Artificial intelligence-powered optimization of KI-67 assessment in breast cancer: enhancing precision and workflow efficiency. a literature review.

Breast Cancer (BC) has evolved from traditional morphological analysis to molecular profiling, identifying new subtypes. Ki-67, a prognostic biomarker, helps classify subtypes and guide chemotherapy decisions. This review explores how artificial intelligence (AI) can optimize Ki-67 assessment, improving precision and workflow efficiency in BC management. The study presents a critical analysis of the current state of AI-powered Ki-67 assessment. Results demonstrate high agreement between AI and standard Ki-67 assessment methods highlighting AI's potential as an auxiliary tool for pathologists. Despite these advancements, the review acknowledges limitations such as the restricted timeframe and diverse study designs, emphasizing the need for further research to address these concerns. In conclusion, AI holds promise in enhancing Ki-67 assessment's precision and workflow efficiency in BC diagnosis. While challenges persist, the integration of AI can revolutionize BC care, making it more accessible and precise, even in resource-limited settings.

Enhancing supercapacitor performance through design optimization of laser-induced graphene and MWCNT coatings for flexible and portable energy storage.

The field of supercapacitors consistently focuses on research and challenges to improve energy efficiency, capacitance, flexibility, and stability. Low-cost laser-induced graphene (LIG) offers a promising alternative to commercially available graphene for next-generation wearable and portable devices, thanks to its remarkable specific surface area, excellent mechanical flexibility, and exceptional electrical properties. We report on the development of LIG-based flexible supercapacitors with optimized geometries, which demonstrate high capacitance and energy density while maintaining flexibility and stability. Three-dimensional porous graphene films were synthesized, and devices with optimized parameters were fabricated and tested. One type of device utilized LIG, while two other types were fabricated on LIG by coating multi-walled carbon nanotubes (MWCNT) at varying concentrations. Characterization techniques, including scanning electron microscopy (SEM), atomic force microscopy (AFM), X-ray diffraction (XRD), Raman spectroscopy, and voltammetry, were employed to analyze the fabricated devices. AFM analysis revealed a surface roughness of 2.03 µm for LIG due to laser treatment. SEM images displayed compact, dense, and porous surface morphology. XRD analysis confirmed the presence of graphene and graphene oxide, which was further supported by energy-dispersive X-ray spectroscopy (EDX) data. Raman spectroscopy indicated that the fabricated samples exhibited distinct D and G bands at 1362 cm-1 and 1579 cm-1, respectively. Cyclic voltammetry (CV) results showed that LIG's capacitance, power density, and energy density were 6.09 mF cm-2, 0.199 mW cm-2, and 3.38 µWh cm-2, respectively, at a current density of 0.2 mA cm-2. The LIG-MWCNT coated electrode exhibited a higher energy density of 6.05 µWh cm-2 and an areal-specific capacitance of 51.975 mF cm-2 compared to the LIG-based devices. The fabricated device has potential applications in smart electronics, nanorobotics, microelectromechanical systems (MEMS), and wearable and portable electronics.

Mechanical Performance of Polymeric ARGF-Based Fly Ash-Concrete Composites: A Study for Eco-Friendly Circular Economy Application.

