Initial Experience with Duodenoscopes with Single-Use End Caps in Pediatric Endoscopic Retrograde Cholangiopancreatography: Infection Prevention Comes at a Cost.

BACKGROUND AND AIMS: Duodenoscopes with single-use end caps were introduced to minimize infection risk, but are unstudied in pediatrics. METHODS: We collected clinical data and endoscopists' evaluations of duodenoscopes with single-use end caps versus reusable duodenoscopes over 18 months. RESULTS: A total of 106 ERCPs were performed for patients aged 1-18 (mean 14.2) years. Forty-six involved single-use end caps, with 9 requiring crossover to reusable duodenoscopes. ERCPs involving single-use end caps resulted in more instances of mucosal trauma (10 vs 0, p<0.05) and post-ERCP pancreatitis (4 vs 1, p<0.05), and accounted for 8 of 9 ERCPs requiring advanced cannulation techniques. No post-ERCP infections occurred. Reported challenges included single-use end cap stiffness and difficulty with their alignment for cannulation. CONCLUSIONS: We report difficulty with advancement, greater reliance on advanced cannulation techniques, and higher rates of PEP when using duodenoscopes with single-use end caps in pediatric ERCP. This area warrants further study.

Pediatric ERCP: Evolving into an Outpatient Procedure.

BACKGROUND: While most adult ERCPs are performed on an outpatient basis, pediatric ERCPs are typically performed on an inpatient basis, or with ERCP followed by at least one night inpatient admission. We have begun performing a substantial proportion of our pediatric ERCPs on an outpatient basis, using our clinical judgment to guide the decision process. In the present study, we compare patient characteristics, indications, and adverse events associated with outpatient vs. inpatient ERCP. METHODS: Using our endoscopy database, we identified patients 18 years of age and under who underwent ERCP from 2019 to 2021. Demographics, hospitalization status, indications, findings, interventions, as well as available adverse event and clinical outcomes data were analyzed. RESULTS: 147 ERCP procedures were performed during the study period by one of two interventional endoscopists. A subset of 51 (34.7%) patients underwent outpatient ERCP. Comparison of the two groups (outpatient vs. inpatient ERCP) was notable for no statistically significant difference in patient age, range of indications, or proportion of index vs. subsequent ERCP. Overall rates of ERCP-associated adverse events were low and there was no statistically significant difference between adverse events in patients who underwent outpatient vs. inpatient ERCP. CONCLUSION: We analyzed outpatient and inpatient pediatric ERCP patient demographics and ERCP characteristics to identify factors that guide decision to determine whether pediatric ERCPs are performed on an outpatient vs. inpatient basis. There was no significant difference in adverse events associated with outpatient vs. inpatient pediatric ERCPs, attesting to the safety of outpatient ERCP for this subset of patients in the studied context. This is an area worthy of future prospective and multi-center study.

What We Have Learned About Combining a Ketogenic Diet and Chemoimmunotherapy: a Case Report and Review of Literature.

Background: A high-fat, moderate-protein, low-carbohydrate ketogenic diet has been reported in the literature as a treatment option for patients with cancer. Case Presentation: A 69-year-old veteran was initially diagnosed with stage III colorectal cancer and progressed to having liver, pancreatic, and omental lymph node involvement despite completing adjuvant FOLFOX (fluorouracil, leucovorin calcium, and oxaliplatin) after surgery. The patient was treated with FOLFIRI (fluorouracil, leucovorin calcium, and irinotecan hydrochloride) and bevacizumab, followed by encorafenib and cetuximab on progression. Subsequently, he received pembrolizumab but continued to progress. The patient was later placed on trifluridine/tipiracil and bevacizumab concurrent with a ketogenic diet. Positron emission tomography and carcinoembryonic antigen levels indicated disease stabilization for 10 months. On progression, the patient was transitioned to ipilumimab and nivolumab and continued to adhere to the ketogenic diet. The patient's disease has continued to remain stable for the past 1 year. His degree of ketosis was determined using the glucose ketone index. The patient continues to have a good quality of life during concurrent ketogenic diet and therapy. Conclusions: This case supports the tolerability of the ketogenic diet along with chemotherapy and immunotherapy and should be considered as an adjunct to standard cancer treatment. In this report, we reviewed the latest literature about cellular mechanism of the ketogenic diet and the efficacy and relationship with chemotherapy and immunotherapy. We are about to open a ketogenic diet protocol at the Veterans Affairs Central California Health Care System in Fresno.

