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Despite declines in incidence, gastric cancer remains a disease with a poor prognosis and limited treatment options due to its often late stage of diagnosis. In contrast, early gastric cancer has a good to excellent prognosis, with 5-year survival rates as high as 92.6% after endoscopic resection. There remains an East-West divide for this disease, with high incidence countries such as Japan seeing earlier diagnoses and reduced mortality, in part thanks to the success of a national screening programme. With missed cancers still prevalent at upper endoscopy in the West, and variable approaches to assessment of the high-risk stomach, the quality of endoscopy we provide must be a focus for improvement, with particular attention paid to the minority of patients at increased cancer risk. High-definition endoscopy with virtual chromoendoscopy is superior to white light endoscopy alone. These enhanced imaging modalities allow the experienced endoscopist to accurately and robustly detect high-risk lesions in the stomach. An endoscopy-led staging strategy would mean biopsies could be targeted to histologically confirm the endoscopic impression of premalignant lesions including atrophic gastritis, gastric intestinal metaplasia, dysplasia and early cancer. This approach to quality improvement will reduce missed diagnoses and, combined with the latest endoscopic resection techniques performed at expert centres, will improve early detection and ultimately patient outcomes. In this review, we outline the latest evidence relating to diagnosis, staging and treatment of early gastric cancer and its precursor lesions.

IntroductionThe Baveno VI consensus provides guidance on using non-invasive methods to identify patients with compensated advanced chronic liver disease (cACLD) who are unlikely to have clinically significant portal hypertension (CSPH) Patients with a platelet count of 150,000/Litre and a liver stiffness of 20kPa, assessed using transient elastography (TE), have a sufficiently low risk of variceal bleeding that they do not require variceal screening endoscopy to examine for oesophageal varices (OV) costing approximately £342 per procedure This identifies potential substantial cost savings to healthcare systems and reduces risk to patients from unnecessary investigations However, concordance with these guidelines, availability of TE and number of avoidable endoscopies is unknown MethodRetrospective data collection from 10 sites across London, 6 teaching hospitals and 4 district general hospitals (DGH), over a 6 month period from 1st January to 30th June 2019 by reviewing oesophagogastroduodenoscopy (OGD) requests and analysing those with indications of ‘variceal screening’, ‘cirrhosis’, ‘liver disease’ or ‘variceal surveillance’ Patient platelet count and TE result within a year of OGD was recorded ResultsData was collected for 353 endoscopies, 7 were excluded due to incomplete data and 89 due to decompensation at the time of endoscopy 141 screening procedures were included Endoscopic findings included: 74 5% no OV, 16 3% grade I OV and 9 2% ≥grade II OV or high risk stigmata 49 7% did not have a recent TE (48 5% in teaching hospitals vs 52 4% in DGH) Of those who did have a recent TE result, 54 (76 1%) met the Baveno criteria for absence of CSPH, of whom 5 (9 3%) were found to have clinically significant varices Median follow-up was 350 5 days and 0 of these patients subsequently bled The performance of the Baveno criteria in this study was: sensitivity 64 3%, specificity 85 9%, positive predictive value 52 9% and negative predictive value 90 7% Avoiding OGD in patients meeting Baveno criteria in this cohort would have potentially saved over £18000 DiscussionOur study shows that TE is not widely used for risk stratifying patients with cACLD across London prior to screening OGD These simple non-invasive markers can achieve substantial cost savings, avoid exposing patients to unnecessary investigations and relieve pressure on endoscopy departments under increased strain due to the Coronavirus pandemic Whilst a small proportion of OV will be missed, the bleeding risk in these is low with adequate follow-up Availability and utilisation of TE for risk stratification in cACLD should be improved

Ectopic thyroid tissue is an uncommon, but well-documented condition. We present a case of an ectopic thyroid gland with an atypical presentation as a new neck mass in a 3-year-old female without symptoms of hypothyroidism. Imaging confirmed ectopic thyroid and suggested thyroiditis due to hyperemia and heterogeneity on ultrasound. However, there were no laboratory findings of hypothyroidism. An understanding of anatomy and sonographic features of ectopic thyroid gland allows the radiologist to provide a more accurate differential diagnosis in the setting of a neck mass. Keywords: Ectopic thyroid, Pediatric neck mass, Thyroid

