients

Background Cardiovascular diseases are one of the major limitations in the evaluation of potential kidney transplantation. The study aimed to assess cardiovascular status, including cardiovascular risk factors in waitlisted hemodialyzed patients. Material and methods From the population of 5,068 hemodialyzed patients (60% men), we included 449 waitlisted and 4,619 not considered for potential kidney transplantation. We assessed demographic data, basal biochemical data, and cardiovascular disease prevalence. Results Waitlisted patients (262 males) were significantly younger when compared to non-listed patients (2,718 males); 53.2 ± 14.2 vs. 67.2 ± 3.3 years (p < 0.001), had lower Charlson comorbidity score (3.33 ± 1.52 vs. 4.42 ± 1.93, p < 0.001), lower BMI (26.3±.5.07 vs. 27.7 ± 6.15 kg/m2, p < 0.001), with lower prevalence of cardiovascular disease (46.5% vs. 66.8%, p < 0.001), diabetes (20.5% vs. 37,8%, p < 0.001). The prevalence of hypertension was similar in both groups (94.7% vs. 92.7%, NS). Blood pressure was significantly higher in waitlisted patients relative to non-waitlisted (143 ± 16 mmHg vs. 140 ± 17 mm Hg, p < 0.001 for systolic blood pressure and 80 ± 9 mmHg vs. 75 ± 9 mmHg, p < 0.001 for diastolic blood pressure). Ultrafiltration was also higher in waitlisted population over non-waitlisted (31.3 ± 12.7 mL/kg per HD session vs. 28.4 ± 12.6 mL/kg per HD session, p < 0.001). Mean dialysis vintage, the mean number of hypotensive medications (mean 2.5), the prevalence of apparent treatment-resistant hypertension, and eKt/V were similar, as well as sex distribution. Conclusion Waitlisted patients are a much healthier population, with fewer comorbidities but blood pressure control not meeting target ranges for the present guidelines. The low number of hypotensive medications should be reassessed and the treatment of hypertension may require further attention.

Thromboembolic Complications From Atrial Fibrillation and Atrial Flutter in Pediatrics and Young Adults: A Multicenter Study.

Atrial fibrillation and atrial flutter are relatively rare in young people and the incidence of thromboembolic complications is unknown. These issues contribute to the limited utility of present guidelines regarding anticoagulation in this population. To report the number of thromboembolic complications in a cohort of pediatric and young adult patients presenting with atrial fibrillation (AFib) or atrial flutter (AFl) while also assessing anticoagulation practice in a multicenter cohort of young patients with these arrhythmias. Multicenter, retrospective cohort of patients aged < 25 years old who presented with atrial flutter (AFl) or atrial fibrillation (AFib) between 2000 and 2019 to several large, quaternary pediatric centers, excluding episodes occurring within 30 days of an invasive cardiac procedure. There were 311 episodes of AFib/AFl among 210 patients with a median age of 17 (IQR 14, 20) years. Structural heart disease (SHD) was present in 120 patients (57%) and 20 patients (10%) had a primary cardiomyopathy. Twelve AFib/AFl episodes (8 with AFL, 4 with AFib) were associated with a thrombus, of which 8 (67%) patients had SHD, 2 (17%) had cardiomyopathy and 5 (42%) ventricular dysfunction. The CHADSVASc score was 0-3 for all patients with a thrombus. Of patients with no thrombus at presentation who were cardioverted, 102 (34%) patients were discharged on aspirin and 80 (27%) on anticoagulation. Two patients had symptoms concerning for a thromboembolic event on follow-up, but none had a newly documented thrombus. Thromboembolic complications occur in children and young adults presenting with AFib/AFl. The majority are associated with SHD, cardiomyopathy, and/or ventricular dysfunction. CHADSVASc was calculated for each patient and was of limited utility. Thromboembolic complications at follow up after cardioversion are rare, and anticoagulation strategies at discharge varied.

International standard of Traditional Chinese Medicine techniques: clinical guidelines for dysmenorrhea (2022).

