Metachronous Squamous Cell Carcinoma of the Esophagus After Resolution of Previous Adenocarcinoma.

Esophageal cancer is the sixth leading cause of cancer-related death worldwide. Metachronous malignancies refer to multiple independent primary cancers diagnosed at least 6 months apart. The incidence of metachronous esophageal cancers with different histologic subtypes is extremely rare. This case presents an unprecedented occurrence of esophageal adenocarcinoma, followed by metachronous squamous cell carcinoma.

A Rare Case of COVID-19 Vaccination-Induced Cholangiopathic Liver Injury.

Drug-induced liver injury is a serious adverse drug reaction that can result in acute liver injury or cholestatic injury affecting the bile ducts, known as cholangiopathic liver injury (CLI). Although CLI is not as familiar as the hepatocellular pattern, emerging evidence suggests that it may occur after coronavirus disease 2019 (COVID-19) vaccination. This case report focuses on an 89-year-old woman who developed CLI after receiving the tozinameran COVID-19 vaccine. The main aim of this report was to raise awareness of the possibility of developing CLI after COVID-19 vaccination and to underscore the critical significance of promptly identifying and managing this infrequent but severe side effect.

Intracardiac leadless versus transvenous permanent pacemaker implantation: Impact on clinical outcomes and healthcare utilization.

BACKGROUND: Transvenous permanent pacemakers are used frequently to treat cardiac rhythm disorders. Recently, intracardiac leadless pacemakers offer potential treatment using an alternative insertion procedure due to their novel design. Literature comparing outcomes between the two devices is scarce. We aim to assess the impact of intracardiac leadless pacemakers on readmissions and hospitalization trends. METHODS: We analyzed the National Readmissions Database from 2016 to 2019, seeking patients admitted for sick sinus syndrome, second-degree-, or third-degree atrioventricular block who received either a transvenous permanent pacemaker or an intracardiac leadless pacemaker. Patients were stratified by device type and assessed for 30-day readmissions, inpatient mortality, and healthcare utilization. Descriptive statistics, Cox proportional hazards, and multivariate regressions were used to compare the groups. RESULTS: Between 2016 and 2019, 21,782 patients met the inclusion criteria. The mean age was 81.07 years, and 45.52 % were female. No statistical difference was noted for 30-day readmissions (HR 1.14, 95 % CI 0.92-1.41, p = 0.225) and inpatient mortality (HR 1.36, 95 % CI 0.71-2.62, p = 0.352) between the transvenous and intracardiac groups. Multivariate linear regression revealed that length of stay was 0.54 (95 % CI 0.26-0.83, p < 0.001) days longer for the intracardiac group. CONCLUSION: Hospitalization outcomes associated with intracardiac leadless pacemakers are comparable to traditional transvenous permanent pacemakers. Patients may benefit from using this new device without incurring additional resource utilization. Further studies are needed to compare long-term outcomes between transvenous and intracardiac pacemakers.

Role of Plasmapheresis in Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a rare abnormality comprising a series of symptoms that make up a syndrome. It usually happens during pregnancy or right after delivery. We describe a case of a 31-year-old female G4P2A2 (Gravida 4 Para 2 Abortions 2) who presented to the hospital for normal vaginal delivery but immediately postpartum developed HELLP syndrome. Acute fatty liver of pregnancy was a differential that the patient also met the criteria for. Her condition improved after starting her on plasmapheresis without considering hepatic transplantation. We emphasize distinguishing the overlap of symptoms between HELLP syndrome vs. acute fatty liver of pregnancy and the outcomes of plasmapheresis in managing HELLP syndrome without needing hepatic transplantation.

Ominous Sign of Pneumatosis Intestinalis With Portal Venous Gas.

