AF (atrial fibrillation) is a common cardiac rhythm disturbance that can lead to severe consequences such as stroke and heart failure. AF can be triggered by various stressful conditions and about 30% of patients undergoing cardiac operations suffer from post-operative AF.
Harri Hemilä from the University of Helsinki, Finland, and Timo Suonsyrjä from the Helsinki University Central Hospital, Finland, carried out a systematic review of vitamin C for preventing AF in high risk patients. They identified 14 randomized trials totalling 2006 patients who had undergone cardiac surgery, and one trial with 44 patients that had investigated the recurrence of AF after a successful cardioversion.
There was substantial heterogeneity between the 14 cardiac surgery trials, but the heterogeneity was explained by the division of them between five trials carried out in the USA and nine trials conducted outside of the USA. The five cardiac surgery trials carried out in the USA uniformly found no effect of vitamin C against post-operative AF. In contrast, the nine cardiac surgery trials conducted outside of the USA found a mean reduction of 44% in the incidence of post-operative AF and there was no heterogeneity between these nine trials. Five of the latter trials were carried out in Iran, two in Greece, one in Slovenia and one in Russia.
The single study on the recurrence of AF after a successful cardioversion, which was carried out in Greece, found that vitamin C decreased the risk of AF recurrence by 87%.
In the non-US cardiac surgery trials, vitamin C decreased the length of hospital stay by 12.6% and intensive care unit stay by 8.0%.
Some of the surgery patients in the non-US studies were administered vitamin C orally, whereas in others vitamin C was administered intravenously. The latter route leads to substantially higher levels of vitamin C in the blood, thus the effects of the two administration methods might differ.
Oral administration of vitamin C decreased the occurrence of post-operative AF by 73%, whereas intravenous administration decreased it by 36%. On the other hand, oral administration shortened the length of hospital stay by only 7% (0.4 days), whereas intravenous administration decreased it by 16% (1.5 days). Thus, the effect of intravenous vitamin C administration was greater for the length of hospital stay, but less for the occurrence of post-operative AF.
According to Drs. Hemilä and Suonsyrjä, “Vitamin C is a safe low-cost essential nutrient. Given the consistent evidence from the less wealthy countries, vitamin C might be administered to cardiac surgery patients, although further studies are needed to find out optimal protocols for its administration. However, there seems to be no rationale for further study of unselected patients in wealthy countries, but the effects of vitamin C for patients who have a particularly low documented level of vitamin C might still be worthwhile.”

ScienceDailyhttp://tinyurl.com/ydek9set

Patients at risk of developing bowel cancer can significantly benefit from a follow-up colonoscopy.

Currently, everyone in the UK over the age of 60 is invited to be screened for bowel cancer, also known as colorectal cancer. It is a major cause of illness and death in developed countries. Small growths in the bowel, called polyps or adenomas, can develop into cancer over a long period of time. However, removing these precancerous growths can drastically reduce the risk of developing bowel cancer.

The new research, funded by the National Institute for Health Research (NIHR), shows that most patients who have had treatment to remove growths in their bowel and are classed as being at ‘intermediate risk’ can benefit substantially from a follow-up or ‘surveillance’ colonoscopy. However, a proportion of this group of patients are at low risk compared with the general population and are unlikely to benefit significantly from colonoscopy surveillance.

The researchers suggest the findings could lead to changes in the way patients are screened and followed-up, and even reduce costs for healthcare services.

Professor Wendy Atkin, from the Department of Surgery and Cancer at Imperial College London and chief investigator on the study, said: ‘The findings could influence national and international guidelines for the screening and surveillance of bowel cancer and could lead to cost savings for the NHS by reducing unnecessary procedures.’

Those patients who have one-to-two large adenomas (1 cm or larger) or three-to-four small adenomas are classed as being at ‘intermediate risk’ and are recommended to have a follow-up colonoscopy three years after their adenomas are removed. Most patients offered this surveillance are at intermediate risk

In the latest study, researchers from Imperial College London looked at the incidence of bowel cancer and the effectiveness of follow-up colonoscopies in reducing incidence in people found to have intermediate-risk adenomas. The study was commissioned on behalf of the UK National Screening Committee to help inform its current bowel cancer screening programme for the NHS.

Professor Atkin, said: ‘Colonoscopies carry a small risk of complications for patients, and are demanding on NHS resources, with around 20 per cent of colonoscopies in the UK performed for surveillance. It is therefore important to assess whether all people classed as being at intermediate risk need to undergo follow-up colonoscopy.’

Researchers looked at data for more than 250,000 patients and identified approximately 12,000 people who were diagnosed with intermediate-risk adenomas across 17 UK hospitals. These patients were monitored over an eight year period, and the incidence of bowel cancer was compared in those who had a follow-up colonoscopy with those who had not.

