Analysis of microplastics in various foods and assessment of aggregate human exposure via food consumption in korea.

Evidence of microplastics in humans has recently been demonstrated. The primary route of human exposure to microplastics is consumption of contaminated food and water. However, quantitative estimations of exposure to microplastics are limited, which hinders human health risk assessments. In this study, abundances of microplastics were measured in eight food types, comprising 90 products of table salts, soy sauces, fish sauces, salted seafood, seaweed, honey, beer, and beverage. Aggregate human exposure to microplastics via food consumption was assessed based on the number and mass of microplastics, using deterministic calculations and Monte Carlo simulations. The determinations revealed that average adult Koreans likely ingest 1.4 × 10-4 and 3.1 × 10-4 g of microplastics per week, respectively. These results are orders of magnitude smaller than earlier estimates of 0.1-5 g of microplastics per week that likely chose experimental outliers. Therefore, careful selection of literature data and estimation methods is needed to provide more realistic exposure estimations from microplastic counts. This study extends our understanding of MP occurrence in food and provides a more thorough estimate of aggregate microplastic exposure via food consumption.

Cardiac papillary fibroelastoma as a cause of acute coronary syndrome.

Cardiac papillary fibroelastoma (CPF) is a benign primary cardiac neoplasm, commonly found in men and above 40 years old. The clinical presentation of CPF ranges from asymptomatic to embolism-related complications such as stroke, myocardial ischemia, infarction, or ventricular fibrillation. Acute coronary syndrome is a rare complication of CPF, which was reported only in a few cases in medical literature. Hence, we report a case of a 50-year-old female with a CPF on the right coronary cusp of the aortic valve diagnosed with multi-modality imaging with definitive diagnosis through histopathologic confirmation. The patient presented with acute onset of fatigue, diaphoresis, and vomiting. Initial electrocardiogram (ECG) demonstrated T wave inversion in aVL. Repeated ECG two hours later showed persistent T wave inversion in aVL with new T wave inversions in lead I and ST depression in V2-V6. Troponin levels were elevated from 3.6 ng/L to 1503 ng/L but the patient did not report chest pain, abdominal pain, or dyspnea. Computed tomography coronary angiography did not show any significant coronary stenosis but revealed a low attenuation node with 7 × 6 mm in dimension attached to the right coronary cusp of the aortic valve. Treatment was discussed among a multidisciplinary team and the CPF was surgically removed. Learning objective: Acute coronary syndrome is a rare, but potentially fatal complication of cardiac papillary fibroelastoma (CPF). Multi-modality imaging is valuable in delineating the evaluation of exact position, dimensions, nature of cardiac masses, diagnostic workup, and preliminary assessment before the surgery. There are no clear guidelines for the treatment of CPF.

Chemoradiation with Hypofractionated Proton Therapy in Stage II-III Non-Small Cell Lung Cancer: A Proton Collaborative Group Phase 2 Trial.

PURPOSE: Hypofractionated radiation therapy has been safely implemented in the treatment of early-stage non-small cell lung cancer (NSCLC) but not locally advanced NSCLC owing to prohibitive toxicities with photon therapy. Proton therapy, however, may allow for safe delivery of hypofractionated radiation therapy. We sought to determine whether hypofractionated proton therapy with concurrent chemotherapy improves overall survival. METHODS AND MATERIALS: The Proton Collaborative Group conducted a phase 1/2 single-arm nonrandomized prospective multicenter trial from 2013 through 2018. We received consent from 32 patients, of whom 28 were eligible for on-study treatment. Patients had stage II or III unresectable NSCLC (based on the 7th edition of the American Joint Committee on Cancer's staging manual) and received hypofractionated proton therapy at 2.5 to 4 Gy per fraction to a total 60 Gy with concurrent platin-based doublet chemotherapy. The primary outcome was 1-year overall survival comparable to the 62% reported for the Radiation Therapy Oncology Group (RTOG) 9410 trial. RESULTS: The trial closed early owing to slow accrual, in part, from a competing trial, RTOG 1308. Median patient age was 70 years (range, 50-86 years). Patients were predominantly male (n = 20), White (n = 23), and prior smokers (n = 27). Most had stage III NSCLC (n = 22), 50% of whom had adenocarcinoma. After a median follow-up of 31 months, the 1- and 3-year overall survival rates were 89% and 49%, respectively, and progression-free survival rates were 58% and 32%, respectively. No acute grade ≥3 esophagitis occurred. Only 14% developed a grade ≥3 radiation-related pulmonary toxic effect. CONCLUSIONS: Hypofractionated proton therapy delivered at 2.5 to 3.53 Gy per fraction to a total 60 Gy with concurrent chemotherapy provides promising survival, and additional examination through larger studies may be warranted.