Importance In a phase 1 trial, single-dose O 6 -benzylguanine with topical carmustine for patients with early stage (stage IA through stage IIA) cutaneous T-cell lymphoma, mycosis fungoides (MF) type, resulted in clinical responses proportional to inhibition of O 6 -alkylguanine–DNA alkyltransferase activity, but a maximum tolerated dose (MTD) was not reached. Objective To determine whether dose escalation of carmustine in combination with dual-dose O 6 -benzylguanine to prolong alkyltransferase inhibition could reach an MTD. Design, Setting, and Participants A single-arm, phase 1-2 clinical trial conducted at a university teaching hospital enrolled 17 adults with stage IA through stage IIA cutaneous T-cell lymphoma, MF type, to evaluate treatment using topical carmustine plus 2 subsequent daily doses of intravenous O 6 -benzylguanine, administered every 2 weeks for up to 24 weeks (12 cycles). All patients who received treatment were included in an intent-to-treat analysis of the response rate. The study was conducted from February 17, 2010, to April 8, 2014. Data analysis was performed from May 1, 2014, to December 1, 2015. Interventions Topical carmustine and intravenous O 6 -benzylguanine. Main Outcomes and Measures Clinical disease response was assessed by the Severity-Weighted Assessment Tool (score range, 0-400; higher score indicates worse disease). Safety data were acquired by review of adverse events at study visits. Results Of the 17 patients enrolled, 12 (71%) were men; mean (SD) age was 45.2 (14.6) years. There were 7 complete responses and 8 partial responses to combination carmustine and O 6 -benzylguanine treatment. The overall clinical response rate was 88%, with a mean (SD) duration of complete response of 14.43 (6.6) months. The MTD was 20 mg of carmustine applied once in combination with 2 daily doses of 120 mg/m 2 of O 6 -benzylguanine. Most adverse events (112 [67%]) were grade I. Of 15 patients with dermatitis, 5 individuals (33%) demonstrated grade II dermatitis that was unresponsive to topical corticosteroid therapy. The dermatitis was characterized by high levels of macrophage activation, and clearance was associated with vitamin D 3 administration. Conclusions and Relevance Compared with single-dose O 6 -benzylguanine and carmustine, dual-dose O 6 -benzylguanine resulted in higher overall response rates and reduced total carmustine doses but was associated with more cutaneous adverse events. The MTD for dual-dose O 6 -benzylguanine plus carmustine was also ascertained. Trial Registration clinicaltrials.gov Identifier:NCT00961220

BACKGROUND The efficacy of patch testing may be enhanced by data allowing the physician to estimate the likelihood that results of a patch-test reading are relevant to a patient's dermatitis. OBJECTIVE The goal of this study was to compare the rates of agreement between the physician's assessment of relevance at the time of final reading and the patients' report 3 months to 3 years later in regard to whether avoidance of an allergen was needed to remain free of dermatitis. We hypothesize that the agreement rates between the physician and patient relevance assessments will vary based on properties both intrinsic and extrinsic to the allergen in question. METHODS We mailed 407 Institutional Review Board-approved questionnaires to patients and analyzed results for the 92 patients reporting greater than 80% improvement of their dermatitis. Cross-reacting allergens tested on the same patient were combined for analysis. Percent agreement was used to assess interrater concordance. RESULTS Percent agreement regarding relevance for each allergen or group of allergens was as follows: formaldehyde and formaldehyde-releasing preservatives, 88%; neomycin sulfate, 78%; nickel sulfate hexahydrate, 71%; fragrance mix and related products, 65%; and gold sodium thiosulfate, 56%. CONCLUSION Relevance varies between allergens. Physician assessment of relevance at the time of final reading is not the ideal method for determining allergen relevance. This has implications for when best to determine the relevance of certain allergens. For allergens with lower agreement, in particular, extended follow-up is recommended to accurately determine an allergen's contribution to a patient's allergic contact dermatitis, especially in those circumstances in which a patient's condition has not improved.

BACKGROUND Doubtful late patch-test readings are often not considered clinically relevant. As a result, allergens with doubtful late readings may not be disclosed to the patient, and relevant allergens may not be avoided. We hypothesize that doubtful late reactions at a day 7 reading may be relevant. OBJECTIVE We compared the patients' assessments of relevance to the strength of reaction at the final reading 168 hours after patch test application to determine if doubtful late patch-test reactions are relevant. METHODS Four hundred seven subjects who underwent patch testing from January 2005 to February 2008 were mailed a survey asking if their dermatitis was more than 80% better than before patch testing and whether they needed to avoid each of their positive patch-test allergens to remain free of dermatitis. Clinical charts of respondents who indicated their dermatitis was more than 80% improved were reviewed for strength of patch-test response at day 7 for each positive patch-test result, which was then compared to the patients' assessments of relevance formulated by the investigators' interpretation of the survey. RESULTS On the basis of survey interpretation, 63% of negative (0) late readings, 79% of doubtful (?+) late readings, 85% of + late readings, 84% of ++ late readings, and 100% of +++ late readings were considered relevant. CONCLUSION Study limitations included small sample size, lack of formal validation of questionnaire, and response bias. However, based on the patients' assessments of relevance, allergens with doubtful late reactions were considered relevant almost as frequently as were allergens with + late readings.