At present, low tensile mechanical properties and a high carbon footprint are considered the chief drawbacks of plain cement concrete (PCC). At the same time, the combination of supplementary cementitious material (SCM) and reinforcement of fiber filaments is an innovative and eco-friendly approach to overcome the tensile and environmental drawbacks of plain cement concrete (PCC). The combined and individual effect of fly ash (FA) and Alkali resistance glass fiber (ARGF) with several contents on the mechanical characteristics of M20 grade plain cement concrete was investigated in this study. A total of 20 concrete mix proportions were prepared with numerous contents of FA (i.e., 0, 10, 20, 30 and 40%) and ARGF (i.e., 0, 0.5, 1 and 1.5%). The curing of these concrete specimens was carried out for 7 and 28 days. For the analysis of concrete mechanical characteristics, the following flexural, split tensile, and compressive strength tests were applied to these casted specimens. The outcomes reveal that the mechanical properties increase with the addition of fibers and decrease at 30 and 40% replacement of cement with fly ash. Replacement of cement at higher percentages (i.e., 30 and 40) negatively affects the mechanical properties of concrete. On the other hand, the addition of fibers positively enhanced the flexural and tensile strength of concrete mixes with and without FA in contrast to compressive strength. In the end, it was concluded that the combined addition of these two materials enhances the strength and toughness of plain cement concrete, supportive of the application of an eco-friendly circular economy. The relationship among the mechanical properties of fiber-reinforced concrete was successfully generated at each percentage of fly ash. The R-square for general relationships varied from (0.48-0.90) to (0.68-0.96) for each percentage of FA fiber reinforced concrete. Additionally, the accumulation of fibers effectively boosts the mechanical properties of all concrete mixes.

Implementation of Omni-D Tele-Presence Robot Using Kalman Filter and Tricon Ultrasonic Sensors.

The tele-presence robot is designed to set forth an economic solution to facilitate day-to-day normal activities in almost every field. There are several solutions to design tele-presence robots, e.g., Skype and team viewer, but it is pretty inappropriate to use Skype and extra hardware. Therefore, in this article, we have presented a robust implementation of the tele-presence robot. Our proposed omnidirectional tele-presence robot consists of (i) Tricon ultrasonic sensors, (ii) Kalman filter implementation and control, and (iii) integration of our developed WebRTC-based application with the omnidirectional tele-presence robot for video transmission. We present a new algorithm to encounter the sensor noise with the least number of sensors for the estimation of Kalman filter. We have simulated the complete model of robot in Simulink and Matlab for the tough paths and critical hurdles. The robot successfully prevents the collision and reaches the destination. The mean errors for the estimation of position and velocity are 5.77% and 2.04%. To achieve efficient and reliable video transmission, the quality factors such as resolution, encoding, average delay and throughput are resolved using the WebRTC along with the integration of the communication protocols. To protect the data transmission, we have implemented the SSL protocol and installed it on the server. We tested three different cases of video resolutions (i.e., 320×280, 820×460 and 900×590) for the performance evaluation of the video transmission. For the highest resolution, our TPR takes 3.5 ms for the encoding, and the average delay is 2.70 ms with 900 × 590 pixels.

Targeted Next-generation Sequencing for Reliable Detection of Genetic Status in Breast Cancer.

OBJECTIVE: To test the germline oncogenic mutations in BRCA1 and BRCA2 genes, associated with triple-negative breast cancer (TNBC) patients under study, by targeted sequencing of their DNA with next-generation sequencing (NGS) platform. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Histopathology Department, Armed Forces Institute of Pathology (AFIP) Rawalpindi, Pakistan from May to June 2020. METHODOLOGY: Peripheral blood of 14 women (aged ≤60) with triple negative breast carcinoma (TNBC) was taken with the consent of performing germline genetic testing. Targeted NGS was performed for all coding regions and splicing sites of BRCA1 and BRCA2 genes, using AmpliSeq for Illumina BRCA Panel and Illumina MiSeq sequencer (placed at AFIP). Analysis and interpretation of the sequencing results have been done by using Illumina bioinformatics tools and external databases. RESULTS: Two hundred and fifty-four variants were detected in BRCA1 and BRCA2 genes, having variant quality score of 100 in all cases under study. As a result, two pathogenic variants and three variants of uncertain significance were interpreted in this germline pipeline. Cases with pathogenic variants had early onset breast cancer with age less than 35. CONCLUSION: Germline variants in BRCA were detected in the known cases of TNBC, which will not only identify the most prevalent mutations in this region; but will also make them a candidate to receive targeted therapies, which was previously not possible without genetic testing. Moreover, this study further validates the importance of early BRCA genetic screening in young patients, who have positive family history of breast carcinoma. Key Words: Breast cancer, Triple negative, Next-generation sequencing, BRCA1, BRCA2.

