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Background: Advances in cancer therapies and improvement in survival of cancer patients have led to a growing number of patients with both cancer and severe aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has been shown to be a safe and effective treatment option for this patient population. There are established racial disparities in utilization and outcomes of both cancer treatments and TAVR. However, the effect of race on TAVR outcomes in cancer patients has not been studied., Objectives: The purpose of this study was to investigate racial disparities in outcomes of TAVR in cancer patients., Methods: 343 patients with cancer who underwent TAVR at a single center over a 6-year period were included in the study. The primary endpoint was a composite of 1-year mortality, stroke, and bleeding. Secondary outcomes included individual components of the primary endpoint as well as 30-day mortality, structural complications, vascular access complications, and conduction system complications. Outcomes were compared between black and white patients by comparing incidence rates., Results: Baseline characteristics including age, sex, BMI, medical comorbidities, STS score, and echocardiographic parameters were similar between races, aside from significantly higher rates of CKD (50.0% vs. 26.6%, p  = 0.005) and ESRD (18.4% vs. 4.9%, p  = 0.005) in black compared to white cancer patients. There was a trend toward worse outcomes in black cancer patients with regard to a composite endpoint of 1-year mortality, stroke, and major bleeding (35.7% vs. 22.6%, p  = 0.095), primarily driven by higher 1-year mortality (31.0% vs. 17.6%, p  = 0.065). 30-day mortality was twice as high in black cancer patients than in white cancer patients (4.8% vs. 2.3%, p  = 0.018)., Conclusions: There is a trend toward worse TAVR outcomes in black cancer patients, with higher periprocedural complication rates and mortality, compared to white cancer patients. Further studies are needed to elucidate the structural, socioeconomic, and biological factors that contribute to racial differences in outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Kotloff, Desai, Desai, Messner, Gnilopyat, Sonbol, Aljudaibi, Tarui, Ives, Shah, Vaish, Chahal, Barr and Mysore.)

Patients with concomitant severe aortic stenosis and significant coronary artery disease present a diagnostic and therapeutic challenge in clinical practice. There are no clear-cut guidelines as to the timing of revascularization in these patients who are referred for transcatheter aortic valve replacement (TAVR). This article aims to show that in patients without high-grade proximal coronary artery disease, revascularization after TAVR is safe, feasible, and practical. Additionally, the use of preoperative TAVR computed tomographic angiography might be used in both intermediate and high-risk patients rather than invasive coronary angiography to assess for significant proximal coronary artery disease to help guide the timing of revascularization., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is lower and the risk for complications higher compared with other non-CTO PCI. Although interventionalists focus on intimal plaque characteristics, the coronary media is an important (especially for techniques involving antegrade dissection and re-entry) but poorly understood structure in CTO PCI., Objectives: The aim of the present study was to investigate coronary medial wall thinning in CTO lesions and determine how this thinning might affect CTO PCI., Methods: A total of 2,586 sections were investigated, from arteries with evidence of CTO from 54 subjects (1,383 sections) and arteries without evidence of CTO from 54 subjects with non-coronary-related deaths (1,203 sections) after matching for age, gender, body weight, and body height., Results: The medial thickness in subjects with CTO was lower than that in those with non-coronary-related death (P < 0.001). In subjects with CTO, CTO lesions had thinner medial walls compared with those with lower luminal narrowing (P < 0.001). At the CTO distal segments, the 6- to 12-mm distal segment from the distal end of the CTO had significantly less luminal narrowing (P < 0.001), and similar medial thickness, compared with the distal end of the CTO. Immunohistochemical analysis revealed that short-duration CTO had more cleaved caspase-3-positive cells in media and had significantly more CD3 + , CD4 + , CD8 + , and CD4 + CD28 null T cells compared with long-duration CTO., Conclusions: CTO lesions demonstrated coronary medial thinning compared with non-CTO lesions. Further investigation of the cause-and-effect relationship among inflammation, apoptosis, and coronary medial wall thinning is warranted in future mechanistic studies., Competing Interests: Funding Support and Author Disclosures This study was supported by the CVPath Institute. Drs Virmani and Finn have received institutional research support from the National Institutes of Health (grant HL141425), a Leducq Foundation grant, 480 Biomedical, 4C Medical, 4Tech, Abbott, AccuMedical, Amgen, Biosensors, Boston