Lymphangitic Carcinomatosis of Possible Urothelial Origin.

Urothelial cancer with lymphangitic carcinomatosis is a rare clinical phenomenon that is not commonly associated with acute respiratory failure. However, the recent prevalence of COVID-19 may predispose a patient's respiratory system to become more susceptible to metastatic lymphangitic spread. We present a case of a 57-year-old male with progressively worsening hypoxic respiratory failure after testing positive for COVID-19 six months prior. Imaging during the hospitalization showed adenopathy consistent with lymphangitic carcinomatosis that was not present six months prior. Acute respiratory deterioration is associated more commonly with infection rather than the progression of cancer, but infectious, autoimmune, and cardiac processes were deemed minimal contributory factors. The patient's respiratory decline only allowed for a T-11 vertebral biopsy which showed poorly differentiated metastatic carcinoma of possible urothelial origin. Urothelial cancer leading to respiratory failure due to lymphangitic carcinomatosis is an uncommon phenomenon, but in the setting of prior COVID-19, it may make the respiratory system more susceptible to lymphangitic spread. However, research is limited due to the recent prevalence of COVID-19, and more research is necessary to investigate a potential correlation with rapid lymphatic carcinomatosis after COVID-19 infection.

Low post-transplant measles and varicella titers among pediatric liver transplant recipients: A 10-year single-center study.

BACKGROUND: Vaccine preventable illnesses are important sources of morbidity, mortality, and increased healthcare costs in pediatric LT recipients. Our aim was to measure the seroprevalence of antibodies to measles and VZV in this population. METHODS: We conducted a retrospective chart review of 44 patients who received LT before age 18 at UCLA Mattel Children's Hospital from January 2008 to December 2017. RESULTS: Median age at transplantation was 2.5 years (IQR 1.2-7.7). Post-transplant measles antibodies were present in 17 of 37 patients (46%); risk factors for seronegativity included younger age at transplant (p = .02) and greater time from transplant to testing (p = .04). Post-transplant VZV antibodies were present in 17 of 39 patients (44%); risk factors for seronegativity included greater time from transplant to testing (p = .04). 6 of 16 patients (38%) who tested positive for pre-transplant VZV antibodies tested negative after transplantation. Fourteen of 20 patients (70%) with at least 1 documented dose of the MMR vaccine tested positive for post-transplant measles antibodies. Ten of 20 of patients (50%) with at least 1 documented dose of the VZV vaccine tested positive for post-transplant VZV antibodies. We also describe 10 patients who received post-transplant measles and VZV vaccines without documented complications. CONCLUSIONS: Our study suggests that pediatric LT patients are at greater risk of contracting measles and VZV despite vaccination status, and that prevalence of measles and VZV antibodies decreases as time from transplantation increases. This should weigh into the institutional risk-benefit assessment when deciding whether or not to administer LAVs to these patients.

A rare case of MGRS with immunotactoid glomerulopathy responding to bortezomib, dexamethasone, and rituximab.

Patients with monoclonal gammopathy of renal significance should be treated with clone-directed therapy against sources of monoclonal proteins in order to prevent progression to more advanced monoclonal gammopathies and renal failure.

The Effect of Radium-223 Therapy in Agent Orange-Related Prostate Carcinoma.

