Giant neurofibroma arising from the intercostal nerve: a rare case report

Neurofibroma is a benign nerve sheath tumor of the peripheral nervous system. A young male presented with complaints of gradually increasing breathlessness and heaviness on the right side of the chest, and percussion notes over the chest were impaired all over the right lung fields except the basal zone. Contrast-enhanced computed tomography scan of the thorax revealed a large heterogeneous mass occupying most of the right hemithorax. Intraoperatively, the huge mass measuring about 18 cm?×?13 cm?×?12 cm was seemed to arise from the right fourth intercostal space. Histopathology revealed a neurofibroma. Giant intrathoracic neurofibroma is very uncommon and its malignant potential should be evaluated.     

Premature Ticagrelor Discontinuation in Secondary Prevention of Atherosclerotic CVD: JACC Review Topic of the Week

Ticagrelor is a cornerstone of modern antithrombotic therapy alongside aspirin in patients with acute coronary syndrome and after percutaneous coronary intervention. Adverse effects such as bleeding and dyspnea have been associated with premature ticagrelor discontinuation, which may limit any potential advantage of ticagrelor over clopidogrel. The randomized trials of ticagrelor captured adverse events, offering the opportunity to more precisely quantify these effects across studies. Therefore, a meta-analysis of 4 randomized clinical trials of ticagrelor conducted between January 2007 and June 2017 was performed to quantify the incidence and causes of premature ticagrelor discontinuation. Among 66,870 patients followed for a median 18 months, premature ticagrelor discontinuation was seen in 25%; bleeding was the most common cause of discontinuation followed by dyspnea. Versus the comparators, the relative risk of dyspnea-related discontinuation during follow-up was 6.4-fold higher, the relative risk of bleeding was 3.2-fold higher, and the relative risk of discontinuation due to any adverse event was 59% higher for patients receiving ticagrelor. Understanding these potential barriers to adherence to ticagrelor is crucial for informed patient-physician decision making and can inform future efforts to improve ticagrelor adherence. This review discusses the incidence, causes, and biological mechanisms of ticagrelor-related adverse effects and offers strategies to improve adherence to ticagrelor.     

Incidence of advanced adenomas at surveillance colonoscopy in patients with a personal history of colon adenomas: a meta-analysis and systematic review

BACKGROUND: Current guidelines stratify patients with a personal history of adenomas as low risk (ie, 1-2 small [<10 mm] adenomas at index colonoscopy) or high risk (> or =3 small adenomas or advanced adenoma at index colonoscopy) for recurrent advanced adenomas. Guidelines recommend longer intervals between surveillance colonoscopies for low-risk patients, but physicians frequently perform surveillance colonoscopy at shorter intervals for these patients. OBJECTIVE: Our purpose was to perform a meta-analysis about the incidence of advanced adenomas at 3-year surveillance colonoscopy among high- and low-risk patients. METHODS: Computer searches of MEDLINE, PREMEDLINE, and EMBASE were performed to identify appropriate studies. Study selection criteria were (1) study design--prospective or registry-based study, (2) study population--patients with a personal history of adenomas, and (3) intervention--completion of surveillance colonoscopy at an interval of > or =2 years. Data were extracted on (1) incidence of advanced adenomas at surveillance colonoscopy, (2) interval between colonoscopies, and (3) risk factors associated with recurrent adenomas. After the validity of study design was assessed and independent, duplicate data extraction was performed from selected trials, summary relative risks (RR) for the incidence of advanced adenomas at 3-year colonoscopy were calculated. RESULTS: Fifteen studies met study selection criteria, but only 5 studies stratified surveillance colonoscopy results according to findings at the index colonoscopy. Patients with > or =3 adenomas at index colonoscopy were more likely to have recurrent advanced adenomas than were patients with 1 to 2 adenomas: RR 2.52, 95% CI 1.07-5.97. Patients with adenomas with high-grade dysplasia at index colonoscopy were also at increased risk for recurrent advanced adenomas: RR 1.84, 95% CI 1.06-3.19. In the individual studies, increasing size of adenomas and increasing number of adenomas at index colonoscopy were the most commonly reported risk factors associated with recurrent advanced adenomas. No studies stratified surveillance colonoscopy results according to the definitions of low risk and high risk used in current guidelines. CONCLUSION: Few published studies stratify the incidence of advanced adenomas at surveillance colonoscopy according to index colonoscopy findings. In the future, large prospective studies or studies using pooled data from existing randomized controlled trial databases or polyp registries should be used to better define which patients are at low risk for advanced adenoma recurrence.     