Genetic Mutations Associated with Pierre Robin Syndrome/Sequence: A Systematic Review.

Pierre Robin syndrome/sequence (PRS) is associated with a triad of symptoms that includes micrognathia, cleft palate, and glossoptosis that may lead to respiratory obstruction. The syndrome occurs in 2 forms: nonsyndromic PRS (nsPRS), and PRS associated with other syndromes (sPRS). Studies have shown varying genetic mutations associated with both nsPRS and sPRS. The present systematic review aims to provide a comprehensive collection of published literature reporting genetic mutations in PRS. Web of Science, PubMed, and Scopus were searched using the keywords: "Pierre Robin syndrome/sequence AND gene mutation." The search resulted in 208 articles, of which 93 were excluded as they were duplicates/irrelevant. The full-text assessment led to the further exclusion of 76 articles. From the remaining 39 articles included in the review, details of 324 cases were extracted. 56% of the cases were sPRS, and 22% of the cases were associated with other malformations and the remaining were nsPRS. Genetic mutations were noted in 30.9% of the 300 cases. Based on the review, SOX9 was found to be the most common gene associated with both nsPRS and sPRS. The gene mutation in sPRS was specific to the associated syndrome. Due to the lack of original studies, a quantitative analysis was not possible. Thus, future studies must focus on conducting large-scale cohort studies. Along with generating data on genetic mutation, future studies must also conduct pedigree analysis to assess potential familial inheritance, which in turn could provide valuable insights into the etiopathogenesis of PRS.

Next Generation Sequencing-Based Germline Panel Testing for Breast and Ovarian Cancers in Pakistan.

BACKGROUND: Pathogenic germline mutations in BRCA1/2 constitute the majority of hereditary breast and/or ovarian cancers worldwide. Incidence and mortality rate of breast and ovarian cancers in Pakistani women is high. Thus, to establish the diagnosis for targeted therapy in Pakistan, we conducted Next-generation sequencing-based germline testing for the detection of BRCA1/2 oncogenic variants associated with breast and ovarian cancer subtype. METHODS: Peripheral blood of 24 women, diagnosed with breast and epithelial ovarian cancers, was taken from the recruited cases with the consent of performing germline genetic testing. DNA was isolated from the peripheral blood and subjected to indexed BRCA Panel libraries. Targeted NGS was performed for all coding regions and splicing sites of BRCA1 and BRCA2 genes using AmpliSeq for Illumina BRCA Panel and Illumina MiSeq sequencer (placed at AFIP). Analysis of the sequencing results has been done by using Illumina bioinformatics tools. RESULTS: We detected 421 variants having a quality score of 100 in all cases under study. The list of identified variants in BRCA1 and BRCA2 genes was narrowed down after filtering out those which did not pass q30 and those with a minor allele frequency (MAF) > 0.05 based on gnomAD browser. To classify these variants, clinical significance was predicted using external curated databases. As a result, we interpreted (n = 4) 16.7% pathogenic variants in BRCA1 and (n = 6) 25% variants of uncertain significance (VUS) in both genes. Descriptive statistics depicted that the age and BMI of BRCA positive cases are less than BRCA negative cases. CONCLUSION: Our findings exhibit an initial report for the NGS based cancer genetic testing in Pakistan.  This will enable us to pursue screening and diagnosis of hereditary BRCA mutation utilizing the latest state-of-the-art technique locally available in Pakistan ultimately resulting in targeted cancer therapy.