Dysmenorrhea is a common gynecological condition that is further divided into two categories, namely primary and secondary dysmenorrhea. Traditional Chinese Medicine (TCM) gives good clinical results for the treatment of dysmenorrhea based on the basic principles of holistic view and syndrome differentiation. However, presently, the clinical practice guidelines in TCM for dysmenorrhea treatment are required. The guideline is formulated in strict accordance with the principles of evidence-based medicine with reference to the General Principles for the Compilation of International Guidelines for Diagnosis and Treatment of Traditional Chinese Medicine Syndromes and General Principles for the Compilation of International Clinical Practice Guidelines for Traditional Chinese Medicine Diseases and accordance with the principles and methods of The Appraisal of Guidelines for Research and Evaluation in China (AGREE-China) and World Health Organization guidelines. This guideline includes clinical issues by literature search and questionnaire survey, and eight background questions and 23 prospect questions were finally created. Based on the evidence retrieval, synthesis, consideration of patient preferences and values, intervention costs, advantages, and disadvantages, recommendations are created using the Delphi method and expert consensus method. This guideline clarified the definition, diagnosis, and TCM syndrome classification for dysmenorrhea, and recommends different TCM treatments based on the level of evidence, including Chinese herbal medicine, Chinese patent medicine, acupuncture, and other auxiliary therapies. The present guideline is an international clinical practice guideline for the treatment of dysmenorrhea using TCM. This guideline will provide substantive evidence and standardized guidance for the treatment of dysmenorrhea using TCM, improve the quality and safety of medical services, and standardize diagnosis and treatment plans for dysmenorrhea.

PET imaging of pheochromocytoma and paraganglioma - 18F-FDOPA vs. somatostatin analogues.

Functional imaging with positron emission tomography (PET) scans is an essential part of the diagnostic workup for pheochromocytoma and paraganglioma (PPGL). The purpose of this review is a) to provide a brief overview of functional imaging for PPGL, b) summarize selected present and older guideline and review recommendations, and c) conduct a literature review on the diagnostic performance of the most used PET tracers for PPGL. We conducted a systematic literature search in PubMed from January 2004 to August 2024 with the search string: ("Pheochromocytoma" OR "Paraganglioma") AND ("Positron-Emission Tomography" OR "Radionuclide Imaging" OR ("PET" AND ("FDG" OR "DOTATOC" OR "DOTANOC" OR "DOTATATE" OR "DOPA" OR "FDOPA"))). Studies involving PET scans of at least 20 individuals with PPGL, or at least five individuals in a rare, well-defined subgroup of PPGL (e.g. sympathetic or head-neck paragangliomas, and specific pathogenic variants) were included. Seventy studies were identified of which 21 were head-to-head comparisons of at least two different PET tracers (18F-fluorodihydroxyphenylalanine, 18F-FDOPA; 68Ga-DOTA-conjugated somatostatin analogues, 68Ga-SSA; and 18F-fluorodeoxyglucose, 18F-FDG). 18F-FDOPA had higher sensitivity for pheochromocytoma compared to 68Ga-SSA and equal sensitivity for metastatic pheochromocytoma. 18F-FDOPA and 68Ga-SSA had similar sensitivity for primary non-SDHx sympathetic and head-neck paraganglioma. However, 68Ga-SSA had higher sensitivity for metastatic sympathetic and head-neck paraganglioma and for SDHx-related paraganglioma. 18F-FDOPA and 68Ga-SSA PET are both sensitive for localizing PPGL. However, 18F-FDOPA is the most sensitive for detecting pheochromocytoma, while 68Ga-SSA is superior to 18F-FDOPA for metastatic sympathetic and head-neck paraganglioma and SDHx-related paraganglioma.

SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery.

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m2), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.

Personalized oncology, ethics and adherence to NCCN guidelines.

Successful personalized oncology today depends on clinicians taking advantage of the extensive, evidence-based information provided by the National Comprehensive Cancer Network (NCCN) Guidelines, which arguably represent the most important advance in cancer care occurring in the last many decades. Personalized oncology also demands that clinicians present guideline information to each patient in a thorough, comprehendible and unbiased manner. Finally, the patient's ability to process that information for shared decision-making about whether an intervention is consistent with their personal preferences, goals and values is perhaps the most important ingredient in truly personalized oncology care. Here, the ethics of sometimes transgressing from the NCCN guidelines with the aim of more personalized care is discussed.

Chromosome 8p Syndromes Clinical Presentation and Management Guidelines.

Rearrangements of the p-arm of Chromosome 8 can result in a spectrum of neurodevelopmental challenges, along with increased risk of epilepsy, structural brain and cardiac malformations, persisting developmental delays, and other health challenges. The majority of patients reported on in this sample are characterized by an inverted-duplication deletion rearrangement, but deletions, duplications, and mosaic ring changes in 8p result in similar phenotype. In this report, we add to the phenotypic and functional description of these patients according to their specific chromosomal rearrangement, share neuro-psychometric values, and propose surveillance care guidelines for caregivers and medical providers of patients with Chromosome 8p Syndromes. Observations from clinical experience with 24 patients seen at our 8p-dedicated Multi-Disciplinary Neurogenetics program are shared.

