Largely Unchanged Annual Incidence and Overall Survival of Pleural Mesothelioma in the USA.

BACKGROUND: Projections based on regulations curtailing asbestos use in the USA suggest that peak incidence of pleural mesothelioma would occur between 2000 and 2005 and then decline. We analyzed the National Cancer Database (NCDB) to assess current trends in disease incidence, patient demographics, cancer treatment, and survival. METHODS: The NCDB was queried to identify patients diagnosed with pleural mesothelioma from 2004 through 2014. Clinical and pathologic characteristics, treatments, and survival were analyzed. Risk factors for death were identified by multivariable Cox regression. RESULTS: A total of 20,988 patients with pleural mesothelioma were reported to the NCDB. The number of cases per year increased from 1783 to 1961, accounting for roughly 0.3% of all reported cancers each year. The proportion of elderly patients increased from 75 to 80%, but distribution by sex remained constant (20% female). The proportion of patients undergoing treatment increased from 34 to 54%. One-year survival increased from 37 to 47% and 3-year survival from 9 to 15% (p < 0.001). Factors associated with improved survival included younger age, female sex, epithelioid histology, treatment in an academic center, health insurance, higher income, and multimodality therapy. CONCLUSIONS: The annual incidence of mesothelioma has not declined this century and remains stable. Reporting of histologic and clinical staging has improved. National trends suggest that survival is slowly increasing despite an aging cohort. Multimodal therapy and treatment at academic centers are modifiable risk factors associated with improved survival.

Correction to: Largely Unchanged Annual Incidence and Overall Survival of Pleural Mesothelioma in the USA.

The following disclaimer is missing from the original article.

Non-Atherosclerotic Obliteration Of Bilateral Supraclinoid Internal Carotid Arteries; A Classic Case Of Moyamoya Disease.

Moyamoya disease is an idiopathic progressive vasculopathy of distal internal carotid artery and circle of Willis which leads to the development of characteristic smoky appearance of the vascular collateral network on angiography. With the highest reported incidence among Japanese population, it has been under recognized as a cause of cerebrovascular accidents in Western countries. Here we report a case of a young 20-year-old Caucasian woman who presented to the emergency department with expressive aphasia, right arm weakness and numbness for three days. Imaging modalities confirmed Moyamoya disease.

Spinal Cord Compression By Metastatic Thoracic Spine Paraganglioma.

Paragangliomas are rare neuroendocrine tumours most commonly located in the adrenal glands. The overall incidence of paragangliomas is 0.8 per 100,000 persons, but the incidence of malignant paraganglioma was found to be 93 cases out of 400 million persons in United States. We present a case of 50 year old male who came to the hospital with back pain and progressive bilateral lower limb weakness for the past 6 months. Imaging studies revealed enhancing lesions on dorsal spines. Bone scintigraphy showed increased tracer uptake at multiple sites. Bone biopsy and immune-histochemical staining proved metastatic paraganglioma. After a thorough literature search only few cases of metastatic spine paraganglioma causing spinal cord compression have been reported to date.

Effect of donor smoking and substance use on post-lung transplant outcomes.

OBJECTIVE: The study objective was to determine effects of donor smoking and substance use on primary graft dysfunction, allograft function, and survival after lung transplant. METHODS: From January 2007 to February 2020, 1366 lung transplants from 1291 donors were performed in 1352 recipients at Cleveland Clinic. Donor smoking and substance use history were extracted from the Uniform Donor Risk Assessment Interview and medical records. End points were post-transplant primary graft dysfunction, longitudinal forced expiratory volume in 1 second (% of predicted), and survival. RESULTS: Among lung transplant recipients, 670 (49%) received an organ from a donor smoker, 163 (25%) received an organ from a donor with a 20 pack-year or more history (median pack-years 8), and 702 received an organ from a donor with substance use (51%). There was no association of donor smoking, pack-years, or substance use with primary graft dysfunction (P > .2). Post-transplant forced expiratory volume in 1 second was 74% at 1 year in donor nonsmoker recipients and 70% in donor smoker recipients (P = .0002), confined to double-lung transplant, where forced expiratory volume in 1 second was 77% in donor nonsmoker recipients and 73% in donor smoker recipients. Donor substance use was not associated with allograft function. Donor smoking was associated with 54% non-risk-adjusted 5-year survival versus 59% (P = .09) and greater pack-years with slightly worse risk-adjusted long-term survival (P = .01). Donor substance use was not associated with any outcome (P ≥ 8). CONCLUSIONS: Among well-selected organs, lungs from smokers were associated with non-clinically important worse allograft outcomes without an inflection point for donor smoking pack-years. Substance use was not associated with worse allograft function. Given the paucity of organs, donor smoking or substance use alone should not preclude assessment for lung donation or transplant.