Scientific, Cagent Vascular, Cardiac Implants, CeloNova BioSciences, Claret Medical, Concept Medical, Cook, Cardiovascular Systems, DuNing, Edwards Lifesciences, Emboline, Endotronix, Envision Scientific, Lutonix Bard, Gateway, LifeTech, LimFlow, MedAlliance, Medtronic, Mercator, Merill, MicroPort Medical, MicroVention, Mitralign, Mitra Assist, North American Science Associates, Nanova, Neovasc, Nipro, Novogate, Occlutech, OrbusNeich Medical, Phenox, Profusa, Protembis, Qool, Recor, Senseonics, Shockwave Medical, SINOMED, Spectranetics, Surmodics, Symic, Vesper, W.L. Gore, and Xeltis. Dr Finn has received honoraria from Abbott Vascular, Biosensors, Boston Scientific, CeloNova BioSciences, Cook Medical, Cardiovascular Systems, Lutonix Bard, Sinomed, and Terumo; and is a consultant to Amgen, Abbott Vascular, Boston Scientific, CeloNova BioSciences, Cook Medical, Lutonix Bard, and Sinomed. Dr Virmani has received honoraria from Abbott Vascular, Biosensors, Boston Scientific, CeloNova BioSciences, Cook Medical, Cordis, Cardiovascular Systems, Lutonix Bard, Medtronic, OrbusNeich Medical, SINOMED, Recor, Terumo, W.L. Gore, and Spectranetics; and is a consultant for Abbott Vascular, Boston Scientific, CeloNova BioSciences, Cook Medical, Cordis, Cardiovascular Systems, Edwards Lifesciences, Lutonix Bard, Medtronic, OrbusNeich Medical, Recor, SINOMED, Spectranetics, Surmodics, Terumo, W. L. Gore, and Xeltis. Dr Konishi has received a research grant from the Ito Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Hangman's fracture is a kind of unstable cervical spine injury which should be treated promptly to avoid life threatening consequences. Advanced neurological monitoring is essential during surgical intrervention. Resource limited setting, where advanced monitors like SSEP and MEP are not available makes it challenging to assess proper reduction of cervical spine without neurological compromise. Dexmedetomidine proved to be very useful drug to assess the neurological status intra operatively by awake sedation., Competing Interests: It is certified that authors have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (© 2024 The Authors.)

Background: Non-alcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease. The prevalence and disease burden of NAFLD are projected to exponentially increase resulting in significant healthcare expenditures and lower health-related quality of life. To date, there are no approved pharmacotherapies for NAFLD or non-alcoholic steatohepatitis (NASH). Semaglutide has glycemic and weight loss benefits that may be advantageous for patients with NAFLD., Aim: To investigate the efficacy and safety of semaglutide in patients with NAFLD., Methods: MEDLINE, CENTRAL, and EMBASE were searched from inception to May 1, 2023, to identify eligible randomized controlled trials (RCTs). Meta-analysis was performed using random effects model expressing continuous outcomes as mean differences (MD) or standardized MDs (SMD), and dichotomous outcomes as odds ratios (OR) with 95% confidence intervals (CI). Statistical heterogeneity was assessed using the Cochran's Q test and I 2 statistic., Results: Three RCTs involving 458 patients were included. Semaglutide increased the likelihood of NASH resolution (OR: 3.18, 95%CI: 1.70, 5.95; P < 0.001), improvement in steatosis (OR: 2.83, 95%CI: 1.19, 6.71; P = 0.03), lobular inflammation (OR: 1.81, 95%CI: 1.11, 2.96; P = 0.02), and hepatocellular ballooning (OR: 2.92, 95%CI: 1.83, 4.65; P < 0.001), but not fibrosis stage (OR: 0.71, 95%CI: 0.15, 3.41; P = 0.67). Radiologically, semaglutide reduced liver stiffness (SMD: -0.48, 95%CI: -0.86, -0.11; P = 0.01) and steatosis (MD: -4.96%, 95%CI: -9.92, 0.01; P = 0.05). It also reduced alanine aminotransferase (MD: -14.06 U/L, 95%CI: -22.06, -6.07; P < 0.001) and aspartate aminotransferase (MD: -11.44 U/L, 95%CI: -17.23, -5.65; P < 0.001). Semaglutide led to improved cardiometabolic outcomes, including decreased HgA1c (MD: -0.77%, 95%CI: -1.18, -0.37; P < 0.001) and weight loss (MD: -6.53 kg, 95%CI: -11.21, -1.85; P = 0.006), but increased the occurrence of GI-related side effects (OR: 3.72, 95%CI: 1.68, 8.23; P = 0.001). Overall risk of serious adverse events was similar compared to placebo (OR: 1.40, 95%CI: 0.75, 2.62; P < 0.29)., Conclusion: Semaglutide is effective in the treatment of NAFLD while maintaining a well-tolerated safety profile. Future studies are required to evaluate its effects on fibrosis regression and different phases of NAFLD., Competing Interests: Conflict-of-interest statement: Zhu K, Kakkar R and Chahal D have no conflicts of interests to declare; Yoshida EM is an investigator of clinical trials sponsored by Gilead Sciences, Pfizer, Genfit, Intercept, Celgene, Allergan, and Madrigal; Yoshida EM has received research funding from Paladin Labs Inc; Hussaini T has received research funding from Transplant Research Foundation of BC, and Paladin Labs Inc., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Competing Interests: Disclosures Drs Ghoreishi, Taylor, and Toursavadkohi are consultants for Gore, WL Gore, Flagstaff, AZ. The other authors report no conflicts.

