Mechanisms of action behind the protective effects of proactive esophageal cooling during radiofrequency catheter ablation in the left atrium.

Proactive esophageal cooling for the purpose of reducing the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures is increasingly being used and has been Food and Drug Administration cleared as a protective strategy during left atrial RF ablation for the treatment of atrial fibrillation. In this review, we examine the evidence supporting the use of proactive esophageal cooling and the potential mechanisms of action that reduce the likelihood of atrioesophageal fistula (AEF) formation. Although the pathophysiology behind AEF formation after thermal injury from RF ablation is not well studied, a robust literature on fistula formation in other conditions (eg, Crohn disease, cancer, and trauma) exists and the relationship to AEF formation is investigated in this review. Likewise, we examine the abundant data in the surgical literature on burn and thermal injury progression as well as the acute and chronic mitigating effects of cooling. We discuss the relationship of these data and maladaptive healing mechanisms to the well-recognized postablation pathophysiological effects after RF ablation. Finally, we review additional important considerations such as patient selection, clinical workflow, and implementation strategies for proactive esophageal cooling.

Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter.

BACKGROUND AND AIMS: GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported. METHODS: Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm2. The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions. RESULTS: Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization. CONCLUSIONS: In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.

Temporal Trends in Incidence and Outcomes of Acute Pancreatitis in Hospitalized Patients in the United States From 2002 to 2013.

OBJECTIVES: We sought to examine temporal trends in incidence and outcomes of acute pancreatitis (AP) in hospitalized adult patients in the United States. METHODS: Subjects were obtained from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for the years 2002-2013. Incidence of AP, all-cause mortality, cost, and duration of hospitalization were assessed. RESULTS: We identified 4,791,802 cases of AP. A significant increase in the incidence of AP was observed from 9.48 cases per 1000 hospitalizations in 2002 to 12.19 per 1000 hospitalizations in 2013 (P < 0.001). In-hospital mortality decreased from 2.99 cases per 100 cases in 2002 to 2.04 cases per 100 cases in 2013 (P < 0.001). Mean length of stay decreased from 6.99 (standard deviation [SD], 9.37) days in 2002 to 5.74 (SD, 7.94) days in 2013 (P < 0.001). Cost of hospitalization increased from $27,827 (SD, $54,556) in 2002 to $49,772 (SD, $106,205) in 2013 (P < 0.001). CONCLUSIONS: Hospital admissions for AP in adults increased significantly in the United States from 2002 to 2013. In-hospital all-cause mortality and mean length of stay significantly decreased. In contrast, total cost of hospitalization rose.

Calciphylaxis in the Setting of Alcoholic Cirrhosis: Case Report and Literature Review.

Calciphylaxis can be a severe life-threatening dermatologic disease that is a known complication associated with end-stage renal disease. However, multiple non-uremic etiologies that are not yet well studied can cause calciphylaxis. We report a rare care of a 40-year-old female with history of alcoholic cirrhosis without any evidence of renal dysfunction who presents with calciphylaxis.

PISMA: A Visual Representation of Motif Distribution in DNA Sequences.

BACKGROUND: Because the graphical presentation and analysis of motif distribution can provide insights for experimental hypothesis, PISMA aims at identifying motifs on DNA sequences, counting and showing them graphically. The motif length ranges from 2 to 10 bases, and the DNA sequences range up to 10 kb. The motif distribution is shown as a bar-code-like, as a gene-map-like, and as a transcript scheme. RESULTS: We obtained graphical schemes of the CpG site distribution from 91 human papillomavirus genomes. Also, we present 2 analyses: one of DNA motifs associated with either methylation-resistant or methylation-sensitive CpG islands and another analysis of motifs associated with exosome RNA secretion. AVAILABILITY AND IMPLEMENTATION: PISMA is developed in Java; it is executable in any type of hardware and in diverse operating systems. PISMA is freely available to noncommercial users. The English version and the User Manual are provided in Supplementary Files 1 and 2, and a Spanish version is available at www.biomedicas.unam.mx/wp-content/software/pisma.zip and www.biomedicas.unam.mx/wp-content/pdf/manual/pisma.pdf.

Klippel-Trenaunay Syndrome of the Rectosigmoid Colon Presenting as Severe Anemia.

A 23-year-old female with Klippel-Trenaunay syndrome presented with abdominal pain and severe anemia. Colonoscopy revealed diffuse venous congestion extending circumferentially from the midsigmoid to the rectum, with multiple large varicosities. This case emphasizes that Klippel-Trenaunay syndrome may have visceral manifestations beyond the classic presentation, which can be a significant source of morbidity and mortality.