Is Helicobacter pylori infection associated with alopecia areata?

Background  Alopecia areata (AA) is an immune-mediated form of hair loss that occurs in all ethnic groups, ages, and both sexes. Helicobacter pylori has been associated with certain extra-digestive dermatological conditions, including chronic urticaria, rosacea, Schönlein-Henoch purpura, Sweet syndrome, systemic sclerosis, and atopic dermatitis.
Objective  The causal relation between alopecia areata and H. pylori is discussed. We have screened for the presence of H. pylori in patients with AA in order to determine any potential role in its pathophysiology.
Patients and methods  We have prospectively studied 31 patients with AA and 24 healthy volunteers of similar gender for the presence of H. pylori surface antigen (HpSag) in stool.
Results  Optical density values for H. pylori infection were positive in 18 of all 31 patients evaluated (58.1%), while in 13 patients, values did not support H. pylori infection (41.9%). While in the control group, 10 of 24 (41.7%) had positive results. Within the group of AA, there was no significant difference between HpSag-positive and HpSag-negative patients.
Conclusions  Based on these results, the relation between H. pylori and AA is not supported. We advise that H. pylori detection should not be included in the laboratory workup of AA.     

Gemella bergeriae endocarditis diagnosed by sequencing of rRNA genes in heart valve tissue

We describe a case of Gemella bergeriae endocarditis in a patient with a bicuspid aortic valve. Diagnosis was confirmed by sequencing of 16S rRNA genes in heart valve tissue. This is the first report of Gemella endocarditis confirmed by molecular detection of bacterial genes in heart valve tissue.     

The knowledge and attitudes of orthodontic trainees towards orthodontic therapists: a national survey

Objective: To assess the knowledge and attitudes of orthodontic trainees towards orthodontic therapists (OTs) in the UK.

Design: Cross-sectional survey.

Setting: UK-based orthodontic trainees.

Materials and methods: An electronic survey was sent to all members of the Training Grades Group of the British Orthodontic Society assessing exposure to OTs and their knowledge regarding current supervision guidelines and scope of practice. Attitudes towards OTs were also explored.

Results: Seventy-six responses (response rate 57%) were returned. Nearly 90% of trainees had no formal training regarding OTs. A total of 15.5% were aware of the correct current supervision guidelines and there was large variation in the knowledge of OTs’ scope of practice. The majority of trainees were happy to supervise OTs, but only 22.4% felt prepared for this during training. In total, 63% of trainees felt that OTs could impact their own future job prospects.

Conclusions: Currently, there is minimal formal training provided to trainees regarding the role of OTs. This is reflected in the lack of knowledge regarding supervision guidelines and scope of practice. Overall, trainees felt OTs were positive for the workforce but were concerned regarding the impact of their own future employment.     

A point-by-point response to recent arguments against the use of statins in primary prevention: this statement is endorsed by the American Society for Preventive Cardiology

Recently, a debate over the merits of statin therapy in primary prevention was published in the Wall Street Journal. The statin opponent claimed that statins should only be used in secondary prevention and never in any primary-prevention patients at risk for cardiovascular events. In this evidence-based rebuttal to those claims, we review the evidence supporting the efficacy of statin therapy in primary prevention. Cardiovascular risk is a continuum in which those at an elevated risk of events stand to benefit from early initiation of therapy. Statins should not be reserved until after a patient suffers the catastrophic consequences of atherosclerosis. Contrary to the assertions of the statin opponent, this principle has been demonstrated through reductions in heart attacks, strokes, and mortality in numerous randomized controlled primary-prevention statin trials. Furthermore, data show that once a patient tolerates the initial treatment period, the few side effects that subsequently emerge are largely reversible. Accordingly, every major guidelines committee endorses statin use in secondary prevention and selectively in primary prevention for those with risk factors. The foundation for prevention remains increased physical activity, better dietary habits, and smoking cessation. However, prevention of heart attacks, strokes, and death from cardiovascular disease does not have to be all or none-all statin or all lifestyle. In selected at-risk individuals, the combination of pharmacotherapy and lifestyle changes is more effective than either alone. Future investigation in prevention should focus on improving our ability to identify these at-risk individuals.