The use of biomass as a heating fuel in northern British Columbia (BC) is an attractive alternative to traditional fossil fuels. The benefits of using biomass in BC include cost savings of at least 50 %, reduced greenhouse gas emissions, and increased energy security in individual communities and opportunities for local employment and engagement. Using the Austrian biomass industry as a model to establish and grow the industry in northern BC, many of the early issues can be avoided, such as over-dimension, resulting in a highly productive and robust network. Achieving a high level of growth in the biomass industry in northern BC would require the involvement of the various levels of government, private businesses, and educational institutions and most importantly, the citizens of the communities it serves. Financing, technical expertise, fuel sources, and biomass technology are all available—it is a matter of engaging local municipalities and First Nation communities by promoting biomass heating as an economic and sustainable alternative.

Early-stage (IA-IIA) mycosis fungoides (MF) tends to follow a chronic course. Treatment toxic effects are therefore of high consideration, and conservative skin-directed therapies and phototherapy are considered first-line therapies.1–3 Disease relapses are common in MF,4,5 and patients consequently exhaust skin-directed treatment options during their lifetime. Treatment-resistant and refractory cases may then require more aggressive treatments, which incur greater risks of toxic effects.1,3,6,7 An alternative skin-directed therapy for early-stage MF is the topical chemotherapeutic agent carmustine [1,3-bis (2-chloroethyl)-1-nitrosourea] While producing high response rates, depending on the dosage, daily topical carmustine may incur systemic toxic effects not observed in most other skin-directed cutaneous T-cell lymphoma (CTCL) therapies, including myelosuppression and hepatotoxicity.8 Nearly all patients experience cutaneous reactions, including tender erythema, hyperpigmentation, and telangiectasias, which may be treatment limiting. Limiting these adverse effects could make carmustine a more useful therapeutic option for patients with MF. Carmustine damages DNA through chloroethyl alkylation at the O6 site of guanine and subsequent cytotoxic interstrand crosslink formation.9–12 Some malignant diseases have an escape mechanism for nitrosourea resistance via the DNA repair enzyme O6-alkylguanine DNA alkyltransferase (AGT), which covalently transfers the carmustine alkyl adduct to its cysteine residue.9–11,13,14 The novel drug O6-benzylguanine may potentiate carmustine efficacy.15 O6-benzylguanine is a guanine analog and AGT substrate, which transfers its benzyl group to the AGT cysteine residue, thereby irreversibly inactivating AGT and preventing DNA repair.16–20 In tumor cell lines and xenograft models, O6-benzylguanine enhances the sensitivity of malignant diseases to nitrosoureas.21–25 Phase I and II trials have been published on O6-benzylguanine alone and in combination with systemic carmustine in advanced solid tumors, particularly malignant gliomas.26–37 O6-benzylguanine and carmustine together (O6-benzylguanine–carmustine) have never been studied in the treatment of MF, and to our knowledge, topical application of carmustine has not previously been examined in combination with O6-benzylguanine. We conducted a phase I trial of a single topical carmustine administration following intravenous O6-benzylguanine administered once every 2 weeks in the treatment of MF to examine pharmacodynamics of AGT in MF lesions, to determine toxic effects and maximum tolerated dose (MTD), and to follow clinical efficacy measures. Hereinafter, “O6-benzylguanine–carmustine” will refer to the combination of O6-benzylguanine and topical carmustine, unless otherwise specified.

Doubtful late patch-test readings are often not considered clinically relevant. As a result, allergens with doubtful late readings may not be disclosed to the patient, and relevant allergens may not be avoided. We hypothesize that doubtful late reactions at a day 7 reading may be relevant.We compared the patients' assessments of relevance to the strength of reaction at the final reading 168 hours after patch test application to determine if doubtful late patch-test reactions are relevant.Four hundred seven subjects who underwent patch testing from January 2005 to February 2008 were mailed a survey asking if their dermatitis was more than 80% better than before patch testing and whether they needed to avoid each of their positive patch-test allergens to remain free of dermatitis. Clinical charts of respondents who indicated their dermatitis was more than 80% improved were reviewed for strength of patch-test response at day 7 for each positive patch-test result, which was then compared to the patients' assessments of relevance formulated by the investigators' interpretation of the survey.On the basis of survey interpretation, 63% of negative (0) late readings, 79% of doubtful (?+) late readings, 85% of + late readings, 84% of ++ late readings, and 100% of +++ late readings were considered relevant.Study limitations included small sample size, lack of formal validation of questionnaire, and response bias. However, based on the patients' assessments of relevance, allergens with doubtful late reactions were considered relevant almost as frequently as were allergens with + late readings.