Surveillance duplex ultrasound prompted interventions after carotid endarterectomy.

OBJECTIVE: Current societal guidelines recommend duplex ultrasound (DUS) surveillance beyond 30 days after carotid endarterectomy (CEA) for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate duration of this surveillance has not yet been identified, and the rate at which DUS surveillance prompts intervention is unknown. Multiple calls for decreasing health care spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance DUS on the ipsilateral or contralateral carotid artery after CEA and determine the value of continued surveillance by determining the rate of DUS-prompted intervention. METHODS: A single-center, retrospective chart review of all patients older than 18 years who had undergone CEA from August 2009 to July 2022 was performed. Patients with at least one postoperative duplex in our Intersocietal Accreditation Council-accredited ultrasound lab were included. Exclusion criteria were patients with incomplete medical charts or patients who underwent a concomitant procedure. The primary end point was return to the operating room for subsequent intervention based on abnormal surveillance DUS findings. Secondary end points were the number of postoperative surveillance duplexes, duration of surveillance, and incidence of perioperative stroke. The study participant data were queried for patients who had a diagnosis of stroke that occurred following their procedure. RESULTS: A total 767 patients, accounting for 771 procedures, were included in this study, which resulted in 2145 ultrasound scans. A total of 40 (5.2%) patients required 44 subsequent interventions that were prompted by DUS surveillance scans. The average number of ultrasound scans per patient was 2.8 (range: 0-14), and the average duration of surveillance was 26.4 months (range: 0-155 months). Of the 767 patients, 669 (87.2%) had a unilateral CEA. A total of 62 of 767 (8.1%) patients had planned endarterectomies on the contralateral side based on initial imaging, not prompted by interval DUS surveillance scans. Of 767 patients, 28 (3.7%) patients who underwent CEA had a subsequent procedure for progression of contralateral disease, which was prompted by duplex surveillance scans. The average duration between index CEA and intervention on contralateral carotid was 29.57 months (range: 3-81 months). A total of 11 patients, accounting for 12 procedures, underwent a subsequent procedure for restenosis of their ipsilateral carotid, prompted by duplex surveillance scans. The average duration between index CEA and reintervention on the ipsilateral carotid was 17.9 months (range: 4-70 months). Three of 767 (0.4%) patients in total were identified as having a perioperative stroke. CONCLUSIONS: The overall rate of ipsilateral reintervention after CEA is low. A small percentage of patients will progress their contralateral disease, ultimately requiring surgical intervention. These data suggest that regular duplex surveillance after CEA is warranted for patients with at least moderate contralateral disease; however, the yield is low for ipsilateral restenosis after 36 months based on this single institution study. Further study is needed to better delineate which patients need follow-up to decrease unnecessary testing while still targeting patients most at risk of restenosis or contralateral progression of disease.

Exploring cell competition for the prevention and therapy of esophageal squamous cell carcinoma.

Esophageal squamous cell carcinoma (ESCC) is characterized by the development of cancer in the esophageal squamous epithelium through a step-by-step accumulation of genetic, epigenetic, and histopathological alterations. Recent studies have demonstrated that cancer-associated gene mutations exist in histologically normal or precancerous clones of the human esophageal epithelium. However, only a small proportion of such mutant clones will develop ESCC, and most ESCC patients develop only one cancer. This suggests that most of these mutant clones are kept in a histologically normal state by neighboring cells with higher competitive fitness. When some of the mutant cells evade cell competition, they become "super-competitors" and develop into clinical cancer. It is known that human ESCC is composed of a heterogeneous population of cancer cells that interact with and influence their environment and neighbors. During cancer therapy, these cancer cells not only respond to therapeutic agents but also compete with each other. Therefore, competition between ESCC cells within the same ESCC tumor is a constantly dynamic process. However, it remains challenging to fine-tune the competitive fitness of various clones for therapeutic benefits. In this review, we will explore the role of cell competition in carcinogenesis, cancer prevention, and therapy, using NRF2, NOTCH pathway, and TP53 as examples. We believe that cell competition is a research area with promising targets for clinical translation. Manipulating cell competition may help improve the prevention and therapy of ESCC.

Pediatric Appendicitis Transfers From Adult Centers: Can Alvarado Scores Help Determine Which Patients Need a CT?