They identified a subgroup of patients within the intermediate-risk group, with large adenomas (2 cm or larger), advanced pathology in the adenomas, or polyps in the upper half of the large bowel who were at a higher risk of developing bowel cancer. These ‘higher-risk’ patients appeared to benefit substantially from at least one follow-up colonoscopy.

In addition, intermediate-risk patients who fell into the ‘lower-risk’ subgroup were found to have a smaller chance of developing bowel cancer than that of the general population. For this group of patients, the researchers suggest that follow-up colonoscopies may not be warranted at all if the initial colonoscopy is of high quality.

According to the researchers, the findings will help to shape current and future guidelines on bowel cancer screening both in the UK and internationally. If the changes are adopted, they could lead to cost savings for the NHS and reallocating of resources to focus on those most at risk.

EurekAlert

www.eurekalert.org/pub_releases/2017-04/icl-fca042617.php

MIT and Harvard Medical School researchers have devised a way to image biopsy samples with much higher resolution — an advance that could help doctors develop more accurate and inexpensive diagnostic tests.
For more than 100 years, conventional light microscopes have been vital tools for pathology. However, fine-scale details of cells cannot be seen with these scopes. The new technique relies on an approach known as expansion microscopy, developed originally in Edward Boyden’s lab at MIT, in which the researchers expand a tissue sample to 100 times its original volume before imaging it.
This expansion allows researchers to see features with a conventional light microscope that ordinarily could be seen only with an expensive, high-resolution electron microscope. It also reveals additional molecular information that the electron microscope cannot provide.
“It’s a technique that could have very broad application,” says Boyden, an associate professor of biological engineering and brain and cognitive sciences at MIT.
Boyden and his colleagues used this technique to distinguish early-stage breast lesions with high or low risk of progressing to cancer — a task that is challenging for human observers. This approach can also be applied to other diseases: In an analysis of kidney tissue, the researchers found that images of expanded samples revealed signs of kidney disease that can normally only be seen with an electron microscope.
“Using expansion microscopy, we are able to diagnose diseases that were previously impossible to diagnose with a conventional light microscope,” says Octavian Bucur, an instructor at Harvard Medical School, Beth Israel Deaconess Medical Center (BIDMC), and the Ludwig Center at Harvard, and one of the paper’s lead authors.
Boyden’s original expansion microscopy technique is based on embedding tissue samples in a dense, evenly generated polymer that swells when water is added. Before the swelling occurs, the researchers anchor to the polymer gel the molecules that they want to image, and they digest other proteins that normally hold tissue together.
This tissue enlargement allows researchers to obtain images with a resolution of around 70 nanometers, which was previously possible only with very specialized and expensive microscopes.
In the new study, the researchers set out to adapt the expansion process for biopsy tissue samples, which are usually embedded in paraffin wax, flash frozen, or stained with a chemical that makes cellular structures more visible.
The MIT/Harvard team devised a process to convert these samples into a state suitable for expansion. For example, they remove the chemical stain or paraffin by exposing the tissues to a chemical solvent called xylene. Then, they heat up the sample in another chemical called citrate. After that, the tissues go through an expansion process similar to the original version of the technique, but with stronger digestion steps to compensate for the strong chemical fixation of the samples.
During this procedure, the researchers can also add fluorescent labels for molecules of interest, including proteins that mark particular types of cells, or DNA or RNA with a specific sequence.
“The work of Zhao et al. describes a very clever way of extending the resolution of light microscopy to resolve detail beyond that seen with conventional methods,” says David Rimm, a professor of pathology at the Yale University School of Medicine, who was not involved in the research.

MIT
news.mit.edu/2017/microscopy-technique-could-enable-more-informative-biopsies-0717

The Eustachian tube is the main connection between the back of the throat and the middle of the ear. Normally, the tube is filled with air and opens when yawning or chewing. “This allows you to equalize pressure” on either side of the eardrum, explained David Kaylie, MD, a Duke otolaryngologist. When the tube is blocked from a cold or sinus, nose or ear infection, air can no longer pass through. Stuffy ears and noses, hearing loss, ear pain and pressure, as well as ringing in the ears (tinnitus) can result.
Blocked Eustachian tubes can be relieved by nasal sprays and antihistamine tablets, which reduce inflammation and congestion. Recurrent Eustachian tube dysfunction requires the surgical placement of tubes in the eardrum, which allows pressure to equalize in the middle ear. Now that the FDA has approved the Aera system, children, and adults with chronic Eustachian tube dysfunction, can opt for a simple, 10-minute procedure instead, Kaylie said.
“This new device has been shown to return the middle ear to normal and greatly eliminate middle ear pressure in properly selected patients,” he said. Studies of the device showed “long term normal Eustachian function after the procedure.”
David Kaylie, MD, performs the minimally invasive procedure in the OR, but no overnight stay is required.
During the minimally invasive procedure, a catheter is used to insert a small balloon through the nose and into the Eustachian tube. The balloon is inflated, which opens the Eustachian tube and allows air to flow through. Once the tube is open, the balloon is deflated and removed.
While Kaylie believes the device will prove useful to many people who currently require ear tube surgery due to Eustachian tube dysfunction, fluid in their ears, or chronic ear infections, he also cautions that there are some people for whom it will not be appropriate. During the clinical trial for the Aera system, some common problems included small tears in the lining of the Eustachian tube, minor bleeding and, sometimes, worsening or their Eustachian tube dysfunction.
Still, Kaylie believes it will be a significant advance for the millions of people who require ear tube surgery. “There are people who need tubes 13 or 14 times,” he said. “Every time the tubes come out, they need the tubes in again. There is a huge need for this procedure, and it will greatly reduce the need for all those ear tubes” and other related surgeries.