Profiling and assessing soil-air exchange of polycyclic aromatic hydrocarbons (PAHs) in playground dust and soil using ex situ equilibrium passive sampling.

Cancer risk can be associated with exposure to polycyclic aromatic hydrocarbons (PAHs) in playground dust and soil. This study investigated the profiles and sources of PAHs from poured rubber-surfaced playground dust and uncovered playground surface soil, by applying an ex-situ equilibrium passive sampling technique. Surface dust and soil samples were collected from 15 different playgrounds in Seoul, Republic of Korea. The total 16 EPA PAHs concentrations in surface dust and soil varied from 198 to 919 µg kg-1 dw and 68-169 µg kg-1 dw, respectively. 4- to 6-ring PAHs were dominant, accounting for approximately 53.8%-94.5% of the total PAHs in surface dust and soil. The diagnostic ratios and principal component analysis suggested that a mixed coal combustion and vehicular emission was likely the main source of PAHs in the surface dust and soil. The higher total organic carbon content can explain the higher PAH accumulation and lower fugacities of PAHs. The fugacity comparison of phenanthrene and pyrene in dust, soil, air, and playground surface material indicated that atmospheric deposition is the main source of PAHs in the dust and soil on rubber-surfaced and uncovered surfaced playgrounds. This study contributes to the understanding of PAHs sources in dust and soil samples in children's playground and helps policymaker determine the right contamination sources for risk management.

Innovative techniques of left atrial exposure in minimally invasive mitral valve repair.

Various atrial retractors have been developed to achieve optimal exposure of mitral valve in minimally invasive surgery. We introduce our technique of only using retraction sutures to expose mitral valve. This method is simple, efficient, and provides good exposure of the left atrium without causing traumatic injury.

Totally endoscopic resection of epicardial cardiac haemangioma under on-pump beating heart.

INTRODUCTION: Cardiac haemangioma (CH) is an extremely rare type of benign heart tumor, with prevalence only 2.8% of all primary cardiac tumors. The symptoms of tumor are often nonspecific. Preoperative screening and diagnosis are based on imaging examinations. Radical surgical resection is indicated in symptomatic patients. CASE PRESENTATION: We report on a case of an incidentally found tumor located on the right-sided epicardium that was successfully removed with the totally endoscopic surgery (TES) and the concomitant use of cardiopulmonary bypass (CPB). DISCUSSION: Excision of these tumors has been described through a median sternotomy approach. In recent years, TES has grown in popularity with many advantages. On the other hand, on-pump beating-heart (ON-BH) technique has been appreciated as a superior myocardial preservation method. The combination of these procedure provides clinical benefits and patient preferences. CONCLUSION: Totally endoscopic resection of CH under ON-BH is a safe, effective procedure, which can be adopted in similar cases.

Image-Guided Hypofractionated Proton Therapy in Early-Stage Non-Small Cell Lung Cancer: A Phase 2 Study.