BACKGROUND: Acute appendicitis is possible for any pediatric patient with abdominal pain. At our tertiary care center, patients are transferred for surgical management with unnecessary or excessive imaging. We hypothesize that using the Alvarado score (AS) to clinically stage patients will identify patient groups that could be transferred prior to imaging. METHODS: Retrospective review of pediatric patients transferred to our hospital for suspected appendicitis between 11/2020 and 3/2022 was performed. Variables collected included AS, imaging, and pathology. Alvarado score was calculated for each patient, and patients were grouped into low score, intermediate score, and high score groups. Positive predictive values (PPVs) were calculated for patients who underwent CT. RESULTS: 196 patients (age 2-17, 58% male) were transferred with suspected appendicitis. CT was obtained in 67% of patients and was not significantly different between groups. The low-score group (n=35) had a rate of appendicitis of 14% and the PPV of CT was 33%. The intermediate-score group (n = 74) had a rate of appendicitis of 62% and the PPV of CT was 88%. In the high-score group (n = 87), the rate of appendicitis was 92% and PPV of CT was 98%. DISCUSSION: Our data show that patients with low, intermediate, and high AS undergo CT at similar rates. We suggest that patients in the low score and high score groups may not benefit from reflexive CT given the likelihood of appendicitis based on the Alvarado score. We propose that CT in these groups be performed at the discretion of the pediatric center in order to expedite transfer and spare children excess radiation.

Identification and Treatment of SMARCA4 Deficient Poorly Differentiated Gastric Carcinoma.

Loss of expression of the SMARCA4 gene, a subunit of the SWI/SNF complex, has been historically associated with thoracic sarcomas. This loss of expression is extremely rare in gastric cancers, and its role in gastrointestinal tract carcinomas has not been fully elucidated. We report a case of a 73-year-old male with poorly differentiated, SMARCA4-deficient gastric cancer, showing that this immunophenotype is not limited to thoracic sarcomas or advanced-stage tumors. These tumors are often resistant to conventional FLOT chemotherapy and have poor prognoses, necessitating the need for early identification and alternative therapeutic approaches. New therapies such as EZH2 inhibitors and etoposide should be considered in cases where standard treatments are ineffective.

Stereotactic Radiosurgery for Type 1 versus Type 2 Trigeminal Neuralgias.

INTRODUCTION: It remains unclear whether stereotactic radiosurgery (SRS) offers the same benefit for patients with type 2 trigeminal neuralgia (TN2) as for those with type 1 trigeminal neuralgia (TN1). The objective of this study is to compare the outcomes of patients with TN1 and TN2 after SRS. METHODS: SRS outcomes of patients with trigeminal neuralgia treated at a single center from 1994 to 2016 were analyzed. Patients with TN1 were matched to those with TN2 in a 1:1 ratio based on sex, age, pretreatment Barrow Neurological Institute (BNI) pain score, previous treatment, previous facial numbness, and maximum dose. The primary outcome was defined as a BNI pain score of ≤3. RESULTS: The matched TN1 and TN2 cohorts each comprised 56 patients. There were no differences in BNI pain scores at last follow-up, new/worse facial numbness, or pain recurrence, or time to recurrence. Time to initial pain relief after SRS was longer for patients with TN2 (5.4 vs. 4.4 months; P = 0.0016). Actuarial initial pain relief rates were 75%, 90%, and 90% for TN1 and 47%, 77%, and 87% for TN2 at 5, 10, and 15 months, respectively. Actuarial pain relief maintenance rates were 72%, 67%, and 52% for TN1 and 53%, 32%, and 32% for TN2 at 1, 2, and 3 years, respectively. CONCLUSIONS: SRS offers similar rates of initial pain relief, pain score distribution, pain recurrence, and time to pain recurrence between patients with TN1 and TN2. The time to initial pain relief was longer for patients with TN2.

Human Coinfection with Borrelia burgdorferi and Babesia microti in the United States.

Borrelia burgdorferi, the causative agent of Lyme disease, and Babesia microti, a causative agent of babesiosis, are increasingly implicated in the growing tick-borne disease burden in the northeastern United States. These pathogens are transmitted via the bite of an infected tick vector, Ixodes scapularis, which is capable of harboring and inoculating a host with multiple pathogens simultaneously. Clinical presentation of the diseases is heterogeneous and ranges from mild flu-like symptoms to near-fatal cardiac arrhythmias. While the reason for the variability is not known, the possibility exists that concomitant infection with both B. burgdorferi and B. microti may synergistically increase disease severity. In an effort to clarify the current state of understanding regarding coinfection with B. burgdorferi and B. microti, in this review, we discuss the geographical distribution and pathogenesis of Lyme disease and babesiosis in the United States, the immunological response of humans to B. burgdorferi or B. microti infection, the existing knowledge regarding coinfection disease pathology, and critical factors that have led to ambiguity in the literature regarding coinfection, in order to eliminate confusion in future experimental design and investigation.