The presence of gas and free air in the extraluminal space of the intestines is known as pneumatosis intestinalis (PI). There are many different causes of this finding, including gastrointestinal, pulmonary, autoimmune, and many more. It is often difficult to differentiate the etiology and clinical importance of the radiographic evidence on pneumatosis intestinalis due to the unclear pathophysiology causing the disease. To complicate things further, the ominous sign of portal venous gas poses the question of whether surgical intervention is needed. We report two cases both with clinical and radiographic evidence of secondary pneumatosis intestinalis with an associated sinister finding of portal venous gas. The cases differ by urgent surgical intervention versus observation before surgery. In this case series, we emphasize the importance of recognizing the radiographic finding and stress the need for further research to standardize a plan of care, including indications for surgery. We encourage more cases like this to be reported to aid in diagnosing and treating this condition early on with the aim of improving the mortality associated with it.

Why Definitional Clarity Matters: Implications for the Operationalization of Emotional Well-Being.

The National Institutes of Health (NIH) is increasingly prioritizing research on health-promoting processes. Park et al. (this issue) respond to a call made by NIH to advance the study of emotional well-being (EWB) and to increase understanding of the fundamental constituents of EWB across the lifespan and among diverse subgroups. They propose a definition of EWB that provides an organizing framework for research on 'psychological aspects of well-being' and health. We commend this important first step and urge consideration of three important issues related to operationalization - the process by which an abstract concept is transformed into variables that can be measured - in future research on EWB. We expect that an iterative process of construct refinement and empirical validation will advance the study of EWB, producing scientific discoveries that can be leveraged to enhance health across the lifespan.

Appendiceal Bulge on Routine Colonoscopy: Not All Disease Is Luminal.

Appendiceal mucocele is an extremely rare pathology accounting for 0.3-0.7% of all appendiceal pathology. It is characterized by appendiceal lumen dilatation by mucinous secretion collection. Though abdominal imaging and tissue Biopsy aids in diagnosis, suspicion should arise when a slight bulge or protrusion is seen on colonoscopy. We present a case of incidental appendiceal bulge found on a routine colonoscopy to evaluate abdominal pain that led to prompt diagnosis and management of appendiceal mucocele.

Regional Anesthesia as an Alternative to Moderate Sedation for Perioperative Pain Control for Percutaneous Gastrostomy Tube Placement.

Percutaneous gastrostomy tube placement is typically performed under moderate sedation. However, some patients are not ideal candidates for moderate sedation because of respiratory compromise, difficult airways, or other factors. The purpose of this study was to evaluate regional anesthesia as an alternative to moderate sedation. A retrospective review of patients who underwent percutaneous gastrostomy tube placement between March 2014 and September 2020 was performed. Data on patient demographics, anesthesia type, pain scores, and opiate usage were collected. A total of 189 patients were included in the study; 35 (18.5%) received regional anesthesia and 154 received moderate sedation. Patients in the regional anesthesia group tolerated the procedure well, with lower mean immediate postprocedural and maximal pain scores of 0.7 vs 2.2 (P = .011) and 4.3 vs 6.5 (P = .003), respectively. Regional anesthesia is effective at controlling perioperative pain and is an alternative with a low complication rate for patients who cannot tolerate moderate sedation.

New types of investments needed to address barriers to scaling up wildfire risk mitigation.