The COVID-19 pandemic has resulted in significant worldwide morbidity and mortality. In this review, we examine the intricate relationships between COVID-19 and liver diseases. While respiratory manifestations of COVID-19 are well known, its impact and consequences in patients with liver diseases remain an area of ongoing investigation. COVID-19 can induce liver injury through various mechanisms and is associated with higher mortality in individuals with preexisting chronic liver disease. Mortality increases with the severity of chronic liver disease and the level of care required. The outcomes in patients with autoimmune hepatitis remain unclear, whereas liver transplant recipients are more likely to experience symptomatic COVID-19 but have comparable outcomes to the general population. Despite suboptimal immunological response, COVID-19 vaccinations are safe and effective in liver disease, although cases of autoimmune hepatitis-like syndrome have been reported. In conclusion, COVID-19 has significant implications in liver diseases; early recognition and treatments are important for improving patient outcomes., Competing Interests: K.Z., O.T., and D.C. have no conflicts of interests to declare. E.M.Y. is an investigator of clinical trials sponsored by Gilead Sciences, Pfizer, Genfit, Intercept, Celgene, Allergan, and Madrigal. E.M.Y. has received research funding from Paladin Labs Inc. T.H. has received research funding from Transplant Research Foundation of BC, and Paladin Labs Inc., (Thieme. All rights reserved.)

Competing Interests: The authors declare no funding or conflicts of interest.

Background: A deeper understanding of coronary medial thickness is important for coronary intervention because media thickness can limit the safety and effectiveness of interventional techniques. However, there is a paucity of detailed data on human coronary medial thickness so far., Materials and Methods: We investigated the thickness of the media by histologic analysis. A total of 230 sections from 10 individuals from the CVPath autopsy registry who died from non-coronary deaths were evaluated. We performed pathological analysis on 13 segments of the following primary vessels from coronary arteries: the left main trunk, proximal left anterior descending artery (LAD), mid LAD, distal LAD, proximal left circumflex artery (LCX), mid LCX, distal LCX, proximal right coronary artery (RCA), mid RCA, and the distal RCA. The following side branches were also evaluated: diagonal, obtuse margin, and posterior descending artery branches., Results: The average age of the studied individuals was 60.4±12.3 years. The median medial thickness for all sections was 0.202 (0.149-0.263) mm. The median medial thickness of the main branches was significantly higher compared to that of the side branches (p<0.001). Although the medial thicknesses of the main branch of LAD and LCX were significantly decreased from proximal to distal segments (p = 0.010, p = 0.006, respectively), the medial thickness of the main branch of RCA was not significantly decreased from proximal to distal (p = 0.170). The thickness of the media was positively correlated with vessel diameter, while it was negatively correlated with luminal narrowing (p<0.001 and p<0.001, respectively)., Conclusions: The human coronary arteries demonstrate variation in medial thickness which tends to vary depending upon an epicardial coronary artery itself, as well as its segments and branches. Understanding these variations in medial thickness can be useful for both the interventionalists and interventional product development teams., Competing Interests: Competing Interest Statement: R.V. and A.V.F. have received institutional research support from NIH (HL141425), Leducq Foundation Grant; 480 Biomedical; 4C Medical; 4Tech; Abbott; Accumedical; Amgen; Biosensors; Boston Scientific; Cagent Vascular; Cardiac Implants; Celonova; Claret Medical; Concept Medical; Cook; CSI; DuNing, Inc; Edwards LifeSciences; Emboline; Endotronix; Envision Scientific; Lutonix/Bard; Gateway; Lifetech; Limflo; MedAlliance; Medtronic; Mercator; Merill; Microport Medical; Microvention; Mitraalign; Mitra Assist; NAMSA; Nanova; Neovasc; NIPRO; Novogate; Occulotech; OrbusNeich Medical; Phenox; Profusa; Protembis; Qool; Recor; Senseonics; Shockwave; Sinomed; Spectranetics; Surmodics; Symic; Vesper; W.L. Gore; Xeltis. A.V.F. has received honoraria from Abbott Vascular; Biosensors; Boston Scientific; Celonova; Cook Medical; CSI; Lutonix Bard; Sinomed; Terumo Corporation; and is a consultant to Amgen; Abbott Vascular; Boston Scientific; Celonova; Cook Medical; Lutonix Bard; Sinomed. R.V. has received