PURPOSE: Due to the excellent outcomes with image-guided stereotactic body radiotherapy for patients with early-stage non-small cell lung cancer (NSCLC) and the low treatment-related toxicities using proton therapy (PT), we investigated treatment outcomes and toxicities when delivering hypofractionated PT. MATERIALS AND METHODS: Between 2009 and 2018, 22 patients with T1 to T2 N0M0 NSCLC (45% T1, 55% T2) received image-guided hypofractionated PT. The median age at diagnosis was 72 years (range, 58-90). Patients underwent 4-dimensional computed tomography simulation following fiducial marker placement, and daily image guidance was performed. Nine patients (41%) were treated with 48 GyRBE in 4 fractions for peripheral lesions, and 13 patients (59%) were treated with 60 GyRBE in 10 fractions for central lesions. Patients were assessed for CTCAEv4 toxicities with computed tomography imaging for tumor assessment. The primary endpoint was grade 3 to 5 toxicity at 1 year. RESULTS: The median follow-up for all patients was 3.5 years (range, 0.2-8.8 years). The overall survival rates at 3 and 5 years were 81% and 49%, respectively. Cause-specific survival rates at 3 and 5 years were 100% and 75%, respectively. The 3-year local, regional, and distant control rates were 86%, 85%, and 95%, respectively. Four patients experienced in-field recurrences between 18 and 45 months after treatment. One patient (5%) developed a late grade 3 bronchial stricture requiring hospitalization and stent. CONCLUSION: Image-guided hypofractionated PT for early-stage NSCLC provides promising local control and long-term survival with a low likelihood of toxicity. Regional nodal and distant relapses remain a problem.

Metastatic Anaplastic Lymphoma Kinase Rearrangement-Positive Adenocarcinoma of Occult Primary Mimicking Ovarian Cancer.

Lung cancer is a worldwide concern and is the leading cause of cancer-related death in the United States. Adenocarcinoma is the most common type of non-small cell lung cancer; however, unlike other types of lung cancer this disease is often seen in light tobacco smokers and non-smokers. The presence of driver mutations, such as the epidermal growth factor receptor (EGFR) and echinoderm microtubule-associated protein-like 4 (EML-4)-anaplastic lymphoma kinase (ALK) rearrangement, appears to be more common in these patients. The presence of the ALK mutation provides a target for ALK-inhibiting agents, such as alectinib. Routine testing for driver mutations is the standard of care in the management of advanced non-small cell lung cancer. Lung cancer frequently metastasizes to distant sites such as the bone, brain, and the adrenal glands, but rarely to the ovaries. We present a young, female, patient who complained of shortness of breath and was found to have pulmonary emboli, extensive lymphadenopathy, and a right ovarian mass. Initial pathology from a cervical lymph node favored a gastrointestinal or an ovarian malignancy. However, immunohistochemical staining ultimately suggested an occult lung adenocarcinoma primary with ovarian metastasis. She had a left oophorectomy that demonstrated similar findings and was positive for the ALK mutation. She was treated with alectinib with good response though ultimately died from her disease. This case demonstrates the rare finding of an ALK-mutated lung adenocarcinoma with ovarian metastasis and, to our knowledge, it is the first with an occult lung adenocarcinoma primary. Driver mutation testing should be considered in metastasis from an occult primary when a pulmonary malignancy is suspected.

Totally endoscopic mitral valve repair without robotic assistance: A case report.

INTRODUCTION: Totally endoscopic mitral valve repair (TEMVR) is the highest level of minimally invasive cardiac surgery (MICS). It brings many benefits to patients but the downside is that a robotic system is always required. The deployment of robotic surgery is very complicated and expensive. Therefore, we improvised, making it possible to perform TEMVR without the aid of a robotic system. PRESENTATION OF CASE: A 66-year-old male patient presented with severe mitral valve regurgitation due to posterior leaflet prolapse. He was treated with TEMVR without robotic assistance. No chest incision was over 1.2 cm. The repair techniques included posterior leaflet resection and annuloplasty with ring implantation. DISCUSSION: A midline sternotomy is still the standard approach for mitral valve repair. In recent years, MICS has gradually replaced conventional surgery with the most advanced strategy being totally robotic mitral valve repair. However, complex surgical techniques and high cost make it less accessible for the majority of patients. Instead of using robot, we improved mitral valve exposure techniques, surgical port placement and therefore were able to perform TEMVR with MICS instruments. CONCLUSION: TEMVR without robotic assistance is a safe, effective and cost-efficient procedure, which can be adopted in most cardiac centers.

Image-guided hypofractionated double-scattering proton therapy in the management of centrally-located early-stage non-small cell lung cancer.