Factors Shaping Physicians’ Adoption of Telemedicine: A Systematic Review, Proposed Framework, and Future Research Agenda

Telemedicine offers transformative solutions for healthcare delivery, particularly in bridging geographical barriers and enhancing patient care. Nevertheless, its adoption by physicians is intricate, driven by diverse factors that require systematic understanding. This systematic review aims to identify and classify the factors influencing physicians’ adoption of telemedicine. From a collection of 2098 articles sourced from Web of Science and Scopus databases, 59 studies met the predetermined criteria and were meticulously assessed. The salient factors from these chosen papers were segmented into distinct categories: psychological and behavioral factors, technological factors, social and cultural factors, security and privacy factors, conditional factors, quality factors, healthcare-related factors, and inhibiting factors. Building on this classification, we proposed a comprehensive framework for telemedicine adoption tailored to physicians. This framework endeavors to act as a scaffold for subsequent empirical investigations. The taxonomy of the factors also aided in offering numerous research agendas to pave the way for more exhaustive studies into telemedicine adoption among medical professionals. The insights procured serve not only to deepen theoretical comprehension but also to present pragmatic guidelines for practitioners, service providers, application developers, and decision-makers.

2024 Spanish Society of Internal Medicine (SEMI) recommendations for the management of cancer-associated venous thromboembolism

Vennous thromboembolism (VTE) is a common complication associated to greater mortality in patients with cancer. Its etiology is multifactorial and depends on the characteristics and co-morbidities of the patient, the tumor type and extension, and the oncological treatment. The management of VTE is more complex in patients with cancer due to an increased risk of recurrence and major bleeding complications during anticoagulation compared to the general non-oncological population. The above differences have led to the development of specific clinical trials to assess the efficacy and safety of anticoagulant therapy in patients with cancer. The present clinical guidelines are intended to provide general recommendations on the management of cancer-associated VTE according to updated according to the most recent scientific evidence.

Extended realities and discrete events simulations: A systematic review to define design trade-offs and directions

Extended Reality (XR) technologies are increasingly popular to support the engagement of different audiences and stakeholders with Discrete Event Simulations (DES) due to their capability to deliver more accessible visual and immersive experiences. XR applications can be developed either using modules integrated into DES software or game engines, providing different sets of opportunities in the environment design. However, there is a lack of development guidelines for such environments, considering visualization, information presentation, interaction, and navigation aspects. The paper presents a systematic review of the use of XR for DES, relating the results to XR design heuristics to identify and discuss major design tradeoffs. Finally, a case study from the mining sector is exemplified to illustrate possible. solutions to balance the trade-offs.

Appropriate Use Criteria (AUC) for the Management of Non-Small Cell Lung Cancer in a Central/Ultra-Central Location: Guidelines from the American Radium Society

IntroductionDefinitive radiation therapy is considered standard therapy for medically inoperable early-stage NSCLC. Nevertheless, for patients with tumors located near structures such as the proximal tracheobronchial tree, esophagus, heart, spinal cord, and brachial plexus, the optimal management regimen is controversial. The objective was to develop expert multidisciplinary consensus guidelines on managing medically inoperable NSCLC located in a central or ultracentral location relative to critical organs at risk. MethodsCase variants regarding centrally and ultracentrally located lung tumors were developed by the 15-member multidisciplinary American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) expert panel. A comprehensive review of the English medical literature was performed from January 1 1946 to December 31 2023 to inform consensus guidelines. Modified Delphi methods were used by the panel to evaluate the variants and procedures, with at least three rating points from median defining agreement/consensus. The guideline was then approved by the ARS Executive Committee and released for public comment per established ARS procedures. ResultsThe Thoracic ARS AUC Panel identified 90 relevant references and obtained consensus in all variants. Radiotherapy alone was considered appropriate, with additional immunotherapy to be considered primarily in the clinical trial setting. Hypofractionated radiotherapy in eight to 18 fractions was considered appropriate for ultracentral lesions near the proximal tracheobronchial tree, upper trachea, and esophagus. For other ultracentral lesions near the heart, great vessels, brachial plexus, and spine, or for non-ultracentral but still central lesions, five-fraction stereotactic body radiation therapy was also considered an appropriate option. Intensity-modulated radiotherapy was considered appropriate and three-dimensional–conformal radiotherapy inappropriate for all variants. Other treatment planning techniques to decrease the risk of overdosing critical organs at risk were also considered. ConclusionsThe ARS Thoracic AUC panel has developed multidisciplinary consensus guidelines for various presentations of stage I NSCLC in a central or ultracentral location.