Safety of percutaneous endoscopic gastrostomy tube placement in patients with continuous-flow ventricular assist devices.

In this retrospective study, the safety of percutaneous endoscopic gastrostomy (PEG) tube placement was evaluated as maintaining adequate nutritional support for patients with left ventricular assist devices is crucial. Nineteen patients who underwent PEG tube placement were followed for an average of 40 days. Overall, minor complications such as infections, bleeding, and PEG tube malposition occurred in just 19% of patients while the rate of major complications such as perforation was 5%. Further randomized control trials are necessary to validate this assertion that the safety of PEG placement in patients with left ventricular assist devices is similar to that of the general population.

Analysis of CpG methylation sites and CGI among human papillomavirus DNA genomes.

BACKGROUND: The Human Papillomavirus (HPV) genome is divided into early and late coding sequences, including 8 open reading frames (ORFs) and a regulatory region (LCR). Viral gene expression may be regulated through epigenetic mechanisms, including cytosine methylation at CpG dinucleotides. We have analyzed the distribution of CpG sites and CpG islands/clusters (CGI) among 92 different HPV genomes grouped in function of their preferential tropism: cutaneous or mucosal. We calculated the proportion of CpG sites (PCS) for each ORF and calculated the expected CpG values for each viral type. RESULTS: CpGs are underrepresented in viral genomes. We found a positive correlation between CpG observed and expected values, with mucosal high-risk (HR) virus types showing the smallest O/E ratios. The ranges of the PCS were similar for most genomic regions except E4, where the majority of CpGs are found within islands/clusters. At least one CGI belongs to each E2/E4 region. We found positive correlations between PCS for each viral ORF when compared with the others, except for the LCR against four ORFs and E6 against three other ORFs. The distribution of CpG islands/clusters among HPV groups is heterogeneous and mucosal HR-HPV types exhibit both lower number and shorter island sizes compared to cutaneous and mucosal Low-risk (LR) HPVs (all of them significantly different). CONCLUSIONS: There is a difference between viral and cellular CpG underrepresentation. There are significant correlations between complete genome PCS and a lack of correlations between several genomic region pairs, especially those involving LCR and E6. L2 and L1 ORF behavior is opposite to that of oncogenes E6 and E7. The first pair possesses relatively low numbers of CpG sites clustered in CGIs while the oncogenes possess a relatively high number of CpG sites not associated to CGIs. In all HPVs, E2/E4 is the only region with at least one CGI and shows a higher content of CpG sites in every HPV type with an identified E4. The mucosal HR-HPVs show either the shortest CGI size, followed by the mucosal LR-HPVs and lastly by the cutaneous viral subgroup, and a trend to the lowest CGI number, followed by the cutaneous viral subgroup and lastly by the mucosal LR-HPVs.

Extra-gastrointestinal stromal tumor presenting as hemorrhagic pancreatic cyst diagnosed by EUS-FNA.

CONTEXT: Pancreatic gastrointestinal stromal tumors (GIST) are rare mesenchymal tumor with only 6 cases reported to date. We report a case of pancreatic GIST presenting as hemorrhagic cyst. CASE REPORT: A 63-year-old female with past medical history of hypertension and pancreatic mass presented with fatigue. She was found to have anemia requiring blood transfusion. An abdominal CT scan revealed an 11x16 cm cystic mass at the pancreatic body that had increased in size compared with previous CT scan. Endoscopic ultrasound confirmed a large complex pancreatic mass and fine needle aspiration demonstrated gross bloody fluid. Cytology revealed a spindle cell lesion. Immunohistochemistry from cyst wall biopsy was strongly positive for CD34 and CD117 confirming the diagnosis of pancreatic GIST. CONCLUSION: We report a case of pancreatic GIST which presented as hemorrhagic cyst. Endoscopic ultrasound guided fine needle aspiration plays an important role in the diagnosis. Although it is an uncommon tumor, pancreatic GIST should be in differential diagnosis of hemorrhagic pancreatic cystic lesions as well as a rare cause of solid pancreatic lesions.

The value of touch imprint cytology in EUS-guided Trucut biopsy.