Background: Wildfire mitigation is becoming increasingly urgent, but despite the availability of mitigation tools, such as prescribed fire, managed wildfire, and mechanical thinning, the USA has been unable to scale up mitigation. Limited agency capacity, inability to work across jurisdictions, lack of public support, and procedural delays have all been cited as barriers to mitigation. But in the context of limited resources and increasing urgency, how should agencies prioritize investments to address these barriers? Results: To better understand different investments for scaling up mitigation, we examined how the wildfire problem is framed, building on existing social science demonstrating that agency approaches depend in part on how problems are framed. Using national-level policy documents and in-depth interviews, we found three ways of framing the barriers to scaling up mitigation, each emphasizing certain aspects of the problem and prioritizing different solutions or investments. The first framing, the Usual Suspects, focused on inadequate resources, cumbersome procedural requirements, delays due to litigation, and lack of public support. The solutions-to increase funding, streamline NEPA, limit litigation, and educate the public-suggest that more resources and fewer restrictions will enable agencies to scale up mitigation. The second framing, Agency-Agency Partnerships, focused on the ways that organizational structure and capacity constrain the development of effective cross-boundary collaboration. Here solutions prioritized organizational changes and capacity building to enable agencies to navigate different missions and build trust in order to develop shared priorities. The third framing, Engaging the Public, focused on lack of public support for mitigation, the need for meaningful public engagement and multi-stakeholder collaboration, and investments to build support to scale up mitigation. Conclusions: This analysis reveals that investing in collaborative capacity to advance agency-agency partnerships and public engagement might not slow down mitigation, but rather enable agencies to "go slow to go fast" by building the support and mechanisms necessary to increase the pace and scale of mitigation work. Reframing the wildfire problem through a careful analysis of competing frames and the underlying assumptions that privilege particular solutions can reveal a broader suite of solutions that address the range of key barriers.

Antecedentes: La mitigación de incendios es una tarea urgente, aunque a pesar de la disponibilidad de herramientas de mitigación, tales como quemas prescriptas, manejo del fuego, y raleos mecánicos, EEUU no ha sido aún capaz de aumentar proporcionalmente la mitigación de sus incendios. Las limitaciones en las capacidades de las agencias, la inhabilidad de trabajar entre jurisdicciones, la falta de apoyo de la sociedad, y demoras en los procedimientos, han sido citados como barreras para la mitigación. Ahora bien, en el contexto de recursos limitados e incrementos en las urgencias, ¿cómo deberían las agencias priorizar las inversiones para enfrentar esas barreras? Resultados: Para entender mejor las distintas inversiones para aumentar proporcionalmente las tareas de mitigación, examinamos cómo el problema de los incendios es enmarcado y construido en la ciencia social existente, demostrando que los enfoques de las agencias dependen, en parte, en cómo esos problemas son abordados. Usando documentos de políticas públicas y entrevistas profundas e intuitivas, encontramos tres vías de enmarcar las barreras para aumentar proporcionalmente la mitigación, cada una enfocando ciertos aspectos del problema y priorizando diferentes soluciones o inversiones. El primer enfoque, las "Sospechas Habituales", estuvo orientado hacia la inadecuación de los recursos, procedimientos incómodos, demoras debidas a litigios, y la falta de respaldo público. Las soluciones -incrementar los recursos, simplificar los procedimientos de la ley ambiental, limitar los litigios, y educar al público- sugieren que más recursos y menos restricciones permitirán a las agencias aumentar proporcionalmente la mitigación. El segundo enfoque "Asociación Agencia-Agencia", se orientó en la forma en que la estructura organizacional y su capacidad condicionan el desarrollo de una colaboración efectiva entre agencias. La solución aquí prioriza los cambios organizacionales y la capacidad de construcción para permitir a las agencias acometer diferentes misiones y crear confianza para poder desarrollar prioridades compartidas. El tercer enfoque "Comprometer al Público" se enfoca en la falta de apoyo del público para la mitigación, y la necesidad de atraer al público y la colaboración de diferentes ciudadanos interesados, en realizar aportes necesarios para construir aportes para el desarrollo de prioridades de mitigación. Conclusiones: Este análisis revela que la inversión en capacidad colaborativa para avanzar en la asociación agencia-agencia y el compromiso público puede no reducir la mitigación, más sin embargo permitir a las agencias "ir despacio para ir más rápido" para construir el soporte y mecanismos necesarios para incrementar la velocidad y la escala del trabajo de mitigación. Reencuadrar el problema de los incendios forestales a través de un cuidadoso análisis de encajes competitivos y suposiciones subyacentes que privilegie soluciones particulares, puede revelar un más amplio conjunto de soluciones que atienda el rango de barreras claves.

Atypical Stress Cardiomyopathy: A Case Report.