Prevalence of advanced liver fibrosis and steatosis in type-2 diabetics with normal transaminases: A prospective cohort study.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) and type-2 diabetes mellitus (T2DM) have an intricate bidirectional relationship. Individuals with T2DM, not only have a higher prevalence of non-alcoholic steatosis, but also carry a higher risk of progression to nonalcoholic steatohepatitis. Experts still differ in their recommendations of screening for NAFLD among patients with T2DM. AIM: To study the prevalence of NAFLD and advanced fibrosis among our patient population with T2DM. METHODS: During the study period (November 2018 to January 2020), 59 adult patients with T2DM and 26 non-diabetic control group individuals were recruited prospectively. Patients with known significant liver disease and alcohol use were excluded. Demographic data and lab parameters were recorded. Liver elastography was performed in all patients. RESULTS: In the study group comprised of patients with T2DM and normal alanine aminotransferase levels (mean 17.8 ± 7 U/L), 81% had hepatic steatosis as diagnosed by elastography. Advanced hepatic fibrosis (stage F3 or F4) was present in 12% of patients with T2DM as compared to none in the control group. Patients with T2DM also had higher number of individuals with grade 3 steatosis [45.8% vs 11.5%, (P < 0.00001) and metabolic syndrome (84.7% vs 11.5%, P < 0.00001)]. CONCLUSION: A significant number of patients with T2DM, despite having normal transaminase levels, have NAFLD, grade 3 steatosis and advanced hepatic fibrosis as measured by liver elastography.

Performance Analysis of Deep-Neural-Network-Based Automatic Diagnosis of Diabetic Retinopathy.

Diabetic retinopathy (DR) is a human eye disease that affects people who are suffering from diabetes. It causes damage to their eyes, including vision loss. It is treatable; however, it takes a long time to diagnose and may require many eye exams. Early detection of DR may prevent or delay the vision loss. Therefore, a robust, automatic and computer-based diagnosis of DR is essential. Currently, deep neural networks are being utilized in numerous medical areas to diagnose various diseases. Consequently, deep transfer learning is utilized in this article. We employ five convolutional-neural-network-based designs (AlexNet, GoogleNet, Inception V4, Inception ResNet V2 and ResNeXt-50). A collection of DR pictures is created. Subsequently, the created collections are labeled with an appropriate treatment approach. This automates the diagnosis and assists patients through subsequent therapies. Furthermore, in order to identify the severity of DR retina pictures, we use our own dataset to train deep convolutional neural networks (CNNs). Experimental results reveal that the pre-trained model Se-ResNeXt-50 obtains the best classification accuracy of 97.53% for our dataset out of all pre-trained models. Moreover, we perform five different experiments on each CNN architecture. As a result, a minimum accuracy of 84.01% is achieved for a five-degree classification.

The air up there - Chilaiditi's syndrome: A case report and review of the literature.

Chilaiditi's sign is the presence of radiolucency in the subdiaphragmatic space as a result of colonic interposition, often misdiagnosed as a pneumoperitoneum. It is caused by anatomical variations that result in transpositioning of bowel within the subdiaphragmatic space. Chilaiditi's syndrome is the presentation of cardiac, respiratory or abdominal symptoms accompanied by Chilaiditi's sign. Symptomatic patients are managed with surgical intervention with the literature suggesting various resective and non-resective techniques to correct the anatomical defect. In this case an open right hemicolectomy was performed in attempt to remove the transpositioning bowel and a hepatopexy was performed to prevent any further reoccurrence of the syndrome. This case report highlights the diagnostic dilemma and management of Chilaiditi's syndrome in a resource constrained Sub-Saharan Hospital.

Case report demonstrating abdominal tuberculosis presenting as an irreducible para-umbilical hernia.