honoraria from Abbott Vascular; Biosensors; Boston Scientific; Celonova; Cook Medical; Cordis; CSI; Lutonix Bard; Medtronic; OrbusNeich Medical; CeloNova; SINO Medical Technology; ReCore; Terumo Corporation; W. L. Gore; Spectranetics; and is a consultant for Abbott Vascular; Boston Scientific; Celonova; Cook Medical; Cordis; CSI; Edwards Lifescience; Lutonix Bard; Medtronic; OrbusNeich Medical; ReCore; Sinomededical Technology; Spectranetics; Surmodics; Terumo Corporation; W. L. Gore; Xeltis. T. K. receives research grants from The Ito foundation. The other authors declare no competing interests." This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Konishi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background and study aims  Hemostatic powders are increasingly used to address limitations in conventional endoscopic techniques for gastrointestinal bleeding. Various agents exist with different compositions, characteristics, efficacy, and adverse events (AEs). We sought to review existing hemostatic powders, from preclinical to established agents. Methods  A literature review on hemostatic powders for gastrointestinal bleeding was undertaken through a MEDLINE search from 2000-2021 and hand searching of articles. Relevant literature was critically appraised and reviewed for mechanism of action, hemostasis and rebleeding rate, factors associated with hemostatic failure, and AEs. Results  The most established agents are TC-325 (Hemospray), EndoClot, and Ankaferd Blood Stopper (ABS). These agents have been successfully applied to a variety of upper and lower gastrointestinal bleeding etiologies, in the form of primary, combination, salvage, and bridging therapy. Few AEs have been reported, including visceral perforation, venous embolism, and self-limited abdominal pain. Newer agents include CEGP-003 and UI-EWD, which have shown results similar to those for the older agents in initial clinical studies. All aforementioned powders have high immediate hemostasis rates, particularly in scenarios not amenable to conventional endoscopic methods, but are limited by significant rates of rebleeding. Other treatments include TDM-621 (PuraStat) consisting of a liquid hemostatic agent newly applied to endoscopy and self-propelling thrombin powder (CounterFlow Powder), a preclinical but promising agent. Conclusions  Rapid development of hemostatic powders and growing clinical expertise has established these agents as a valuable strategy in gastrointestinal bleeding. Further research will continue to refine the efficacy and applicability of these agents., Competing Interests: Competing interests Dr. Kastrup is the inventor on patents and intellectual property, and Dr. Ali-Mohamad, Dr. Donnellan, and Dr. Kastrup are involved in commercialization activities related to self-propelling thrombin powder., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Forty percent of hepatitis B carriers have no knowledge of their diagnosis. A prior study in British Columbia suggested high rates of hepatitis B among immigrants. The authors undertook a large-scale screening study to validate these rates., Methods: Attendees at Asian health fairs without knowledge of their hepatitis B status participated. They completed a questionnaire, and blood was drawn for HBV serologies. Active HBV was defined as HBV surface antigen positive., Results: Of 2,726 patients, 1,704 (62.5%) were female and 1,022 (37.5%) male. Mean age was 62.7 (SD 22.1) years, and mean time of residing in Canada was 27.5 (SD 15.3) years. Most patients originated from China (1,042 patients, 38.2%) and Hong Kong (871, 31.2%). Fifty-six patients tested positive (seroprevalence rate 2.05%, 95% CI 1.52%-2.59%). Most seropositive patients were from China (28 patients, 50.0%). Mean time of residence in Canada for seropositive patients (23.8 [SD 2.1] y) was less than seronegative patients (27.6 [SD 0.3] y) ( p = 0.06). There was a trend towards association of seropositivity with time of residence in Canada (OR 0.98, 95% CI 0.96-1.00, p = 0.09). 8 (14.3%) seropositive patients did not have family doctors, compared with 128 (4.8%) seronegative patients. Lack of a family doctor was strongly associated with seropositivity (OR 3.31, 95% CI 1.32-7.25, χ2 = 10.42, p = 0.001)., Interpretation: The authors have shown that high risk immigrant populations may have seroprevalence rates as high as 2,700 per 100,000. Lack of a family physician was associated with seropositivity. These results should be used to design improved outreach programs., Competing Interests: The other authors have nothing to disclose., (Copyright © 2022 Canadian Association for the Study of the Liver.)