BACKGROUND: Radium-223 (Ra-223) radioisotope has been reported to increase median survival in bone metastatic prostate carcinoma. The addition of Ra-223 to abiraterone was associated with an increased risk of bone fractures. There has been no comprehensive data for using Ra-223 in veterans who were exposed to Agent Orange (AO+). METHODS: We present a retrospective study of veterans with bone metastatic castration-resistant prostate cancer (CRPC) who received standard doses of Ra-223 and other sequential therapies at US Department of Veterans Affairs Pittsburgh Healthcare System in Pennsylvania from January 2014 to January 2019. Veterans were divided into 2 groups: those who were exposed to Agent Orange (AO+) and those who had no exposure (AO-). Time to study was calculated from the initiation of Ra-223. Time to skeletal-related events (SRE), progression of prostate specific antigen (PSA), bone metastasis, and alkaline phosphatase (ALP) were calculated in months using unpaired t test with 2-tailed P values. Median survival was calculated by Kaplan Meier R log-rank test. RESULTS: There were 34 veterans with bone metastatic CRPC: 17 veterans (50%) were AO+ and 17 veterans (50%) were AO-. The mean age of diagnosis of AO+ veterans was 62 years and 69 years (P = .005) for AO- veterans (the mean Gleason score 8.2 and 8.0, respectively [P = .71]). The median number of Ra-223 cycles was 6 (60%). Ten veterans received Ra-223 as first line (29%) and 24 veterans received Ra-223 later (71%). There were 12 SREs with median survival of 15 months. There was no difference in mean time to SRE between AO+ (8 veterans, 10.6 months) and AO- (4 veterans, 10.3 months) (P = .93). The mean time to PSA progression for AO+ was 5.4 months and AO- was 6.8 months (P = .28). Mean time to bone progression for AO+ was 7.6 months and AO- was 10.1 months (P = .16). Mean time to ALP progression for AO+ and AO- was 6.3 months and 8.7 months, respectively (P = .05). Twenty veterans (58%) had died. Median survival for Ra-223 first was 32 months and for Ra-223 later was 15 months (P = .14; hazard ratio [HR] 0.48; 95% CI, 0.17-1.3). Median survival for AO+ and AO- veterans was 12 months and 18 months, respectively (P = .15; HR, 2.0; 95% CI, 0.77-5.0). CONCLUSIONS: There was no statistical difference between AO+ and AO- veterans in terms of time to SRE, PSA, bone and ALP progression, even though there was a trend of shorter duration in AO+ veterans. There was no median survival difference between Ra-223 first vs Ra-223 later as well as between AO+ and AO- but there is a trend of worse survival in AO+ veterans.

A Rare Case of Systemic Mastocytosis With Associated Clonal Hematological Non-Mast Cell Lineage Disease That Transformed to Acute Leukemia With IDH2 Mutation.

An elderly 72-year-old man presented with anemia, thrombocytopenia, monocytosis, splenomegaly and lymphadenopathy. Bone marrow biopsy was consistent with mast cell neoplasm with positive CD117, CD25, CD34 myeloblasts and polymerase chain reaction (PCR) revealed mutation of D816V. He developed bilateral femoral neck fractures and biopsy confirmed that he has systemic mastocytosis (SM). He received cladribine and midostaurin with stable disease for 21 months. His SM with associated clonal hematological non-mast cell lineage disease (SM-AHNMD) transformed to acute myelogenous leukemia with isocitrate dehydrogenase 2 (IDH2) mutation. A trial of enasidenib was given for 5 months but without any response. Patient decided to go with home hospice and died afterwards.

A Rare Case of Sunitinib-Induced Rhabdomyolysis in Renal Cell Carcinoma.