Acute Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis.

BACKGROUND/AIMS: More than 100 million people to date have been affected by the coronavirus disease-2019 (COVID-19) pandemic. Patients with COVID-19 have a higher risk of bleeding complications. We performed a systematic review and meta-analysis to evaluate the outcomes of COVID-19 patients with signs and symptoms of acute gastrointestinal bleeding (GIB). METHODS: A systematic literature search was carried out for articles published until until November 11, 2020, in the Embase, MEDLINE, Web of Science, and Cochrane Library databases. We included studies on COVID-19 patients with signs and symptoms of GIB. RESULTS: Our search yielded 49 studies, of which eight with a collective 127 patients (86 males and 41 females) met our inclusion criteria. Conservative management alone was performed in 59% of the patients, endoscopic evaluation in 31.5%, and interventional radiology (IR) embolization in 11%. Peptic ulcer disease was the most common endoscopic finding, diagnosed in 47.5% of the patients. Pooled overall mortality was 19.1% (95% confidence interval [CI]; 12.7%-27.6%) and pooled mortality secondary to GIB was 3.5% (95% CI; 1.3%-9.1%). The pooled risk of rebleeding was 11.3% (95% CI; 6.8%-18.4%). CONCLUSION: The majority of COVID-19 patients with GIB responded to conservative management, with a low mortality rate associated with GIB and the risk of rebleeding. Thus, we suggest limiting endoscopic and IR interventions to those with hemodynamic instability and those for whom conservative management was unsuccessful.

Urgently listed lung transplant patients have outcomes similar to those of electively listed patients.

OBJECTIVES: To (1) determine outcomes after urgent listing compared with elective listing for lung transplant and (2) compare in-hospital morbidity and mortality, survival, and allograft function in these 2 groups. METHODS: From January 2006 to September 2017, 201 patients were urgently and 1423 electively listed. Among urgently listed patients, 130 subsequently underwent primary lung transplant as did 995 electively listed patients. Competing-risks analysis for death and transplant after listing and weighted balancing score matching (76 pairs) were used to compare in-hospital morbidity and survival. Mixed-effect longitudinal modeling was used to compare allograft function to 8 years post-transplant. RESULTS: At 1 month, mortality was 26% in urgently listed patients, and 58% were transplanted. Risk factors for death included older age, higher bilirubin, and transfer from an outside hospital. At transplantation, urgently listed transplant patients were younger (53 ± 13 vs 55 ± 12 years), had more ventilator and extracorporeal membrane oxygenation support (32/25% vs 20/2.0%), more restrictive lung disease (95/73% vs 509/51%), and a higher lung allocation score (82 ± 13 vs 47 ± 17). In-hospital morbidity and mortality, time-related survival, and longitudinal allograft function were similar between matched groups. CONCLUSIONS: Urgent listing more often than not leads to transplantation. Although urgently listed patients are sicker overall, after transplant their perioperative morbidity and mortality, overall survival, and allograft function are similar to those of electively listed patients. Appropriate patient selection and aggressive supportive care allow urgently listed lung transplant patients to achieve these similar post-transplant outcomes.

Reining in Sternal Wound Infections: The Achilles' Heel of Bilateral Internal Thoracic Artery Grafting.