Field measurement and numerical simulation on vertical temperature gradient of steel box girders

The vertical temperature gradient (VTG) is a critical factor contributing to thermal stresses or deformations in bridge structures. However, the current provisions concerning the VTG of steel box girders are inadequate. Accordingly, this paper systematically investigated the VTG of a steel box girder in Wuhan using field measurement and numerical simulations. The temperature distributions of the steel box girder were first characterised based on measured temperature data. A thermal model of the steel box girder was then established using measured time-varying meteorological data, with the convective heat transfer coefficient obtained through an inversion method to update the model. The numerical findings align well with the observed temperature, and the fitted unfavourable VTG values exceed the current normative threshold. Furthermore, parametric investigations were carried out to reveal the impacts of meteorological and structural parameters on the VTG. The results indicate that solar radiation and pavement thickness have a considerable impact on the VTG. Finally, this research recommends that the present VTG guidelines should be modified by introducing appropriate adjustment factors related to the level of solar radiation intensity in different regions to strengthen their capacity for safeguarding.

Diagnosis and Treatment of Hypersensitivity Pneumonitis - S2k Guideline of the German Respiratory Society and the German Society for Allergology and Clinical Immunology

Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease (ILD) in sensitized individuals caused by a large variety of inhaled antigens. The clinical form of acute HP is often misdiagnosed, while the chronic form, especially the chronic fibrotic HP, is difficult to differentiate from other fibrotic ILDs. The present guideline for the diagnosis and treatment of HP replaces the former German recommendations for the diagnosis of HP from 2007 and is amended explicitly by the issue of the chronic fibrotic form, as well as by treatment recommendations for the first time. The evidence was discussed by a multidisciplinary committee of experts. Then, recommendations were formulated for twelve questions on important issues of diagnosis and treatment strategies. Recently published national and international guidelines for ILDs and HP were considered. Detailed background information on HP is useful for a deeper insight into HP and the handling of the guideline.

Development of the International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) Grade-Based Guidelines on the Surgical Treatment of Obesity Using Multimodal Strategies: Design and Methodological Aspects.

Background: The prevalence of obesity is already a worldwide health concern. The development of straightforward guidelines regarding the whole available armamentarium (i.e., medical, endoscopic, and surgical interventions in conjunction with a guidance program) is paramount to offering the best multimodal approach to patients with obesity. Methods: The International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) identified a panel of experts to develop the present guidelines. The panel formulated a series of clinical questions (based on the patient, intervention, comparison, and outcome conceptual framework), which have been voted on and approved. A GRADE methodology will be applied to assess the quality of evidence and formulate recommendations employed to minimize selection and information biases. This approach aims to enhance the reliability and validity of recommendations, promoting greater adherence to the best available evidence. Results: These guidelines are intended for adult patients with a body mass index (BMI) ≥ 30 kg/m2 who are candidates for metabolic bariatric surgery (MBS). The expert panel responsible for developing these guidelines comprised 25 panelists (92% were bariatric surgeons) and 3 evidence reviewers, with an average age of 50.1 ± 10.2 years. The panel focused on 3 key questions regarding the combined use of structured lifestyle interventions, approved obesity management medications, and endoscopic weight loss procedures with MBS. Conclusions: The complexity of obesity as a chronic disease requires a comprehensive knowledge of all the available and feasible therapeutic options. The IFSO-EC society felt the urgent need to develop methodologically valid guidelines to give a full picture and awareness of the possible surgical and non-surgical therapeutic strategies employed with a multimodal approach.

Practice Guidelines for Bipolar Disorder by the JSMD (Japanese Society of Mood Disorders).

The Japanese Society of Mood Disorders (JSMD) published treatment guidelines of bipolar disorder in 2011. The present guidelines incorporating new findings were developed to comply to the guidelines of the National Academy of Medicine (NAM) by utilizing systematic reviews and meta-analysis and taking patient and family opinions as well as insights from multiple professional fields into account. They support combination therapy using mood stabilizers and second-generation antipsychotics in many aspects. They also have limitations, including the grouping of mood stabilizers and second-generation antipsychotics when meta-analysis was performed despite their distinct properties, due to the scarcity of drug-specific evidence. Despite the limitations, these guidelines provide clinical decision support for psychiatrists in Japan.

Delayed Presentation of Malrotation after Infancy: A Systematic Review Based on Clinical Presentations, Associated Anomalies, Diagnosis, and Management.