INTRODUCTION: Abdominal tuberculosis is a common form of extrapulmonary tuberculosis. Clinical manifestations and presentations are diverse depending on the organ involved within the abdominal cavity. PRESENTATION OF CASE: 26-year-old female with a background history of human immunodeficiency virus (HIV) presented with multiple irreducible para-umbilical hernias as the primary presentation of abdominal tuberculosis. Emergency hernia repair surgery revealed features of abdominal TB that was confirmed on polymerase chain reaction and histopathology. The patient was initiated on anti-tuberculosis therapy and was in a stable condition upon discharge. DISCUSSION: The uncommon presentation described is very rare with only one documented case of abdominal tuberculosis diagnosis with an umbilical hernia. Abdominal tuberculosis can present with a wide range of symptoms with a variety of imaging and invasive modalities available to confirm the diagnosis. CONCLUSION: This case report is the second documented case of abdominal tuberculosis within a paraumbilical hernia. The case report highlights paucity within literature related to the histopathological diagnosis of hernial sacs within an endemic area of tuberculosis. Further research within hernia registries of the histopathological diagnosis of hernia sacs will be beneficial for surgeons in endemic areas of abdominal tuberculosis.

Reevaluation of the Efficacy of First Line Regimen for Helicobacter pylori.

BACKGROUND: Helicobacter pylori is a common cause of gastritis, peptic ulcer disease, and non-ulcer dyspepsia, and is also associated with gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma. Despite being known about for more than 30 years, finding an effective therapeutic strategy against it remains a challenge. AIM: There are no US studies evaluating the efficacy of a Levofloxacin based therapy for H. pylori infection. We here intend to study the efficacy of Levofloxacin based triple antibiotic regimen as compared to Clarithromycin based triple therapy and Bismuth based quadruple therapy in our patient population. METHODS: This is a retrospective single center observational study. Patients with Helicobacter pylori infection who underwent treatment for H. pylori with one of the three therapies, i.e. Clarithromycin triple, Bismuth Quadruple or Levofloxacin triple, were included in the study and the eradication rates were compared. The confirmation of the H. pylori was done 4 weeks after the completion of anti-microbial therapy. RESULTS: A total of 177 individuals underwent the H. pylori treatment in our retrospective review. Of these, 54% (n=97) of patients were treated with Clarithromycin based triple therapy (Group 1), 35% (n=63) were treated with Levofloxacin based regimen (Group 2), and the remaining 11% (n=17) were treated with Bismuth based quadruple therapy (Group 3). The eradication rates were significantly higher in patients treated with Clarithromycin based triple therapy as compared to Levofloxacin based triple therapy and Bismuth quadruple therapy (78.3% vs 49.2% vs 41.1% P=0.001). CONCLUSION: In conclusion, our study shows significantly lower eradication rates with Levofloxacin triple therapy among a selected US population. Thus, it may not be a good first-line therapy among this US population and the Clarithromycin based regimen may still be used successfully.

Co-Occurrence of Rarest Type of Dysphagia Lusoria (Type N-1) and Eosinophilic Esophagitis in a Cognitively Disabled Individual.

Dysphagia is an expressive symptom, described by an individual as "difficulty in swallowing." Dysphagia due to esophageal compression from an aberrant right subclavian artery is rare, and it is termed as "dysphagia lusoria." We present a rare case of co-occurrence of dysphagia lusoria with esophageal eosinophilia in a patient with cognitive disability which portends a case with diagnostic challenge and treatment dilemma. A 31-year-old man with intellectual disability, cerebral palsy, previous history of feeding difficulty, and esophageal food impaction presented with esophageal foreign body impaction. He has no known history of atopy and food allergies. There was no laboratory evidence of peripheral eosinophilia. The IgE-mediated allergic test was unremarkable. His prior presentation revealed a diagnosis of eosinophilic esophagitis. The imaging studies showed proximal esophageal dilatation with extrinsic compression at the level of the upper esophagus. The foreign bodies were removed successfully through the help of upper endoscopy. Subsequent evaluation revealed a rare type of dysphagia lusoria (type N-1) due to an aberrant left subclavian artery arising from the right-sided aortic arch. The patient's family refused further management of artery lusoria. Prolonged stasis of secretions and food in the esophagus can also lead to increased esophageal eosinophils. In our case, it remains undetermined whether increased number of esophageal eosinophils resulted from primary eosinophilic esophagitis or due to prolonged food stasis from esophageal compression caused by an aberrant subclavian artery. However, food impaction right above the compression site makes dysphagia lusoria the likely etiology.