Background: Although the survival advantage of bilateral internal thoracic artery grafting (BITA) is well known in patients undergoing coronary artery bypass grafting (CABG), this technique has not been widely adopted. This is mainly because of the increased risk of deep sternal wound infections (DSWI) associated with its use. However, in recent years the overall risk of DSWI has decreased. This is mainly because of strategies that have been adopted to decrease the risk of these infections in patients undergoing CABG. Conclusion: In this review we identified DSWI preventive strategies and described them in detail so that their use by surgeons can be increased. This would minimize the risk of DSWI after BITA grafting and maximize the use of this highly effective surgical technique.

Acute Pancreatitis Secondary to Use of Appetite Suppressant: Garcinia cambogia.

Due to the global epidemic of obesity, weight loss and appetite suppressant herbal products are quite popular. As these medications are not United States Food and Drug Administration-approved and are regulated as dietary supplements, little evidence exists regarding their safety. This case discusses an 82-year-old man with the past medical history of obesity who presented to the emergency department with abdominal pain in the epigastric region. His serum lipase was elevated, and an abdominal computed tomography revealed acute pancreatitis (AP). He reported two episodes of AP in the past. He denied any alcohol use and reported no recent changes in his medications. He reported taking Garcinia cambogia (GC) recently as an appetite suppressant. Due to prior cholecystectomy, no alcohol abuse, no recent changes in medications and recent use of GC, a likely etiology of AP was thought to be secondary to the use of GC. He was treated with bowel rest and intravenous fluid hydration with significant improvement in his symptoms. He was advised to avoid GC in the future. Clinicians should be vigilant in evaluating their patients with AP and should get a meticulous history regarding their use of over-the-counter medications and herbal products.

Transformation of Recurrent Respiratory Papillomatosis: Squamous Cell Carcinoma in a Pregnant Teen.

Recurrent respiratory papillomatosis is a rare intractable benign disease with a bimodal age distribution. We present a rare case of malignant transformation of juvenile-onset recurrent respiratory papillomatosis in a 19-year-old pregnant woman, who was found to have a right upper lobe mass and cavitary nodules bilaterally that were biopsy proven to be node-negative, multifocal squamous cell carcinoma. In her second trimester, she underwent video-assisted thoracoscopic right upper lobectomy and middle lobe lateral segmentectomy, followed by left lower lobe segmentectomy 0 months later. Recovery was uneventful, and she remains disease-free 1 year following both resections.

Per oral endoscopic myotomy: Another tool in the toolbox.

OBJECTIVE: Use of per oral endoscopic myotomy is increasing for the treatment of achalasia, with potential for rapid recovery and less invasiveness. We report our experience with per oral endoscopic myotomy to better understand how it fits into a modern paradigm of achalasia management. METHODS: A total of 152 patients with achalasia underwent per oral endoscopic myotomy from April 2014 to March 2018. Type II achalasia was the most prominent subtype in 69 patients (49%), and 33 patients (21.5%) had a prior Heller myotomy. Postoperative Eckardt scores, integrated relaxation pressure, and timed barium esophagram column height and width at 2 months were compared with preoperative measurements. RESULTS: Per oral endoscopic myotomy was completed in 149 patients (98%). Median operative time was 96 minutes (75 minutes for the last 30 cases), and length of stay was 1 day (interquartile range, 1-2). The most common morbidities were mucosal perforation in 2 patients (1.3%) and bleeding in 3 patients (2.0%), although no nonendoscopic intervention was required. Mortality was zero. Postoperatively, the median Eckardt score decreased from 6 to 0 (P < .001), residual lower esophageal sphincter pressure decreased from 22 mm Hg to 6 mm Hg (P < .001), and timed barium esophagram column height and width at 5 minutes decreased from 8 and 2.5 cm to 1.5 and 0.8 cm (P < .001), respectively. Median time to return to daily activity was 7 days; 49 patients (49.5%) had abnormal acid reflux on 24-hour pH testing postprocedure. CONCLUSIONS: Per oral endoscopic myotomy is a safe and effective intervention that provides clear subjective and objective improvement in patients with achalasia. High postprocedure acid reflux raises concern about future sequelae if used in a nonselective fashion.

Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae.

INTRODUCTION: Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED: This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY: Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.

Does epiaortic ultrasound screening reduce perioperative stroke in patients undergoing coronary surgery? A topical review.

Although the occurrence of stroke in patients undergoing coronary artery bypass grafting (CABG) is decreasing, it remains an important concern. Therefore, it is important to identify and adopt strategies that can decrease the incidence of stroke in these patients. One of the strategies that have demonstrated the potential to decrease the rate of post-CABG stroke is an assessment of aorta for atherosclerosis before surgery and changing the surgical plan accordingly to minimize the stroke risk. This assessment can be done through palpation of the aorta, transesophageal echocardiography (TEE), and epiaortic ultrasound scanning (EAS). EAS has shown superiority over both palpation and TEE for intraoperative evaluation of aorta. However, despite the evidence demonstrating reduced stroke rates with the EAS-guided approach, EAS is not yet the standard of care procedure in patients undergoing CABG. Therefore, we have reviewed the literature for evidence that supports the routine use of EAS in patients undergoing coronary surgery and have presented solutions to overcome the barriers to its routine use.

Acute Pancreatitis Secondary to Severe Hypertriglyceridemia: Management of Severe Hypertriglyceridemia in Emergency Setting.

Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP). The incidence of AP is around 10-20% with levels > 2,000 mg/dL. We present here a case of a 44-year-old male with history of uncontrolled diabetes mellitus and HTG admitted with severe abdominal pain. Labs revealed elevated lipase and amylase. CT of abdomen with contrast showed AP. He was found to have a triglyceride (TG) level of 6,672 mg/dL. Besides conventional treatment for AP with intravenous (IV) hydration, he was started on IV regular insulin along with dextrose saline. He had marked improvement in his TG level the next day. He was continued on insulin and dextrose saline with hourly glucose monitoring until TG was < 500 mg/dL. He was discharged on statins and fenofibrate. The goal of management of AP secondary to severe HTG in emergency setting is to lower the TG levels to less than 500 as quickly as possible as lower levels are associated with good clinical outcomes. Apheresis and IV insulin are both helpful in lowering TG levels with no randomized controlled trials showing greater efficacy of one over other. Further episodes of AP can be prevented by lifestyle modification and lipid lowering drugs to keep TG levels below 500 mg/dL. Fibrates are first-line drugs to lower TG and used either alone or in conjunction with statins. Periodic plasmapheresis can also be considered in some non-compliant patients with recurrent episodes of pancreatitis.

Allopurinol-Induced Granulomatous Hepatitis: A Case Report and Review of Literature.

Liver enzyme elevation is a common reason for referral to a gastroenterologist. Drugs are one of the most common reasons for asymptomatic elevation of liver enzymes. We present here a case of granulomatous hepatitis (GH) secondary to long-term use of allopurinol. An 83-year-old male with a history of chronic gout and hypertension was evaluated for elevation of liver enzymes. He denies any complaints of abdominal pain, nausea, fever, chills, weight loss, night sweats, or yellowness of skin. He denies any use of herbal medications. He was on losartan and allopurinol for years. No new medications reported. Physical examination was unremarkable. Labs showed aspartate transaminase 101 U/L, alanine transaminase 81 U/L, and alkaline phosphatase 645 U/L. Ultrasound of the abdomen showed coarse liver texture. Liver biopsy was done that showed mixed GH. Given negative autoimmune and viral serologies, allopurinol-induced GH was suspected. Allopurinol was held, and repeat liver enzymes were checked in 3 months, which showed improvement in transaminase and alkaline phosphatase levels. This case highlights the importance of reviewing medications carefully when evaluating a patient with liver enzymes elevation, as stopping the offending drug can normalize the abnormalities in liver chemistries and can prevent subsequent expensive testing.