Background: Lean NAFLD may differ from NAFLD found in overweight or obese patients. We used the UK biobank to conduct a cross-sectional study that examined features that distinguish lean NAFLD from overweight or obese NAFLD., Methods: MRI-PDFF data were used to identify patients with NAFLD, with NAFLD defined as PDFF ≥ 5%. BMI patient cohorts were identified, with lean defined as a BMI < 25, and overweight or obese defined as a BMI ≥ 25. Variables of interest to fatty liver disease, including single nucleotide polymorphisms, were chosen from the UK biobank data portal. Logistic regression was used to generate models predictive of NAFLD in each cohort., Results: 1007 patients had NAFLD, and of these, 871 had BMI ≥ 25, and 136 BMI < 25. Factors associated with NAFLD in patients with BMI < 25 included male sex, white blood cell count, red blood cell count, triglycerides, ALT, creatinine, visceral adipose tissue, rs58542926 T, and rs738409 G. In contrast, factors associated with NAFLD in patients with BMI ≥ 25 included male sex, waist circumference, HDL cholesterol, triglycerides, serum glucose, ALT, creatinine, urate, visceral adipose tissue, rs1260326 T, rs1044498 C, rs58542926 T, and rs738409 G. For lean patients, our generated prediction score had an AUC of 0.92, sensitivity of 0.90 and specificity of 0.81. For overweight or obese patients, the prediction score had an AUC of 0.86, sensitivity of 0.87 and specificity of 0.70., Conclusions: Our analysis suggests that lean and overweight or obese NAFLD are distinct entities. We have developed a risk score incorporating both clinical and genetic factors that accurately classify lean patients with NAFLD, with the potential to serve as a tool for screening purposes., (© 2022. Asian Pacific Association for the Study of the Liver.)

Abstract: Liver disease etiology and transplantation outcomes may vary by ethnicity. We aimed to determine if disparities exist in our province.We reviewed the provincial database for liver transplant referrals. We stratified cohorts by ethnicity and analyzed disease etiology and outcomes.Four thousand nine hundred sixteen referrals included 220 South Asians, 413 Asians, 235 First Nations (Indigenous), and 2725 Caucasians. Predominant etiologies by ethnicity included alcohol (27.4%) and primary sclerosing cholangitis (PSC) (8.8%) in South Asians, hepatitis B (45.5%) and malignancy (13.9%) in Asians, primary biliary cholangitis (PBC) (33.2%) and autoimmune hepatitis (AIH) (10.8%) in First Nations, and hepatitis C (35.9%) in Caucasians. First Nations had lowest rate of transplantation (30.6%, P = .01) and highest rate of waitlist death (10.6%, P = .03). Median time from referral to transplantation (268 days) did not differ between ethnicities (P = .47). Likelihood of transplantation increased with lower body mass index (BMI) (hazard ratio [HR] 0.99, P = .03), higher model for end stage liver disease (MELD) (HR 1.02, P < .01), or fulminant liver failure (HR 9.47, P < .01). Median time from referral to ineligibility status was 170 days, and shorter time was associated with increased MELD (HR 1.01, P < .01), increased age (HR 1.01, P < .01), fulminant liver failure (HR 2.56, P < .01) or South Asian ethnicity (HR 2.54, P < .01). Competing risks analysis revealed no differences in time to transplant (P = .66) or time to ineligibility (P = .91) but confirmed increased waitlist death for First Nations (P = .04).We have noted emerging trends such as alcohol related liver disease and PSC in South Asians. First Nations have increased autoimmune liver disease, lower transplantation rates and higher waitlist deaths. These data have significance for designing ethnicity specific interventions., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Early onset colorectal cancer (EoCRC), diagnosed in those <50 years old, is increasing in incidence. We sought to differentiate characteristics and outcomes of EoCRC in patients with sporadic disease or preexisting conditions., Methods: We evaluated 2,135 patients with EoCRC in a population-based cohort from the Canadian province of British Columbia. Patients were identified on the basis of presence of hereditary syndromes ( n = 146) or inflammatory bowel disease (IBD; n = 87) and compared with patients with sporadic EoCRC ( n = 1,902)., Results: Proportions of patients with preexisting conditions were highest in the youngest decile of 18-29 (34.3%, P < 0.0001). Patients with sporadic EoCRC were older, more likely female, and had increased BMI ( P < 0.05). IBD-related EoCRC had the highest rates of metastatic disease, poor differentiation, adverse histology, lymphovascular, and perineural invasion ( P < 0.05). Survival was lower in patients with IBD (HR, 1.80; 95% CI, 1.54-3.13; P < 0.0001) and higher in hereditary EoCRC (HR, 0.47; 95% CI, 0.45-0.73; P < 0.0001) compared with sporadic. Prognosis did not differ between ulcerative colitis or Crohn's disease but was lower in those with undifferentiated-IBD (HR, 1.87; 95% CI, 1.01-4.05; P = 0.049). Lynch syndrome EoCRC had improved survival over familial adenomatous polyposis (HR, 0.31; 95% CI, 0.054-0.57; P = 0.0037) and other syndromes (HR, 0.43; 95% CI, 0.11-0.99; P = 0.049). In multivariate analysis controlling for prognostic factors, hereditary EoCRC was unchanged from sporadic; however, IBD-related EoCRC had worse overall survival (HR, 2.21; 95% CI, 1.55-3.16; P < 0.0001)., Conclusions: EoCRC is heterogenous and patients with preexisting conditions have different characteristics and outcomes compared with sporadic disease., Impact: Prognostic differences identified here for young patients with colorectal cancer and predisposing conditions may help facilitate treatment planning and patient counseling. See related commentary by Hayes, p. 1775 ., (©2021 American Association for Cancer Research.)

Background: Hemospray (TC-325) is now approved for use in gastrointestinal bleeding. Data regarding their use pattern, efficacy, complications, and impact on clinical outcomes is limited., Methods: Electronic search from relevant databases was conducted up to January 2019. Etiologies, therapy characteristics, hemostasis rates, rebleed rates, additional procedures, complications and mortality rates were extracted and pooled., Results: Twenty-seven articles were included for analysis (n=1916). Pooled hemostasis was 94.5%. Pooled rebleed rate within 3 days was 9.9%, and within 30 days 17.6%. Pooled repeat Hemospray use was 13.6%. Radiology guided embolization was required with rate of 3.3% and surgery at rate of 4.7%. Rate of adverse events directly attributable to Hemospray was 0.7%. 30-day mortality was 11.8%. Comparison of conventional endoscopic therapy to Hemospray augmented therapy demonstrated that Hemospray therapy had increased immediate hemostasis [odds ratio (OR) 4.40]. There was no difference in rate of rebleeding at 8 days (OR 0.52) or overall mortality at 30 days (OR 0.53). Benign nonvariceal bleeds, malignant bleeds, and postprocedural bleeds had similar rates of hemostasis but rebleed rate at 30 days was less for postprocedural bleeding., Conclusions: The addition of Hemospray to conventional therapy appears to increase immediate hemostasis but does not decrease rebleeding or mortality. As such, the use of Hemospray will likely be limited to clinical situations requiring urgent, but temporary, hemostasis to bridge to more definitive therapy., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Percutaneous mitral valve repair with MitraClip device has been approved for treatment of mitral regurgitation in symptomatic patients deemed high risk for surgical repair. This study compares outcomes of Mitraclip in patients with systolic (SHF) versus diastolic heart failure (DHF)., Methods: The study population was extracted from the 2016 Nationwide Readmissions Data (NRD) using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system (ICD-9-CM/PCS) codes for the Mitraclip, SHF, DHF, and procedural complications. Study endpoints included in-hospital all-cause mortality, cardiogenic shock, acute myocardial infarction (AMI), acute kidney injury (AKI), stroke, acute respiratory failure, bleeding, blood transfusion, length of hospital stay (LOS) as well as 30-day readmission rate., Results: A total of 1681 discharges that had Mitraclip during the index hospitalization and had a history of SHF (909) or DHF (772) were included in this analysis. The mean age was 78.5 years and 46.6% were female. SHF group was associated with higher post-procedural cardiogenic shock (7.3% versus 2.0%, p < 0.01), AMI (2.1% versus 0.8%, p = 0.03), AKI (21.0 versus 