BACKGROUND: The treatment of centrally-located early-stage non-small cell lung cancer (NSCLC) with image-guided stereotactic body radiotherapy (SBRT) is challenging due to the proximity of critical normal structures to the tumor target. The purpose of this study was to report the results of our experience in treating centrally-located early-stage NSCLC with hypofractionated proton therapy (PT). MATERIAL AND METHODS: Between 2009 and 2018, 23 patients with T1-T2N0M0 NSCLC (T1, 46%; T2, 54%) were treated with image-guided hypofractionated double-scattering PT. The median age at the time of treatment was 74 years (range, 58-88). Patients underwent 4-dimensional computed tomography (CT) simulation following fiducial marker placement, and daily image guidance was performed. All patients were treated with 60 GyRBE in 10 fractions. Patients were assessed for CTCAEv4 toxicities weekly during treatment, and at regular follow-up intervals with CT imaging for tumor assessment. Overall survival, cause-specific survival, local control, regional control, and metastases-free survival were evaluated using cumulative incidence with competing risks. RESULTS: Median follow-up for all patients was 3.2 years (range, 0.2-9.2 years). Overall survival rates at 3 and 5 years were 81% and 50% (95% CI, 27-79%), respectively. Cause-specific survival rates at 3 and 5 years were 81% and 71% (95% CI, 46-92%). The 3-year local, regional, and distant control rates were 90%, 81%, and 87%, respectively. Three patients (13%) experienced local recurrences as their first recurrence, at a median time of 28 months from completion of radiation (range, 18-61 months). Two patients (9%) experienced late grade 3 toxicities, including 1 patient who developed a bronchial stricture that required stent placement. CONCLUSION: Image-guided hypofractionated PT for centrally-located early-stage NSCLC provides excellent local control with low rates of grade ≥3 toxicities. For tumors in sensitive locations, PT may provide safer treatment than photon-based treatments due to its dosimetric advantages.

Hypofractionated Proton Therapy with Concurrent Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer: A Phase 1 Trial from the University of Florida and Proton Collaborative Group.

PURPOSE: We report the safety data from the first multicenter phase 1 trial investigating the use of hypofractionated proton therapy with concurrent chemotherapy for patients with stage II or III non-small cell lung cancer. METHODS AND MATERIALS: From 2013 through 2018, patients with newly diagnosed stage II or III non-small cell lung cancer were enrolled in a multicenter phase 1 clinical trial evaluating concurrent chemotherapy with increasing dose-per-fraction proton therapy. This was a stepwise 5 + 2 dose-intensification protocol with the following dose arms: (1) 2.5 GyRBE per fraction to 60 GyRBE; (2) 3.0 GyRBE per fraction to 60 GyRBE; (3) 3.53 GyRBE per fraction to 60.01 GyRBE; and (4) 4.0 GyRBE per fraction to 60 GyRBE. A dose arm was considered tolerable if no radiation therapy-attributable severe adverse event (SAE) occurred within 90 days of treatment among 5 patients enrolled on the arm or if 1 SAE occurred among 7 patients enrolled. Dose constraints to the heart, brachial plexus, and spinal cord were more conservative at higher doses per fraction. RESULTS: The study closed early because of slow accrual and competing enrollment in NRG 1308 before accrual was met, with no maximum tolerated dose identified. Eighteen patients were treated, including 5 patients on arms 1 and 2, 7 patients on arm 3, and 1 patient on arm 4. Two SAEs occurred among 7 patients treated at 3.53 GyRBE per fraction; however, per outside expert review, both were attributed to chemotherapy and unrelated to radiation therapy. CONCLUSIONS: Hypofractionated proton therapy delivered at 2.5 to 3.53 GyRBE per fraction to a dose of 60 GyRBE with concurrent chemotherapy has an acceptable toxicity profile. Further exploration of this regimen is warranted on a phase 2 clinical trial.

Impact of unfavorable factors on outcomes among inoperable stage II-IV Nonsmall cell lung cancer patients treated with proton therapy.

