Large Cell Neuroendocrine Carcinoma of the Gallbladder: Where Survival Is a Rare Entity - Case Report and Review of the Literature.

Introduction: Carcinoma of the gallbladder is extremely rare, papillary adenocarcinoma comprises 90% of these cases. Although neuroendocrine neoplasms (NENs) comprise 0.5% of the cases of gallbladder cancer, the incidence is rising. NEN is classified into a well-differentiated neuroendocrine tumor and poorly differentiated neuroendocrine cancer (NEC). Histologically, NEC is small-cell or large-cell carcinoma. We present the extremely rare case, 15th in the literature to be precise, of large cell neuroendocrine carcinoma of the gallbladder. Case Presentation: A 72-year-old male presented to the emergency department with constipation and right upper quadrant pain for 3 months. Computed tomography scan of the abdomen demonstrated an ill-defined 7.2 × 4.9 cm hypodense lesion in the gallbladder fossa with extension into the liver. Histopathological and immunohistochemical analysis of the biopsy specimen confirmed the diagnosis of large cell neuroendocrine carcinoma of the gallbladder. He was started on palliative chemotherapy. Conclusion: The plethora of tumors present in the gallbladder necessitates a search for risk factors for gallbladder neoplasia, and underscores the need to more carefully examine the nature of "asymptomatic gallstones." Further studies may reveal subclasses of cholelithiasis, gallbladder morphology, or imaging to define which patients should be followed more carefully, and may clarify additional risk factors for cancer of the gallbladder.

Granular Cell Tumor of the Ascending Colon.

Granular cell tumor (GCT) was first described by Abrikossoff in 1926. It is a mostly benign tumor with rare malignant transformation. It is defined as a soft tissue neoplasm with abundant eosinophilic cytoplasm. The mean age of diagnosis for GCT is around 45 years. It is rare for GCT to be found in the gastrointestinal (GI) tract. Within the subset of GI tract, the colon is an extremely rare site for it to be found. Franburg-Smith histopathology criteria are used to differentiate a benign from a malignant GCT. The malignant form is aggressive with high recurrence rates after resection. Histopathology and immunohistochemical stains are used to make a definitive diagnosis. Herein, we present a rare case of an ascending colon polyp that was resected and found to be a benign GCT.

Trends in Palliative Care, Hospice Utilization, and Outcomes in Hospitalized Pancreatic Cancer Patients: A Nationwide Analysis.

Background and objective The prognosis of pancreatic cancer (PC) is generally poor. PC responds only modestly to chemotherapy and chemoradiation, and surgical resection remains the only curative option. The risk of recurrence is high. PC patients are encountered in the hospital on initial diagnosis and later for surgeries and complications from PC. We analyzed PC hospitalizations in the United States as reported in the National Inpatient Sample (NIS) database from 2005 to 2011 to determine the extent to which aggressive interventions could be avoided, thereby decreasing the cost of hospitalization. We analyzed trends in palliative care utilization and hospice services. Methods The International Classification of Disease 9th Revision (ICD-9) codes were used to identify diagnoses and procedures performed. Weighted analysis was performed using SPSS Statistics 28.0 (IBM Corp., Armonk, NY). Dispositions at discharge were noted. Complications and procedures performed were also documented. Results A total of 574,522 cases with PC were identified. Trends are reported chronologically (2005 to 2011). Over time, inpatient deaths for PC have decreased (11.2%, 11.1%, 9.8%, 9.8%, 9.5%, 8.4%, 8.1%; p<0.001), and hospice discharges (HD) have increased (10.2%, 11.4%, 11.4%, 12,2%, 12.6%, 12.4%, 12.7%; p<0.001). Palliative care utilization has increased (2.9%, 3.9%, 3.8%, 5.6%, 8.8%, 10.2%, 11.9%; p<0.001). Complications including peritonitis, thrombosis, hypovolemia/shock, and acute kidney injury (AKI) have increased mortality rates and HD. Conclusion There is an increasing trend of palliative care and hospice service utilization among hospitalized PC patients. Until better-targeted treatments and screening become available, mortality and morbidity will remain high. The proportion of patients receiving aggressive interventions remains high and is associated with poor outcomes. It is desirable to conduct palliative care evaluation (PCE) early in patients with advanced disease and avoid aggressive interventions.

Early Colonoscopy in Hospitalized Patients With Acute Lower Gastrointestinal Bleeding: A Nationwide Analysis.

