Disparities in Liver Transplantation for Nonalcoholic Steatohepatitis in Women.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is the fastest-growing indication for liver transplantation (LT). Sex disparities among patients with cirrhosis on the LT waitlist are well known. We wanted to understand these disparities further in women with end-stage liver disease patients listed for NASH cirrhosis in a contemporary cohort. METHODS: We used data from the Scientific Registry of Transplant Recipients to assess sex racial, and ethnic differences in NASH patients listed for LT. Adults transplanted from August 1997 to June 2021 were included. Inferential statistics were used to evaluate differences with univariate and multivariate comparisons, including competitive risk analysis. RESULTS: During the study time period, we evaluated 12 844 LT for NASH cirrhosis. Women were transplanted at a lower rate (46.5% versus 53.5%; P < 0.001) and higher model for end-stage liver disease (MELD) (23.8 versus 22.6; P < 0.001) than men. Non-White women were transplanted at a higher MELD (26.1 versus 23.1; P < 0.001) than White women and non-White male patients (26.1 versus 24.8; P < 0.001). Graft and patient survivals were significantly different (P < 0.001) between non-White women and White women and men (White and non-White). CONCLUSIONS: Evaluation of LT candidates in the United States demonstrates women with NASH cirrhosis have a higher MELD than men at LT. Additional disparities exist among non-White women with NASH as they have higher MELD and creatinine at LT compared with White women. After LT, non-White women have worse graft and patient survival compared with men or White women. These data indicate that non-White women with NASH are the most vulnerable on the LT waitlist.

Biennial Endoscopic Surveillance of Gastrointestinal Metaplasia and Its Subtypes Reduces Gastric Cancer Mortality and Is Cost-Effective in a Markov State Transition Model.

OBJECTIVES: Gastric cancer in the United States has a low survival rate mainly because of the late stage of diagnosis. Furthermore, there are no well-established guidelines concerning screening and surveillance even for higher risk patients such as those with nondysplastic noncardia gastrointestinal metaplasia (GIM), and thus they are not routinely performed. This study was designed to provide new evidence-based data that can be used to support the implementation of biennial surveillance guidelines in individuals with nondysplastic noncardia GIM. This practice can help detect early malignant lesions, thereby decreasing morbidity and mortality. We evaluated the cost-effectiveness of surveillance endoscopies for noncardia gastric cancer in populations with two different pathological diagnoses: mixed GIM and incomplete GIM (iGIM). METHODS: Markov state transition models were developed using a cohort simulation of 1000 hypothetical patients. Analysis was conducted for both mixed and iGIM. Quality-adjusted life-years and transition probabilities were derived from the published medical literature. Costs associated with endoscopy, cancer care, and surgery were based on Medicare reimbursement. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used to determine cost-effectiveness. RESULTS: Our study determined that it is significantly cost-effective to perform biennial endoscopy surveillance in patients who have been incidentally found to have noncardia mixed GIM, with a cost savings of $5783.84 per person, and in those with iGIM, with a cost savings of $8093.08 per person. CONCLUSIONS: Biennial endoscopy surveillance should be considered in all individuals found to have mixed or incomplete noncardia GIM on endoscopy. Furthermore, screening specifically for iGIM after differentiating between the two groups can lead to further cost savings. As such, we recommend that pathologists routinely differentiate between the two and recommend robust routine surveillance of iGIM.

Use of Upadacitinib in Refractory Esophageal Lichen Planus: Endoscopic Improvement in "Planus" Sight.

Although rarely reported, esophageal lichen planus is a chronic inflammatory disease that can lead to debilitating symptoms. It is reported to affect adult women in the fourth and fifth decades of life. Treatment ranges from medical therapy to endoscopic dilation. Owing to underdiagnoses and limited data on therapies, little guidance is provided in the literature regarding treatment of refractory cases. We report a case of a 68-year-old woman with esophageal lichen planus who had symptoms and lack of histological improvement despite being on budesonide and mycophenolate. She was then transitioned to upadacitinib 30 mg daily and had significant symptomatic and endoscopic improvement.

Primary Hepatic Extra-gastrointestinal Stromal Tumors: Molecular Pathogenesis, Immunohistopathology, and Treatment.

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract. They originate from the interstitial cells of Cajal and are usually found in extrahepatic gastrointestinal sites. However, a small subset are derived from the liver and are known as primary hepatic gastrointestinal stromal tumors (PHGIST). They have a poor prognosis and are historically difficult to diagnose. Our objective was to review and update the latest evidence-based knowledge concerning PHGIST, with a focus on epidemiology, etiology, pathophysiology, clinical presentation, histopathology, and treatment. These tumors are usually found incidentally, occur sporadically, and are associated with mutations of KIT and PDGFRA genes. PHGIST is a diagnosis of exclusion, as it has the same molecular, immunochemistry and histological appearance as gastrointestinal stromal tumors (GIST). Thus, imaging, such as positron emission tomography-computed tomography (PET-CT) must be used to rule out metastatic GIST before a diagnosis can be made. However, with mutation analysis and pharmacological advances, tyrosine kinase inhibitors are typically pursued with or without surgical intervention. Other potential treatments include transcatheter arterial chemoembolization and tumor ablation. However, these are typically considered palliative options. As there are only a limited number of publications regarding PHGIST, data concerning morbidity and mortality are not yet available. Immunohistopathology can help develop screening guidelines and evaluating resistance to treatment.