PURPOSE: To investigate the impact of unfavorable risk factors among patients with locally advanced nonsmall cell lung cancer (LA-NSCLC) treated with proton therapy (PT). MATERIAL AND METHODS: From May 2008 through July 2015, 90 consecutive patients with unresectable stage II-IV (oligometastatic) NSCLC were treated with PT. Unfavorable factors including age ≥80 years, stage IV, weight loss >10% in 3 months, performance status (PS) ≥2, FEV1 < 1.0 or O2 dependency, prior lung cancer, prior lung surgery, prior 2nd cancer in the past 3 years, and prior chest irradiation were evaluated. All patients received standard fractionation of 1.8-2 Gy(RBE) (median dose, 70 Gy[RBE]). Overall survival (OS) and progression-free survival (PFS) were calculated with the Kaplan-Meier method. The impact of unfavorable factors was analyzed in Cox regression models. RESULTS: Twenty-six percent were favorable-risk, while 42%, 22%, and 10% had 1-, 2-, or ≥3 unfavorable factors. The 2-year OS was 52% and 45% (p = .8522), and 2-year PFS was 21% and 44% (p = .0207), for favorable and unfavorable risk patients, respectively. Among patients with stage III-IV, only PS ≥2 adversely impacted OS (p = .0015). CONCLUSION: Most patients treated with PT for LA-NSCLC have unfavorable risk factors. These patients had similar outcomes to favorable-risk patients. Enrollment in future clinical trials may improve if eligibility is less restrictive.

Survivor and Caregiver Expectations and Preferences Regarding Lung Cancer Treatment.

PURPOSE: Treatment success in lung cancer is no longer restricted to objective measures of disease-specific outcomes and overall survival alone but now incorporates treatment morbidity and subjective quality of life (QoL). This study reports how lung cancer patients, survivors, and caregivers define treatment success and prioritize treatment decisions. MATERIALS AND METHODS: An online survey with both ranking and free-response questions was administered among lung cancer survivors and caregivers. Responses were used to evaluate treatment priorities, perceptions of treatment success based on Eastern Cooperative Oncology Group (ECOG) Performance Status, and troublesomeness of treatment-related toxicities. RESULTS: Among 61 respondents (29 lung cancer survivors, 28 caregivers of survivors, and 4 who were both survivors and caregivers), cancer cure was the highest priority when making treatment decisions for 74.5% of respondents, with QoL during and after treatment ranking second and third. Seventy percent of respondents felt that treatment morbidity resulting in complete dependence on others and spending the entire day confined to bed or chair would represent unsuccessful treatment. Requiring oxygen use was ranked as a very or extremely troublesome treatment toxicity by 64%, followed by shortness of breath (62%), fatigue (49%), chronic cough (34%), and appetite loss (30%). Even with remission, a 3- to 7-day hospital admission for pneumonia during treatment was deemed an unsuccessful outcome by 30%. CONCLUSION: This study highlights the importance of physicians discussing in detail with their lung cancer patients their desires and goals. Accounting for factors like expected performance status following treatment, troublesomeness of treatment toxicities, and hospitalization rates may help guide treatment decisions.

Demand and willingness to pay for different treatment and care services among patients with heart diseases in Hanoi, Vietnam.

INTRODUCTION: In Vietnam, cardiovascular diseases (CVDs) are serious health issues, especially in the context of overload central heart hospitals, insufficient primary healthcare, and lack of customer-oriented care and treatment. Attempts to measure demand and willingness-to-pay (WTP) for different CVD treatments and care services have been limited. This study explored the preferences and WTP of patients with heart diseases for different home- and hospital-based services in Hanoi, Vietnam. METHODS: A cross-sectional survey was performed at the Hanoi Heart Hospital from July to December 2017. A contingent valuation was adopted to determine the preferences of patients and measure their WTP. Interval regressions were employed to determine the potential predictors of patients' WTP. RESULTS: Hospital-based services were most preferred by patients, with demand ranging from 45.6% to 82.3% of total participants, followed by home-based (45.4%-45.8%) and administrative services (28.9%-34%). WTP for hospital-based services were in the range of US$ 9.8 (US$ 8.4-11.2)-US$ 21.9 (US$ 20.3-23.4), while figures for home-based and administrative services were US$ 9.8 (US$ 8.4-11.2)-US$ 22 (US$ 18.7-25.3) and 1.9 (US$ 1.6-2.2)-US$ 7.5 (US$ 6.3-8.6), respectively. Patients who lived in urban areas, were employed, were having higher level of education, and were not covered by health insurance were willing to pay more for services, especially home-based ones. CONCLUSION: Demand and WTP for home-based services among heart disease patients were moderately low compared with hospital-based ones. There is a need for more policies supporting home-based services, better communication of services' benefits to general public and patients, and introduction of services packages based on patients' preferences.