BACKGROUND: EUS-guided Trucut biopsy (TCB) enables the acquisition of tissue cores for histologic assessment. Touch imprint cytology (TIC) can be performed at the time of a biopsy to assess the adequacy of the sample; however, limited information is available on the diagnostic value of TIC of these specimens. OBJECTIVE: To investigate the diagnostic accuracy of TIC compared with a TCB. PATIENTS AND DESIGN: Consecutive EUS-guided TCB and TIC (n = 109) were retrospectively and independently reviewed by a surgical pathologist (for the TCB) and a cytopathologist (for TIC) blinded to the final diagnoses. SETTING: University of Iowa Hospitals and Clinics, Iowa. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of a TCB, TIC, and combined TCB + TIC. RESULTS: The diagnostic accuracy of a TCB was 92.7% (95% CI, 83.1%-97.3%), TIC was 82.6% (95% CI, 74.3%-88.6%), and TCB + TIC was 95.4% (95% CI, of 89.4%-98.3%). The diagnostic accuracy of a TCB alone was superior to TIC alone (P = .038); a TCB was diagnostic in 14 cases that were nondiagnostic by TIC. The addition of TIC allowed for the identification of 3 malignancies (2.8%) that were not identified on TCB alone. In 22 cases, TIC was considered diagnostic, but a TCB provided additional specific diagnostic information. LIMITATIONS: Retrospective study and relatively low numbers. CONCLUSIONS: TIC is a valuable tool for use in a EUS-guided TCB; TIC is independently diagnostically accurate, which allows for confidence in a rapid preliminary diagnosis, and it provides additional diagnostic value when combined with TCB.

Endoscopic argon plasma coagulation of Marlex mesh erosion after vertical-banded gastroplasty.

BACKGROUND: Marlex mesh erosions may occur as late complications after vertical-banded gastroplasty. Experience with the endoscopic treatment is limited. OBJECTIVE: To describe the use of argon plasma coagulation in the endoscopic treatment of eroded Marlex mesh. DESIGN: Case report. SETTINGS: Endoscopy Unit, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. PATIENTS: We describe the endoscopic treatment of eroded Marlex mesh in 2 patients who presented with symptoms of gastric-outlet obstruction. INTERVENTIONS: In both cases, argon plasma coagulation was used to break down the eroded Marlex mesh. Fragments were subsequently removed with forceps and electrocautery snares. We did not encounter any complications with this method. RESULTS: The endoscopic treatment resulted in lasting symptomatic improvement in both patients. LIMITATIONS: Our experience is limited to 2 cases. CONCLUSIONS: Argon plasma coagulation appears to be a promising option for the endoscopic treatment of eroded Marlex mesh. It allows the fragmentation of large mesh portions and enables subsequent removal with a snare and a forceps. This method can result in symptomatic improvement and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.

Palliative endoscopic ultrasound-guided drainage of a malignant pancreatic cyst causing gastric outlet obstruction.

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has been well described but it is not an established therapy for malignant pancreatic cystic neoplasms. We report the first EUS-guided cystogastrostomy for the palliative treatment of a cystic pancreatic adenocarcinoma. CASE REPORT: We describe a 70-year-old male with a nonresectable cystic pancreatic adenocarcinoma causing partial gastric outlet obstruction treated successfully with palliative EUS-guided cystogastrostomy stent placement. The diagnosis was confirmed by EUS-guided fine needle aspiration. Computerized tomography (CT) and EUS staging revealed vascular invasion precluding the patient from surgical resection. Cystogastrostomy was performed entirely under EUS guidance utilizing a 10-Fr double pigtail stent. After cystogastrostomy stent placement, the patient developed dramatic symptomatic improvement of gastric outlet obstructive symptoms, although subsequent imaging did not reveal complete collapse of the cystic structure. CONCLUSION: EUS-guided cystogastrostomy can be considered in the palliative treatment of nonresectable pancreatic cystic neoplasms. Cyst decompression may result in significant symptomatic improvement, although the architecture of malignant cysts may prevent complete resolution.

EUS characteristics of celiac ganglia with cytologic and histologic confirmation.