Pediatric Autoimmune Pancreatitis: A Single-Center Retrospective Case Series.

OBJECTIVES: Autoimmune pancreatitis (AIP) is a rare form of a chronic, immune-mediated, inflammatory pancreatic condition. There is limited data regarding presentation and outcome in the pediatric population. We described a single-center case series of 4 pediatric patients with AIP to better understand the presentation, symptoms, and outcomes of this rare condition. METHODS: Data collected included demographics, serology markers, symptoms at presentation, imaging, additional organ involvement, histology, treatment methods, and outcomes. The diagnosis of AIP was made by a combination of serology, pancreatic imaging, histology, extrapancreatic manifestations, and steroid response. RESULTS: All patients were diagnosed with type 2 AIP. Abdominal pain, emesis, and obstructive jaundice were the most common symptoms at presentation. Autoimmune markers were negative. Cross-sectional abdominal imaging showed diffuse/focal pancreatic gland enlargement and common bile duct stricture universally and main pancreatic duct irregularity in half of the patients. Biopsies showed lymphoplasmacytic infiltration with associated pancreatic fibrosis and atrophy. Treatment with an 8-week tapering course of prednisone showed prompt response with resolution of symptoms and normalization of laboratory test results. CONCLUSIONS: Our case series shows that AIP in children is a rare entity with a distinct clinical presentation, classical radiographic and histological features with good long-term prognosis.

Type 1 Autoimmune Pancreatitis Unmasked by COVID-19 Vaccine.

Autoimmune pancreatitis is a rare fibro-inflammatory disease with 2 distinct subtypes of which each has their own clinical presentation, risk factors, and histopathological patterns. We present a case of newly diagnosed type 1 autoimmune pancreatitis in a symptomatic 54-year-old man with stable ulcerative colitis 1 month after COVID-19 vaccination. Previous reports have indicated that vaccinations can trigger autoimmune disease in predisposed individuals. This case discusses the occurrence of autoimmune pancreatitis triggered after COVID-19 vaccination.

Inferior Mesenteric Vein Thrombosis Resulting in Pylephlebitis in a Patient With Inflammatory Bowel Disease.

Although uncommon, pylephlebitis is a life-threatening complication of mesenteric vein thrombosis. It is reported to affect adult men more commonly than women, with a median age of 57 years. Furthermore, few cases have been reported of pylephlebitis in patients with inflammatory bowel disease. Owing to low prevalence, there is a paucity of data regarding the diagnosis and management of pylephlebitis. Treatment approach ranges from conservative management (antibiotics and/or systemic anticoagulation) to surgical management. We report a case of a 62-year-old man diagnosed with inflammatory bowel disease with a course complicated by pylephlebitis of the inferior mesenteric vein managed successfully with antibiotics and anticoagulation.

Machine learning techniques to characterize functional traits of plankton from image data.

Plankton imaging systems supported by automated classification and analysis have improved ecologists' ability to observe aquatic ecosystems. Today, we are on the cusp of reliably tracking plankton populations with a suite of lab-based and in situ tools, collecting imaging data at unprecedentedly fine spatial and temporal scales. But these data have potential well beyond examining the abundances of different taxa; the individual images themselves contain a wealth of information on functional traits. Here, we outline traits that could be measured from image data, suggest machine learning and computer vision approaches to extract functional trait information from the images, and discuss promising avenues for novel studies. The approaches we discuss are data agnostic and are broadly applicable to imagery of other aquatic or terrestrial organisms.

Neutropenic Enterocolitis in a Patient With Acute Myeloid Leukemia.

Neutropenic enterocolitis (NE) is a medical emergency that occurs in neutropenic patients characterized by diffuse circumferential mural thickening predominantly involving the cecum. It is not easily differentiated from various other abdominal conditions (i.e., appendicitis, intussusception, ischemic colitis, small bowel obstruction, pseudomembranous colitis, and viral gastroenteritis), but clinicians should be aware of the diagnostic criteria in order to assist with prompt diagnosis. Although standard treatment has yet to be established, it is necessary to initiate early supportive care to reduce mortality risk. Here we present a case of NE with small bowel obstruction in a patient with acute myeloid leukemia (AML). Clinical findings and CT abdomen/pelvis were consistent with NE. Unfortunately, the patient succumbed to the illness.

Peritoneal Carcinomatosis as an Initial Presentation of Gastrointestinal Stromal Tumor: A Case Report and Review of the Literature.

Gastrointestinal stromal tumors (GISTs) are a rare type of tumor with a high risk of malignant transformation. The majority of GISTs are asymptomatic. Surgical resection remains the mainstay of treatment given that GIST is resistant to traditional chemotherapy and radiotherapy. In the last two decades, the discovery of targeted therapy with tyrosine kinase inhibitor therapy (TKI) and widespread mutation analysis of tumors have transformed the treatment of GIST. We present a case of a patient in whom imaging findings were consistent with carcinomatous peritonitis concerning a gynecological malignancy but who was later found to have an unresectable GIST which locally regressed with TKI.