Preclinical cardiac disease in nonalcoholic fatty liver disease with and without metabolic syndrome.

BACKGROUND: Metabolic syndrome is associated with preclinical cardiac disease and nonalcoholic fatty liver disease (NAFLD). It is uncertain whether preclinical cardiac disease is present in patients with NAFLD without metabolic syndrome (MetS). OBJECTIVE: To explore preclinical cardiac disease in patients with NAFLD. METHODS: A total of 64 patients with NAFLD, based on computed tomography scans liver attenuation, were identified. A control group, matched to age and gender, comprising of 94 patients was also drafted. Finally, two additional groups of patients with metabolic syndrome, with (n = 40) and without (n = 74) NAFLD, were also identified. Patients with hypertension, diabetes mellitus, and other concomitant liver diseases were excluded from the NAFLD group. Echocardiograms of all groups were reviewed. RESULTS: Severe NAFLD compared to control was associated with a higher left ventricular mass after normalization for height2.7 (LVMHt2.7) (95% CI = 0.39, 12.92) and lower ratio of peak "E" (early) and "A" (late) diastolic ventricular filling velocities (E/A) - 0.39 (95% CI = -0.58, -0.19). Patients with metabolic syndrome (95% CI = 0.02, 0.09), metabolic syndrome with NAFLD (95% CI = 0.02, 0.08), or severe NAFLD (95% CI = 0.02, 0.09) compared to control was associated with a higher relative wall thickness (RWT). CONCLUSION: Healthy adults with NAFLD without metabolic syndrome, after adjusting for body mass index, demonstrated significant echocardiographic changes. Our results show that NAFLD is associated with preclinical cardiac disease, and this association is independent of traditional risk factors like systemic hypertension and diabetes mellitus.

Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach.

BACKGROUND: Various degree of extrinsic compression of the oesophagus and stomach are experienced during upper endoscopy. However, its utility in clinical practice has not been studied. METHODS: Electronic chart review of all upper gastrointestinal endoscopies done at our hospital between 2005 and 2016 was performed. A total of 79 patients with documented extrinsic compression on upper gastrointestinal procedure report who had a preceding or subsequent abdomen/chest CT imaging performed within 6 months were included. RESULTS: 30 (38%) out of 79 patients had abnormal finding on CT scan. 14 (47%) out of 30 patients had an associated malignant lesion, whereas remaining had a benign lesion. Overall, patients with associated gastrointestinal symptoms (60% vs 22%, p=0.001) or history of weight loss (50% vs 16%, p=0.001) had increased odds of having an abnormal finding on CT scan compared with the patients who lacked such symptoms. Pancreatic cancer was the most commonly diagnosed malignancy. On subgroup analysis of patients with extrinsic compression and malignant lesion on imaging study, the likelihood of a malignancy was higher in blacks as compared with Hispanics (71%:29% vs 39%:61%, p=0.031), and with presence of gastrointestinal symptoms (64% vs 22%, p=0.003), presence of weight loss (64% vs 16%, p=0.0001) and hypoalbuminaemia (p=0.001). CONCLUSION: Finding an extrinsic compression of the oesophagus and stomach on an upper endoscopy may suggest malignancy, and hence should prompt further work-up. Posterior wall gastric body compression may signal the presence of pancreatic cancer.

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature.

BACKGROUND: Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging. CASE PRESENTATION: A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough. CONCLUSION: Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.

Revisiting the Reliability of the Endoscopy and Sedation-Assisted High-Resolution Esophageal Motility Assessment.