14.2%, p < 0.01), acute respiratory failure (13.2% versus 9.6%, p = 0.02), and longer LOS (9.6 versus 5.7 days, p < 0.01). There were no significant differences between groups in terms of in-hospital all-cause mortality (3.4% versus 2.3%, p = 0.18), stroke (0.7% versus 1.4%, p = 0.15), bleeding (10.7% versus 8.9%, p = 0.23), need for blood transfusion (5.7% versus 3.6%, p = 0.05), or 30-day readmission rate (15.7% versus 16.1%, p = 0.86)., Conclusions: In comparison to DHF, patients with SHF undergoing the MitraClip had higher in-hospital morbidities and longer LOS but comparable mortality and 30-day readmission rates., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Although duodenal neuroendocrine tumors (dNETs) are rare, the incidence, particularly for lesions ≤ 10 mm, continues to rise with the advent of widely available, high-quality endoscopy. Given their rarity and controversy regarding prognostication factors, limited guidelines exist for resection of well-differentiated, ≤ 20-mm dNETs. Importantly, lesions ≤ 10 mm in a duodenal location are ideal for consideration of endoscopic management given both morbidity and technical challenges associated with surgery and their accessibility to a wide range of endoscopic techniques., Objectives: The primary objective of this study was to demonstrate the safety and efficacy of the endoscopic resection of dNETs <10 mm in a case series and literature review., Methods: We performed a literature review and present a series of nine cases to demonstrate the viability of endoscopic resection for diminutive dNETs as an alternative to surgery., Results: Our case series included nine well-differentiated diminutive dNETs in seven patients, the majority resected using endoscopic mucosal resection (EMR), 67%, and there was no residual disease at follow-up. The literature review of 178 patients demonstrated that EMR was the most used method of resection of diminutive dNETs, 81%, compared to endoscopic submucosal dissection, 19%. The most common complication was intraoperative bleeding in 9.55%, and only 2.25% of patients had recurrence., Conclusion: While complications may arise with endoscopic resection of diminutive dNETs, they are usually managed endoscopically and compare favorably with the literature on surgical complication rates and typically result in shorter hospitalizations.

Background: Patients with cirrhosis are at risk of developing cirrhotic cardiomyopathy. This syndrome is unique to cirrhosis and is generally defined as subnormal cardiac function in the absence of prior heart disease. There is no systematic or comprehensive review of cirrhotic cardiomyopathy to date., Aims: To comprehensively review the literature on the definition, pathogenic mechanisms, diagnostic criteria, prevalence, management and influence on liver transplantation including reversibility of cirrhotic cardiomyopathy., Methods: Electronic searches of the EMBASE, MEDLINE, EBM Reviews-Cochrane Central Register of Controlled Trials, EBM Reviews-Cochrane Database of Systematic Reviews and Google Scholar databases were conducted. MeSH terms focused on cirrhosis, cardiomyopathy, medication classes and epidemiology. Literature up to August 2020 was reviewed., Results: New diagnostic criteria for the definition of cirrhotic cardiomyopathy have recently been published, consisting of systolic and diastolic dysfunction parameters as assessed by echocardiographic methods. The roles of electrocardiographic disturbances and biomarkers in the definition criteria remain unclear. Pathogenic mechanisms underlying cirrhotic cardiomyopathy are likely related to the inflammatory phenotype of cirrhosis. Prevalence rates of 26%-81% in cirrhotic patients are reported. Several medical therapies have been proposed, but none with clear evidence of efficacy. The presence of cirrhotic cardiomyopathy complicates the liver transplantation process with a higher risk of adverse cardiovascular events post-transplant. Complete reversibility of the syndrome after transplantation remains controversial but most studies suggest that it does not occur at least within the first post-operative year., Conclusions: Cirrhotic cardiomyopathy is a clinically relevant syndrome that affects morbidity and mortality in patients with cirrhosis., (© 2021 John Wiley & Sons Ltd.)