BACKGROUND: Celiac ganglia have not been previously identified by EUS. OBJECTIVE: To assess whether celiac ganglia can be detected by EUS and to define their characteristics. DESIGN: Retrospective review followed by prospective study. METHODS: Retrospective characterization was performed of all celiac ganglia that were incidentally identified by EUS-guided FNA or tru-cut needle biopsy from January 2004 to October 2005. We also prospectively assessed if these structures could be visualized in consecutive patients undergoing curved linear-array EUS. PATIENTS: Seven patients with celiac ganglia diagnosed by EUS-guided FNA (n = 7) and/or tru-cut needle biopsy (n = 1) were reviewed. Twenty-two patients were prospectively evaluated by curved-linear-array EUS. SETTINGS: Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. MAIN OUTCOME MEASUREMENTS: EUS features and detection rate of celiac ganglia. RESULTS: All retrospectively evaluated celiac ganglia were identified anterior to the aorta, slightly to the left, and cephalad to the celiac artery take-off, and medial to the left adrenal gland. The mean distance from the celiac artery take-off was 10 mm (+/-3 mm); mean size was 13 mm (+/-3 mm) by 6 mm (+/-2 mm). They appeared as hypoechoic and multilobulated structures with hyperechoic strands. Celiac ganglia with sonographic features as described above were identified in 16 of 22 prospectively evaluated patients (73%). LIMITATIONS: Small number of patients; no tissue confirmation of prospectively evaluated patients. CONCLUSIONS: Celiac ganglia can be identified with curved linear-array EUS in the majority of patients. Their typical EUS appearance allows distinction from celiac lymph nodes.

Pancreatic metastasis of an ovarian malignant mixed Mullerian tumor identified by EUS-guided fine needle aspiration and Trucut needle biopsy.

CONTEXT: Malignant mixed Mullerian tumors are rare ovarian neoplasms that account for less than 2% of ovarian malignancies. They have a generally poor prognosis and often develop recurrent disease. To our knowledge, this is the first report of a malignant mixed Mullerian tumor with metastasis to the pancreas. The metastatic tumor was identified by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and Trucut needle biopsy of the pancreas. CASE REPORT: We describe a 69-year-old female with concomitant Duke's C adenocarcinoma of the colon and stage III-C malignant mixed Mullerian tumor that presented with malignant ascites, increasing abdominal girth and a pancreatic head mass. EUS revealed an 11 cm cystic mass in the head of the pancreas that was characterized as a carcinosarcoma/malignant mesodermal mixed tumor by EUS-FNA and Trucut needle biopsy. The tumor was morphologically identical to the surgical specimen of her ovarian mass. The patient was treated with palliative chemotherapy and a three-month follow up CT scan did not reveal any new metastatic lesions. CONCLUSION: The pancreas is a rare site of metastasis and more commonly seen in renal cell carcinoma, melanoma or lung tumors; amongst others. Although ovarian adenocarcinoma has been reported as a primary site of pancreatic metastasis, it has not been previously described originating from a mixed Mullerian tumor of the ovary presenting as a cystic pancreatic head mass.

Low-volume oral colonoscopy bowel preparation: sodium phosphate and magnesium citrate.

BACKGROUND: Low-volume oral colonoscopy preparations are easier to tolerate and are gaining popularity at the expense of large-volume lavage solutions. The aims of this two-part study were to compare two oral colonoscopy bowel preparations, sodium phosphate (NaP) and magnesium citrate (Mg), and to assess the effects of timing and dilution of NaP. METHODS: Part 1 included 300 ambulatory patients randomized to receive NaP or Mg on the day before colonoscopy. Patients completed a questionnaire before colonoscopy. The endoscopist, blinded to the type of bowel preparation, rated bowel cleansing and recorded the presence of any rectosigmoid aphthous ulcers. In part 2, a total of 297 patients received NaP diluted into 3 doses 10 minutes apart the evening before and the morning of the day of colonoscopy. This group was compared with the group in part 1 that received NaP in two separate single doses entirely the day before colonoscopy. RESULTS: NaP and Mg were well tolerated. When preparations were taken the day before colonoscopy, Mg achieved better bowel cleansing (p < 0.001). Taking NaP entirely the day before colonoscopy resulted in poor right colon cleansing (27%). In contrast, taking NaP the evening before and morning of colonoscopy improved cleansing in the right colon (p < 0.001). Vomiting occurred less frequently with dilution of NaP. Rectosigmoid aphthous ulcers occurred more often with NaP (5.5%) than Mg (1%), p < 0.01. For patients who, according to questionnaire, had received a previous bowel preparation, NaP and Mg were both preferred over large-volume lavage solutions, whereas NaP was preferred over Mg. CONCLUSIONS: When taken entirely the day before colonoscopy, Mg is superior to NaP. Taking NaP the evening before and morning of colonoscopy improved bowel cleansing compared with taking it entirely the day before. Dilution of NaP reduces vomiting. NaP induces rectosigmoid aphthous ulcers more often than Mg.