Approximately 75% of patients with classic malrotation and midgut volvulus present in neonatal age-group; another 15% may present up to one year. In these, the diagnosis is made because of typical presentation. However, there are many cases in which malrotation has been detected after infancy. In-spite of the variable case reports and studies in literature, there is no specific data on the incidence of malrotation after infancy, its presentation and management guidelines. With this systematic review, we aim to coalesce these findings from various individual case reports and studies. This systematic review was performed as per the PRISMA (preferred reporting items for systematic review and meta-analyses) guidelines. The authors conducted thorough searches in databases like PubMed/MEDLINE, SCOPUS, Google Scholar and Web of Science for relevant articles. Studies were reviewed for clinical presentation and outcome for malrotation diagnosed beyond infancy. Clinical presentation of malrotation after infancy can be acute as well as chronic; acute presentation being common under 2 years of age and chronic symptoms present as age increases. Sudden onset of abdominal pain and bilious vomiting are commonest acute symptoms and intermittent episodes of recurring vague abdominal pain associated with vomiting and diarrhoea are the commonest chronic symptoms. The diagnostic modalities vary from UGI Contrast series to USG with colour Doppler and CECT scan. Management is operative open as well as laparoscopic Ladd's procedure is being favoured.

ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD. The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process. The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements. The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.

PRO: The Goblet Cell: Is It Needed for a Diagnosis of Barrett Esophagus, and Does It Impact Surveillance and Treatment?

Barrett esophagus and esophageal adenocarcinoma are sequential complications of gastroesophageal reflux disease. The diagnosis of Barrett esophagus leads to surveillance, which is aimed at early diagnosis of adenocarcinoma. Surveillance does not prevent adenocarcinoma. The first and universal requirement for diagnosis of Barrett esophagus is the presence of visible columnar lined esophagus at endoscopy. Without endoscopy, Barrett esophagus remains hidden. In the United States, intestinal metaplasia defined by goblet cells, which has a strong association with adenocarcinoma, is a second requirement for the diagnosis of Barrett esophagus. This limits surveillance to patients at highest risk. Patients with only cardiac mucosa have either no or lower risk of carcinoma until they develop goblet cells. Including patients without goblet cells will result in an increase in the surveillance pool with a likely negative cost-benefit. The more fundamental issue is that present guidelines delay pathologic diagnosis of gastroesophageal reflux disease to the point at which Barrett esophagus is detected. 85% of patients who develop adenocarcinoma have never had an endoscopy. To prevent esophageal adenocarcinoma, pathologic diagnosis of reflux disease must occur prior to the development of Barrett esophagus, however it is defined. Recent evidence and consensus indicate that cardiac mucosa distal to the squamocolumnar junction in the endoscopically normal person represents the pre-Barrett esophagus pathology of gastroesophageal reflux disease. Turning our attention to the presence and length of cardiac mucosa may provide a method of reaching the objective of preventing the late stages of gastroesophageal reflux disease manifested by Barrett esophagus and adenocarcinoma.

Replacement Dose for Overt Hypothyroidism Induced by Programmed Cell Death Protein 1 Antibodies May Be Higher than Recommended.

The present recommendations, consensus, or guidelines for the replacement dosage for hypothyroidism induced by programmed cell death protein 1 (PD-1) therapy are not uniform, and there are very few special clinical trials that have examined the replacement dosage for it. This article illustrates the clinical characteristics of hypothyroidism induced by PD-1 antibodies (Abs) and reports the recommended replacement dosage for hypothyroidism. Eighteen patients with overt primary hypothyroidism induced by PD-1 Abs (group 1) were selected from 655 patients with different tumor types. Retrospective analysis was performed on patients in group 1 and 18 patients with natural courses of overt primary hypothyroidism who were age- and sex-matched with the patients in group 1 (group 2). The replacement dosages required for the patients in the two groups were compared. Thyroid dysfunction occurred in group 1 after approximately 3.0 ± 1.4 cycles of PD-1 therapy (1-6 stages), with a median time of 61.5 days. The median time of onset of hypothyroidism among all patients was 87.5 days (30-240 days). Most of the patients with hypothyroidism were asymptomatic, and the onset of hypothyroidism was independent of age, sex, TPOAb, TgAb and TSH in group 1 (P>0.05). The average replacement dosage for patients in group 1 was 1.8 ± 0.6 μg/kg/d (0.6-3.2 μg/kg/d). Multiple linear regression analysis showed that sex, age, TPOAb, TgAb and TSH were not correlated with drug dosage. It seemed that the average maintenance dosage of levothyroxine might need to be 1.8 μg/kg/day for patients with overt hypothyroidism induced by PD-1 Abs.