Stress cardiomyopathy is a reversible cause of cardiomyopathy characterized by a transient dysfunction in left ventricular systolic function. It is most common in postmenopausal women and usually occurs following an emotional and/or physical stressor. The classical imaging finding is described as left ventricular apical ballooning. However, several rare variants have been reported with a strikingly different regional distribution of wall motion abnormalities. We describe a case of a 65-year-old female who was found to have stress cardiomyopathy with variant wall motion abnormality on the left ventriculogram without a preceding stressor event. We postulate that there may be a link between stress-induced cardiomyopathy without a preceding stressor event and variant wall motion abnormality patterns.

Emerging Cybersecurity Threats in Radiation Oncology.

PURPOSE: Modern image guided radiation therapy is dependent on information technology and data storage applications that, like any other digital technology, are at risk from cyberattacks. Owing to a recent escalation in cyberattacks affecting radiation therapy treatments, the American Society for Radiation Oncology's Advances in Radiation Oncology is inaugurating a new special manuscript category devoted to cybersecurity issues. METHODS AND MATERIALS: We conducted a review of emerging cybersecurity threats and a literature review of cyberattacks that affected radiation oncology practices. RESULTS: In the last 10 years, numerous attacks have led to an interruption of radiation therapy for thousands of patients, and some of these catastrophic incidents have been described as being worse than the coronavirus disease of 2019 impact on centers in New Zealand. CONCLUSIONS: Cybersecurity threats continue to evolve, making combatting these attacks more difficult for health care organizations and requiring a change in strategies, tactics, and culture around cyber security in health and radiation oncology. We recommend an assume breach mentality (threat-informed defense posture) and adopting a cloud-first and zero-trust security strategy. A reliance on computer-driven technology makes radiation oncology practices more vulnerable to cyberattacks. Health care providers should increase their resilience and cyber security maturity. The increase in the diversity of these attacks demands improved preparedness and collaboration between oncologic treatment centers both nationwide and internationally to protect patients.

A multi-institutional assessment of COVID-19-related risk in radiation oncology.

PURPOSE: The COVID-19 pandemic has presented challenges to delivering safe and timely care for cancer patients. The oncology community has undertaken substantial workflow adaptations to reduce transmission risk for patients and providers. While various control measureshave been proposed and implemented, little is known about their impact on safety of the radiation oncology workflow and potential for transmission. The objective of this study was to assess potential safety impacts of control measures employed during the COVID-19 pandemic. METHODS: A multi-institutional study was undertaken to assess the risks of pandemic-associated workflow adaptations using failure mode and effects analysis (FMEA). Failure modes were identified and scored using FMEA formalism. FMEA scores were used to identify highest-risk aspects of the radiation therapy process. The impact of control measures on overall risk was quantified. Agreement among institutions was evaluated. RESULTS: Thirty three failure modes and 22 control measures were identified. Control measures resulted in risk score reductions for 22 of the failure modes, with the largest reductions from screening of patients and staff, requiring use of masks, and regular cleaning of patient areas. The median risk score for all failure modes was reduced from 280 to 168. There was high institutional agreement for 90.3% of failure modes but only 47% of control measures. CONCLUSIONS: COVID-related risks are similar across oncology practices in this study. While control measures can reducerisk, their use varied. The effectiveness of control measures on risk may guide selection of the highest-impact workflow adaptions to ensure safe care in oncology.

Introduction to Special Topic: Serving Children with Disabilities Within Multitiered Systems of Support.

Since the conception of the Education for All Handicapped Children Act in 1975 there has been substantial progress regarding the education of learners with disabilities. Nevertheless, significant challenges remain for addressing the diverse needs of these learners and improving in- and out-of-school outcomes. This special issue focuses on an approach that holds promise for the delivery of interventions that are aligned to learners' social, emotional, behavioral, and learning needs - multi-tiered systems of support (MTSS). The four articles that comprise the special issue highlight the need for actionable information for schools implementing MTSS, early intervention for children with or at risk for disabilities, and an enhanced focus on intensive interventions. This introduction to the special issue provides information on the meeting that motivated the special issue, a summary of each of the four articles, and paths forward for early and sustained intervention for learners with or at risk for disabilities.