We report a rare case of metastatic renal cell carcinoma (RCC) in a patient who developed rhabdomyolysis while on sunitinib. He was admitted to the hospital due to muscle weakness, fatigue, poor oral intake, and difficulty swallowing in March 2017. He was found to have pancytopenia, liver failure, kidney failure, high uric acid, and increased creatine phosphokinase of more than 5000. He quickly developed lactic acidosis and acute respiratory failure. He was transferred to the ICU, but his condition declined rapidly. He died 3 days later. In this article we discussed about sunitinib-mediated inhibition of adenosine monophosphate kinase (AMPK) as a possible pathophysiology of rhabdomyolysis. Our case is the third sunitinib-induced rhabdomyolysis reported in the literature.

Initiating a Standard Venous Thromboembolism Prophylaxis Order Set Designed to Improve Patient Outcomes at Los Angeles County+University of Southern California.

Improving patient safety is vital for all hospitals due to increasing public reporting and pay-for-performance reimbursement. Venous thromboembolism (VTE) remains a leading cause of preventable mortality accounting for 5 per cent of inpatient deaths. The purpose of this study was to outline the process of implementing standard VTE prophylactic order sets in a 600-bed academic safety net hospital and assess the resulting change in patient outcomes. Outcomes were assessed by comparing the rate that eligible inpatients receive VTE prophylaxis and the rate of preventable VTE's compared with total VTE's. From 2011 to 2015, random samples of 60 Los Angeles County+University of Southern California inpatients were generated monthly to examine compliance rates by comparing ICD-9 diagnostic codes to ordered VTE prophylaxis. All inpatient VTE's are retrospectively analyzed. Baseline-ordered VTE prophylaxis was 37 per cent in 2010. The target of 85 per cent was exceeded by the second quarter of 2012 to 2013 when compliance reached 88 per cent, a 51 per cent increase from baseline (P < 0.01). These results suggest VTE protocols are effective though standardization across service lines is often difficult. Despite these challenges, after implementing standard order sets, we saw compliance increase significantly. Ongoing analysis to determine whether VTE rates have significantly decreased is presently underway.

Erratum to: Modified Atkins diet in advanced malignancies-final results of a safety and feasibility trial within the Veterans Affairs Pittsburgh Healthcare System.

[This corrects the article DOI: 10.1186/s12986-016-0113-y.].

A Case of Metastatic Adamantinoma That Responded Well to Sunitinib.

Adamantinoma is a rare low-grade malignant bone tumor of epithelial origin. Metastatic adamantinoma has been reported to be resistant to chemotherapy. We report a case of metastatic adamantinoma to the lung, 10 years after the initial diagnosis of tibial mass. The patient received radiation therapy to the lung with partial response. A surveillance PET scan revealed progression of the lung mass and biopsy confirmed to be progressive residual metastatic adamantinoma. He received carboplatin and etoposide for 7 months and achieved a partial response. Four months later, PET scan showed disease progression. We started him on sunitinib, a multikinase inhibitor. He achieved a good partial response for 3 years. He died due to pneumonia at the age of 72.

Modified Atkins diet in advanced malignancies - final results of a safety and feasibility trial within the Veterans Affairs Pittsburgh Healthcare System.