BACKGROUND: Esophageal high-resolution manometry (HRM) is performed for evaluation of dysphagia or the pre-operative evaluation before esophageal surgery. The esophageal manometry parameters, interpreted as per the Chicago classification (CC), are meant to be acquired in an awake state. At times, the patient intolerance or inability to traverse the manometry catheter across the esophagogastric junction (EGJ) renders incomplete esophageal motility evaluation; hence, sedation or endoscopy assistance is required. There have been concerns raised regarding the use of sedation and resultant alteration of the manometry parameters. The aims were to study the effects of intravenous sedation on esophageal motility parameters and analyze its impact on outcomes of patients with dysphagia who are intolerant to awake manometry procedure. METHODS: The study population comprised patients who had sedation or the endoscopy assistance for the HRM. The indication for HRM, necessity for the sedation, manometry findings, barium esophagogram results, procedural timings and patient outcomes were reviewed. The diagnostic impact of the 10% correction in integrated relaxation pressure (IRP) was also studied. RESULTS: There were 14 patients from 179 awake manometry procedures that required the sedation or the endoscopy assistance. The mean age was 60.7 years and there was equal gender distribution. Dysphagia (n = 9) remained the predominant indication for the HRM, followed by the pre-operative evaluation for the esophageal surgery (n = 5). In eight patients, awake manometry failed due to the coiling of the catheter above the EGJ and six patients were intolerant to awake catheter insertion technique. Six patients were diagnosed with achalasia and two with EGJ obstruction. The correction of the possible 10% inflation of the IRP did not alter the final diagnosis in majority except one patient with the EGJ obstruction. The findings of the barium esophagogram corroborated the manometry diagnosis. CONCLUSION: Esophageal HRM should be done in awake state as much as possible. Sedation may be a feasible option as against aborting the further workup in patients who fail with current techniques involving awake catheter insertion. However, one needs to be mindful of sedation effects on manometry parameters and interpret results carefully.

Case of Gastric Diffuse Large B-Cell Lymphoma.

The gastrointestinal (GI) tract is the predominant site of extra nodal lymphoma involvement. In the United States (US), gastric lymphoma is the most common extra nodal site of lymphoma. Most of these lesions are either extra nodal marginal zone B cell lymphoma of mucosa associated lymphoid tissue (MALT) type or diffuse large B cell lymphoma (DLBCL). We report a case of diffuse large B-Cell Gastric Lymphoma who initially presented with sore throat, dysphagia and hiccups for a few months. Esophagogastroduodenoscopy showed lower esophageal stenosis and a large, infiltrative, ulcerated, circumferential mass at the gastro esophageal junction and cardia. Histopathology showed diffuse large B cell lymphoma. Positron emission tomography scan showed advanced disease with presence of lymph nodes on both sides of the diaphragm. The patient was considered to have Stage IV gastric lymphoma. Subsequently, he was treated with R-CHOP regimen (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin (vincristine), and prednisone).

Small-Cell Type, Poorly Differentiated Neuroendocrine Carcinoma of the Gallbladder: A Case Report and Review of the Literature.

The poorly differentiated small-cell type, neuroendocrine carcinoma (NEC) of the gallbladder is a very uncommon subtype of a neuroendocrine tumor of the gastrointestinal tract. Nonsecretory NEC by virtue of its nonspecific and subtle clinical presentation of the tumor is usually diagnosed at an advance stage with presenting symptoms related to either locally advance disease or from metastatic disease. Though the radiologic imaging does identify the gall bladder cancer, the tumor lacks a specific diagnostic test; therefore, the diagnosis is almost always confirmed on histopathologic and immunohistochemical staining. We present a case of a poorly differentiated, small-cell neuroendocrine tumor of the gallbladder. The patient died within 3 months after the definitive diagnosis was made. Survival from this deadly malignancy can be improved with aggressive surgical treatment followed by chemotherapy and radiotherapy on a case-by-case scenario. The systemic chemotherapy remained the treatment of choice for an unresectable tumor (Chen et al., 2014).