FMEA of MR-Only Treatment Planning in the Pelvis.

PURPOSE: To evaluate the implementation of a magnetic resonance (MR)-only workflow (ie, implementing MR simulation as the primary planning modality) using failure mode and effects analysis (FMEA) in comparison with a conventional multimodality (MR simulation in conjunction with computed tomography simulation) workflow for pelvis external beam planning. METHODS AND MATERIALS: To perform the FMEA, a multidisciplinary 9-member team was assembled and developed process maps, identified potential failure modes (FMs), and assigned numerical values to the severity (S), frequency of occurrence (O), and detectability (D) of those FMs. Risk priority numbers (RPNs) were calculated via the product of S, O, and D as a metric for evaluating relative patient risk. An alternative 3-digit composite number (SOD) was computed to emphasize high-severity FMs. Fault tree analysis identified the causality chain leading to the highest-severity FM. RESULTS: Seven processes were identified, 3 of which were shared between workflows. Image fusion and target delineation subprocesses using the conventional workflow added 9 and 10 FMs, respectively, with 6 RPNs >100. By contrast, synthetic computed tomography generation introduced 3 major subprocesses and propagated 46 unique FMs, 15 with RPNs >100. For the conventional workflow, the largest RPN scores were introduced by image fusion (RPN range, 120-192). For the MR-only workflow, the highest RPN scores were from inaccuracies in target delineation resulting from misinterpretation of MR images (RPN = 240) and insufficient management of patient- and system-level distortions (RPN = 210 and 168, respectively). Underestimation (RPN = 140) or overestimation (RPN = 192) of bone volume produced higher RPN scores. The highest SODs for both workflows were related to changes in target location because of internal anatomy changes (conventional = 961, MR-only = 822). CONCLUSIONS: FMEA identified areas for mitigating risk in MR-only pelvis RTP, and SODs identified high-severity process modes. Efforts to develop a quality management program to mitigate high FMs are underway.

First large-scale ecological impact study of desalination outfall reveals trade-offs in effects of hypersalinity and hydrodynamics.

Desalination is an increasingly common method of meeting potable water demands, but the associated ecological risks are not well understood. Seawater desalination plants discharge large volumes of hypersaline brine directly into the ocean, raising concerns about potential impacts to marine life. In order to reduce impacts of brine, newer desalination outfalls are often fitted with high-pressure diffusers that discharge brine at high velocity into the water column, increasing the mixing and dilution of brine with ocean water. However, there are few published studies of marine impacts of desalination brine, and no well replicated before-after designs. Here we report a six-year study testing for impacts and subsequent recovery of sessile marine invertebrate recruitment near a desalination outfall with high-pressure diffusers. We used a Multiple Before-After-Control-Impact (MBACI) design to test for impacts and recovery at two distances (30 m and 100 m) from a 250 ML/day plant outfall, as well as a gradient design to test the strength of impacts relative to distance from the outfall. The diffusers achieved the target of less than 1 psµ salinity difference to surrounding ambient waters within 100 m of the discharge outfall, but sessile invertebrates were nonetheless impacted. Polychaetes, bryozoans and sponges reduced in cover as far as 100 m from the outfall, while barnacles showed the opposite pattern and were more abundant near the discharging outfall. Ecological impacts were disproportionate to the relatively minor change in salinity (∼1 psµ), suggesting a mechanism other than salinity. We propose that impacts were primarily driven by changes in hydrodynamics caused by the diffusers, such as higher near-bed flow away from the outfall. This is consistent with flow preferences of various taxonomic groups, which differ due to differences in settlement and feeding abilities. High-pressure diffusers designed to reduce impacts of hypersalinity may inadvertently cause impacts through hydrodynamics, leading to a trade-off in minimizing combined salinity and hydrodynamic stress. This study provides the first before-after test of ecological impacts of desalination brine on sessile marine communities, and rare insight into mechanisms behind impacts of a growing form of human disturbance.