Duke Universityhttp://tinyurl.com/yanrxgb8

Elderly patients with early-stage oesophageal cancer that received treatment had an increased 5-year overall survival when compared to patients who received observation with no treatment.

Oesophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of death related to cancer. In the United States, there are over 16,000 people diagnosed with the disease annually with an even higher prevalence in other parts of the world. The National Comprehensive Cancer Network (NCCN) guidelines suggest surgery as the standard treatment for stage I oesophageal cancer. Despite these guidelines, various factors prevent a patient from being managed surgically such as age of the patient, multiple comorbidities and differences in socio-demographic and socioeconomic status. The median age of patients diagnosed with oesophageal cancer is around 67 years with a 5-year overall survival (OS) rate of 18.8percent. Age often drives treatment decisions of elderly patients (≥ 80 years of age) representing a unique and challenging subpopulation to health care providers. Randomized clinical trials have shown that survival of patients with oesophageal cancer correlates with the degree of treatment intensity they receive. However less aggressive, nonsurgical therapy such as chemoradiation is commonly provided to elderly patients even with early-stage disease.

A group of researchers in the United States conducted a retrospective study to evaluate the practice patterns and outcomes of elderly patients (≥ 80 years of age) with stage I oesophageal cancer who received four different types of treatment: oesophagectomy (Eso), local excision (LE), chemoradiotherapy (CRT) and observation (Obs). The National Cancer Data Base (NCDB) was queried for patients ≥ 80 years of age diagnosed with cT1-T2 N0 oesophageal cancer from 2004 to 2012. Patients meeting the criteria were divided into four groups: Eso, LE, CRT, and Obs. Patient, tumour, and treatment parameters were extracted and compared. Analyses were performed on OS and postoperative 30- and 90-day mortality.

From the NCDB query, 923 patients were identified and analysed. Of these, 43percent were observed, 22percent underwent CRT, 25percent had LE and 10percent had Eso. The median age was 84 years (range 80-90) for the overall cohort and lower in the Eso group compared to Obs (82 years vs. 85 years, p<0.001). Patients were predominantly male and Caucasian; however, the highest proportion of females and African Americans were found in the nonsurgical groups (Obs or CRT; p<0.001). Patients undergoing Obs were older, had more comorbidities, were treated at non-academic centers and lived ≤ 25 miles from the facility. Patients receiving surgery (Eso/LE) were more commonly younger, male, Caucasian and in the top income quartile. Five-year OS was 7percent for Obs, 20percent for CRT, 33percent for LE and 45percent for Eso. Postoperative 30-day mortality between the LE and Eso groups was 1.3percent and 9.6percent (p<0.001), which increased to 2.6percent and 20.2percent at 90 days. Multivariate analysis showed improved OS for all treatments when compared to Obs: CRT (HR: 0.42, 95percent CI [0.34 - 0.52], p<0.001), LE (HR: 0.30, CI [0.24-0.38], p<0.001), Eso (HR: 0.32, CI [0.23-0.44], p<0.001). The authors comment that, ‘In general, health disparities were observed in this study, which are important to characterize. When stratifying the elderly by any surgery vs. CRT/Obs, female patients, African Americans and patients of lower income quartile were less likely to undergo surgery – findings that corroborate the results from other retrospective studies in non-elderly cohorts. Another key factor that drives the treatment of choice and subsequent outcome is the type of treating facility. Although more than half of patients were treated within the community, 82percent of these patients did not undergo surgery compared to 42percent of patients treated in an academic centre. A rather compelling finding was that patients living closer to treating institutions tended to undergo observation. This study demonstrated that a surprisingly large proportion of patients age ≥ 80 years with stage I oesophageal cancer remain under clinical observation after their diagnosis. Any form of local therapy, including CRT, statistically improved OS when compared to observation. Finally, if surgery is feasible then LE should be considered over CRT and Eso, given the potentially lower toxicity profile and postoperative mortality rates.’
The International Association for the Study of Lung Cancerwww.iaslc.org/news/treatment-improved-5-year-overall-survival-elderly-patients-early-stage-esophageal-cancer