BACKGROUND: Dysfunctional mitochondrial processes limit malignant cells ability to use energy from fatty acids and ketones. Animal studies using ketogenic diets for cancer show encouraging results. We tested the diet's safety and feasibility in cancer patients across a broad variety of solid tumors. METHODS: We recruited 17 advanced cancer patients who were not on chemotherapy. They consumed 20 to 40 g of carbohydrates daily with evaluations performed weekly until week 4, then every 4 weeks until 16 weeks. Quality of life questionnaires monitored for tolerability and compliance. Positron emission/computerized tomography was ordered at baseline, 4,8 and 16 weeks. Student t-testing evaluated differences between baseline and last visit scores for quality of life, weight, body mass index, and serum parameters. Correlations between weight loss and serum ketones, glucose, lipids and creatinine were done. Two-tailed unpaired t-testing of the mean weight loss compared responders against non-responders. RESULTS: Eleven out of seventeen enrolled patients were evaluable. Mean age was 65+/- 11.7 years, weight 203 +/- 4.98 lbs. (92 ± 2.3 kgs.) and previous treatment failures was 1.7, +/- 0.97. All lost significant weight with hematologic, biochemical and lipid tests remaining stable. Quality of life scores slightly improved. At 4,8 and 16 weeks, six (54.5 %), five (45.4 %) and four (36 %) patients were stable or improved. We observed no correlations between serum glucose, ketones or lipids. Clinical response did not correlate with ketosis or glycemia. Responders (stable disease or partial responders) lost statistically more weight than non-responders. Dietary compliance was difficult. Only three patients continued dieting past 16 weeks. Out of these, two patients developed brain metastases and were on steroids. They survived 80 and 116 weeks respectively. The third patient underwent residual tumor resection and has no disease at 131 weeks. CONCLUSIONS: Modified Atkins diets are safe and feasible in advanced cancer. Quality of life was preserved. Patients who lost at least 10 % of their body weight responded the best. Steroid intake affected optimal ketone and glucose levels. Despite this, survival improved in some melanoma and lung cancer patients. Further studies are recommended. TRIAL REGISTRATION: Clinicaltrials.gov NCT01716468. Registered on September 18, 2012.

Lung cancer with gastrointestinal metastasis - review of theories of metastasis with three rare case descriptions.

Approximately 1 in 14 men and women during their lifetime will be diagnosed with lung cancer, which is the leading cause of cancer-related mortality in the world. As of January 1, 2008, there were about 373,500 men and women living with lung cancer in the United States. Fewer than 60,000 of these are estimated to be alive by January 2013, reflecting a poor overall 5-year relative survival rate of under 16 %. With metastatic cancer, the overall 5-year survival is meager 4 %. On the other hand, the overall five-year survival is over 50 % when the cancer is still in the localized stage. However, unfortunately, more than half of cases of lung cancer are diagnosed at an advanced stage Howlader et al. (2010). Cancer metastasis, the single most critical prognostic factor, is still poorly understood and a highly complex phenomenon. The most common sites of lung cancer metastasis are the lymph nodes, liver, adrenals, brain and bones. The gastrointestinal (GI) tract is an exceptionally rare site of metastasis; with only a handful of cases reported in the literature Centeno et al. (Lung Cancer, 18: 101-105, 1997); Hirasaki et al. (World J Gastroenterol, 14: 5481-5483, 2008); Carr and Boulos (Br J Surg, 83: 647, 1996); Otera et al. (Eur Respir Rev, 19: 248-252, 2010); Antler et al. (Cancer, 49: 170-172, 1982); Fujiwara et al. (Gen Thorac Cardiovasc Surg, 59: 748-752, 2011); Stinchcombe et al. (J Clin Oncol, 24: 4939-4940, 2006); John et al. (J Postgrad Med, 48: 199-200, 2002); Carroll and Rajesh (Eur J Cardiothorac Surg, 19: 719-720, 2001); Brown et al. (Dis Colon Rectum, 23: 343-345, 1980). We report three cases of non-small cell (squamous cell) lung cancer with GI tract metastasis-two in the colon and one in the jejunum. Then we present a review of literature exploring various theories of metastasis, as an attempt to understand the reason of preferential tumor metastasis.

Salvage paclitaxel chemotherapy for metastatic collecting duct carcinoma of the kidney.

We report a case of metastatic collecting duct carcinoma (CDC) incidentally found on computer assisted tomography in an 18-year-old male who presented status post a motor vehicle crash (MVC). The patient underwent total nephrectomy/renal vein thrombectomy with retroperitoneal lymph node dissection, followed by multimodal therapy, with gemcitabine and platinum salt therapy, effecting a short lived complete response, followed by single agent paclitaxel chemotherapy effecting a similarly short lived partial response. We conclude that cytoreductive nephrectomy and lymphadenectomy combined with chemotherapy may be useful for extending and increasing the quality of life of selected patients with CDC.