Background: Performing colonoscopy within 24 h of presentation to the hospital is the accepted standard of care for patients with an acute lower gastrointestinal bleed (LGIB). Previous studies have failed to demonstrate the benefit of early colonoscopy (EC) on mortality. In this study, we wanted to see if there was a change in inpatient deaths (primary outcome), length of stay (LOS), and hospitalization charges (TOTCHG) (secondary outcomes) with EC compared to previous studies. Methods: Adults diagnosed with LGIB were identified using the International Classification of Disease 10th Revision codes from the National Inpatient Sample database for 2016 to 2019. EC was defined as the procedure performed within 24 h of hospitalization. Delayed colonoscopy (DC) was defined as a procedure performed after 24 h of presentation. The patient population was divided into EC and DC groups, and the effects of several covariates on outcomes were measured using binary logistic and multivariate regression analysis. Inverse probability treatment weighting (IPTW) was performed to adjust for confounding covariates. Results: There were 1,549,065 cases diagnosed with LGIB, of which 285,165 cases (18.4%) received a colonoscopy. A total of 107,045 (6.9%) patients received early colonoscopies. EC was associated with decreased inpatient deaths (0.9% in EC, and 1.4% in DC, P < 0.001). However, upon IPTW, this difference was not present. EC was associated with a decreased LOS (median 3 days vs. 5 days, P < 0.001) and TOTCHG (median $32,037 vs. $44,092, P < 0.001). Weekend admissions (WA) were associated with fewer EC (31.6% in WA, and 39.5% in non-WA, P < 0.001). WA did not affect inpatient deaths. Conclusions: EC was not associated with decreased inpatient deaths. There was no difference in endoscopic interventions in both EC and DC groups. The difference in inpatient deaths observed between the two groups was not evident upon adjusting the results for confounders. EC was associated with a decreased LOS, and TOTCHG in patients with LGIB.

Ingested Potassium Chloride Pills on Imaging Misdiagnosed As Foreign Bodies in the Stomach: An Insight on Radiopaque/Hyperdense Substances in the Gastrointestinal Tract.

Foreign bodies are very common in the GI tract. Around 100,000 cases are reported each year in the United States. A total of 80% of those foreign body ingestions occur in the pediatric population. There are several reasons for foreign body impaction in the GI tract in adults. Psychiatric problems, anatomical abnormalities in the GI tract such as esophageal web, diverticula, stricture, and eating big food boluses are frequent causes of foreign body impaction in adults. Rarely do radio-opaque ingested materials appear as a foreign body in imaging studies. Such objects include several commonly used medications such as iron preparations, potassium chloride pills, amiodarone, spironolactone, bisoprolol, and lisinopril. Herein, we present one such case of potassium chloride pill ingestion, where it appeared as a foreign body in the stomach. However, on the endoscopic examination and repeat X-ray, the foreign body had been digested and disappeared.

An Extremely Rare Case of Rectal Signet Ring Cell Carcinoma.

Signet ring cell carcinoma of the rectum is a rare variant of colorectal cancer. When found, it is often diagnosed in late stages and has poor prognosis. This case depicts a patient with a history of Crohn's disease who presented to the hospital for perirectal abscesses. During the evaluation of both the abscesses and Crohn's disease, he was found to have stage IV adenocarcinoma with signet ring cell features. The patient was started on chemotherapy before surgical resection was considered, however, showed little response. The patient's family eventually pursued hospice care with comfort measures only. Colorectal signet ring cell carcinoma is rare but has poor prognosis as it is diagnosed generally at late and advanced stages. There is a need for more research in earlier detection of these rare cancers.

Optimal Hair Transplant Recipient Site Slit Design: Minimizing Vascular Damage.

An often overlooked aspect of hair transplantation is the art of recipient site design and slit creation. There is also a lack of consensus on which technique provides the optimum coverage while minimizing vascular damage. This paper aims to provide logical arguments to determine the optimal instrument and method of slit creation, in order to ensure maximum density, optimal survival, minimal pop-out, and minimal damage to scalp vascularity. The use of semiconical blades reduces the damage to the dermis and vascular plexus as compared with rectangular blades and needles, as the depth of penetration required is lower. The use of acute angle reduces the depth of penetration for the same length of slit and decreases damage to deep plexus. Coronal slits produce less vascular damage than that of sagittal slits with the same size blades. We believe that these recommendations provide the optimum volume slits while causing minimal vascular damage.

Modifications of Multi Slit Knife for Enhanced Versatility in Balding and Vertex Area Hair Transplant.

In hair transplantation, recipient-site creation is an important step. It is a repetitive and time-consuming step, which increased the "out-of-body time" for the grafts, which could hamper their survival. To solve this problem, we had devised an instrument called the Multi Slit Knife (MSK). The MSK has advantages of creating a high-density brick pattern of recipient sites in significantly less time. It had the undesirable side effect of damaging the preexisting hair follicles while making slits in the balding region. The MSK had some limitations. It was also difficult to maneuver the MSK in the vertex region where maintaining the natural whorl pattern of hair is important to obtain optimal aesthetic results. To overcome the shortcomings of the original MSK, we made a few changes to it to make a new modified MSK. It has fewer knives and a smaller platform as compared to the original MSK, better ergonomics, and more customizability with choices for blade sizes, number, and spacing. It tries to retain the advantages of the original MSK while reducing the damage to the preexisting hairs in the recipient regions. It is also better adapted at creating the recipient sites in a whorl pattern, closely mimicking the natural direction and angles of the hair in the vertex region. The modified MSK can be used singly or in combination with the original MSK, based on the patient's recipient areas, making it a versatile set of instrument for making multiple coronal slits for hair transplant.