Fatal Type B Lactic Acidosis Associated With Metastatic Colorectal Cancer: A Case Report With Review of Literature, Pathogenesis, and Treatment.

Type B lactic acidosis associated with malignancy is a life-threatening complication and mostly seen in hematological malignancies but can also be seen in solid tumors. We report a rare case of a 64-year-old female diagnosed with metastatic adenocarcinoma of the colon with liver metastasis associated with severe type B lactic acidosis. We discuss pathophysiology, previously reported cases, and their outcomes. The most widely used therapies are bicarbonate infusion, thiamine supplementation, chemotherapy, and supportive care but is associated with poor outcomes, and no standard treatment recommendations are available. Early chemotherapy administration remains the only intervention that has shown some survival benefit. Physicians should be aware and proactive for early diagnosis and management of this condition with further research needed to guide optimal therapy.

A Novel Treatment With Obinutuzumab-Chlorambucil in a Patient With B-Cell Prolymphocytic Leukemia: A Case Report and Review of the Literature.

We report the case of a patient with B-cell prolymphocytic leukemia who was successfully treated with the novel humanized monoclonal antibody obinutuzumab. This patient was previously treated with the combination of rituximab and bendamustine and had recurrent infusion reactions. Her treatment with rituximab and bendamustine was discontinued when she developed disease progression after 3 cycles of therapy. She was then treated with obinutuzumab 1000 mg on day 1 of every cycle and chlorambucil 0.5 mg/kg on days 1 and 15 every 28 days to which she had greater tolerability. After 4 cycles of treatment, she had resolution of her clinical symptoms, massive splenomegaly, and normalization of her white blood cell count.

Metastasectomy of Solitary Adrenal Metastasis From Small Cell Lung Cancer.

Most extensive-stage small cell lung cancers have disseminated disease at diagnosis, and solitary adrenal metastasis from small cell lung cancer is rare. We report the case of a 51-year-old man with extensive-stage small cell lung cancer with solitary right adrenal metastasis (T2N0M1), who was cured with resection of primary tumor, chemotherapy (cisplatin, etoposide), adrenalectomy, consolidative thoracic radiotherapy, and prophylactic cranial irradiation. He remained cancer free, 7.5 years since diagnosis. For small cell lung cancer with solitary adrenal gland metastasis, metastasectomy combined with chemotherapy and radiotherapy can be curative and enable long-term survival. This treatment approach should be further studied, and similar cases should be reported.

High-frequency Coastal Overwash Deposits from Phra Thong Island, Thailand.

The 26th December 2004 Indian Ocean Tsunami (IOT) emanated from an Mw 9.2 earthquake that generated a 1600 km-long rupture along the Sumatran Megathrust and generated tsunami waves up to 30 m high. The IOT directly impacted the Bay of Bengal and east Africa, with over 283,000 people perishing. At the time, this catastrophic event was considered unprecedented and sparked intense investigations to test this claim. It is now believed that four pre-2004 IOT events have occurred in the last 2500 years, recurring every 550 to 700 years. Much of this information comes from Phra Thong Island, Thailand, where a sequence of four stacked sandsheets separated by organic units has been recognised and compared to the 2004 IOT event. Recently, ground-penetrating radar on Phra Thong Island identified a region that could not be explained by the known stratigraphy. The stratigraphy of the area was investigated from auger cores and pits, and several previously-unrecognised sandsheets were identified and compared to the known tsunami sandsheets. The proximity of the newly-recognised sandsheets to the palaeo-coastline of Phra Thong Island does not preclude the impacts of localised storms in sandsheet emplacement or that tsunamigenic earthquake recurrence may have been more frequent in the past.