Nonmelanoma Skin Cancer in Nonwhite Organ Transplant Recipients.

Importance: Organ transplant recipients have a higher incidence of skin cancer. This risk is magnified over time and with continued exposure to immunosuppression. Skin cancer in nonwhite patients is associated with greater morbidity and mortality owing to diagnosis at a more advanced stage, which suggests that nonwhite organ transplant recipients are at even higher risk. Objective: To describe demographic and clinical factors and the incidence of skin cancer in nonwhite organ transplant recipients. Design, Setting, and Participants: We performed a retrospective medical record review of patients who were organ transplant recipients (154 were white and 259 nonwhite [black, Asian, Hispanic, Pacific Islander]) seen from November 1, 2011, to April 18, 2016 at an academic referral center. Main Outcomes and Measures: Variables were analyzed and compared between racial groups, including sex, age, race/ethnicity, Fitzpatrick type, type and location of skin cancer, type of organ transplanted, time to diagnosis of skin cancer after transplantation, and history of condyloma acuminata and/or verruca vulgaris. Results: Most of the 413 patients (62.7%) evaluated were nonwhite organ transplant recipients; 264 were men, and 149 were women. Their mean (SD) age was 60.09 (13.59) years. Nineteen skin cancers were identified in 15 patients (5.8%) representing 3 racial/ethnic groups: black (6 patients), Asian (5), and Hispanic (4). All squamous cell carcinomas in blacks were diagnosed in the in situ stage, located on sun-protected sites, and occurred in patients whose lesions tested positive for human papilloma virus (HPV) and/or who endorsed a history of condyloma acuminata or verruca vulgaris. Most skin cancers in Asians were located on sun-exposed areas and occurred in individuals who emigrated from equatorial locations. Conclusions and Relevance: Nonwhite organ transplant recipients are at risk for developing skin cancer posttransplantation. Follow-up in a specialized transplant dermatology center and baseline total-body skin examination should be part of posttransplantation care in all organ transplant recipients, including nonwhite patients. A thorough inspection of the groin and genitalia is imperative in black organ transplant recipients. History of HPV infection, particularly in black organ transplant recipients, and sun exposure/emigration history in Asian organ transplant recipients should be documented. Vigilant photoprotection may be of lesser importance in the prevention of skin cancer in black organ transplant recipients. Risk factors for nonwhite organ transplant recipients differ between races/ethnicities and warrant further study in efforts to better counsel and prevent skin cancer in these patients.

How low can they go when going with the flow? Tolerance of egg and larval fishes to rapid decompression.

Egg and larval fish that drift downstream are likely to encounter river infrastructure and consequently rapid decompression, which may result in significant injury. Pressure-related injury (or barotrauma) has been shown in juvenile fishes when pressure falls sufficiently below that at which the fish has acclimated. There is a presumption that eggs and larvae may be at least as, if not more, susceptible to barotrauma injury because they are far less-developed and more fragile than juveniles, but studies to date report inconsistent results and none have considered the relationship between pressure change and barotrauma over a sufficiently broad range of pressure changes to enable tolerances to be properly determined. To address this, we exposed eggs and larvae of three physoclistic species to rapid decompression in a barometric chamber over a broad range of discrete pressure changes. Eggs, but not larvae, were unaffected by all levels of decompression tested. At exposure pressures below ∼40 kPa, or ∼40% of surface pressure, swim bladder deflation occurred in all species and internal haemorrhage was observed in one species. None of these injuries killed the fish within 24 h, but subsequent mortality cannot be excluded. Consequently, if larval drift is expected where river infrastructure is present, adopting design or operational features which maintain exposure pressures at 40% or more of the pressure to which drifting larvae are acclimated may afford greater protection for resident fishes.