Liver allografts are unique in solid organ transplantation as they are less susceptible to both acute and chronic rejection. Operational tolerance, defined as prolonged graft survival in the absence of immunosuppression, is also achieved more frequently with liver allografts. It is unknown if the presence of multiple allografts in the same individual, levels of immunosuppression, or the presence of cystic fibrosis (CF) impacts the livers ability to ward off rejection or achieve operational tolerance. We describe an unsensitized, ABO-compatible patient with CF who underwent double lung transplantation and several years later a combined liver-kidney transplant. He developed isolated late acute T-cell mediated rejection of his liver allograft despite a high level of immunosuppression (IS) required for his lung and kidney allografts. To our knowledge, this is the first case of isolated liver rejection in a patient with 3 separate organ allografts, or in a patient with CF, to be reported in the literature. This isolated liver rejection is out of keeping with typically accepted ideas about orthotopic liver tolerance., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Artificial intelligence (AI) has emerged as a powerful and exciting new technology poised to impact many aspects of health care. In endoscopy, AI is now being used to detect and characterize benign and malignant GI lesions and assess malignant lesion depth of invasion. It will undoubtedly also find use in capsule endoscopy and inflammatory bowel disease. Herein, we provide the general endoscopist with a brief overview of AI and its emerging uses in our field. We also touch on the challenges of incorporating AI into clinical practice, such as workflow integration, data storage, and data privacy., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Primary sclerosing cholangitis (PSC), with or without inflammatory bowel disease (IBD), confers the risk of cholangiocarcinoma. Isolated IBD may be an independent risk factor for cholangiocarcinoma. We sought to compare cholangiocarcinoma phenotype and outcomes between patients with PSC, IBD, and neither., Methods: Patients with malignancy were separated into cohorts by the presence of PSC and IBD. Data regarding demographics, clinical presentation, therapeutic regimens, and survival were collected. Statistical analysis was carried out using GraphPad and R-Studio., Results: Of 946 patients, 22 had PSC, and 18 had isolated IBD. PSC and IBD patients were younger than controls ( P  < 0.001, P = 0.01). Cholangiocarcinoma prevalence was estimated at 0.01% for IBD patients, 0.6% for PSC patients, and 0.002% for all other patients. All cohorts most often presented at stage 4. PSC patients presented more often at stage 3 ( P = 0.04) and with perihilar disease ( P = 0.001). Patients with PSC or IBD received less chemotherapy ( P = 0.004, 0.01). Median overall survivals were 15 months (PSC), 11 months (IBD), and 10 months (controls) ( P = 0.79). Patients with intrahepatic tumors had longer survival ( P  < 0.001). Curative intent resection improved survival in all cohorts ( P  < 0.001). Multivariate regression identified resection as a predictor of improved survival. Extrahepatic, perihilar, gallbladder, and unspecified biliary tumors were predictors of death., Conclusions: Cholangiocarcinoma presents at a late stage and portends dismal survival regardless of PSC or IBD status. Survival was dependent on tumor location and surgical resection. These data suggest that efforts should focus on developing protocols that are able to detect and treat cholangiocarcinoma in high-risk populations (PSC) at an early stage., (© 2020 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background & Aims: Hemospray (TC-325, Cook Medical) has recently been approved for use in GI bleeding. Specific clinical indications and predictors of success or failure have not been well delineated., Methods: We conducted a retrospective cohort study of Hemospray use at a tertiary center. We assessed demographics and characteristics of Hemospray use. We analyzed outcomes of hemostasis, rebleeding, need for embolization or surgery, and death., Results: 86 applications of Hemospray were identified. The most common etiology of upper GI bleeds were ulcers (67.1%) whilst the etiology of lower GI bleeds varied. Hemospray was applied as monotherapy in 28 procedures (32.6%). Immediate hemostasis rate was 88.4%, but there was a high rate of re-bleeding (33.7%). Most re-bleeds occurred within 7 days (86.2%). Syncope was an independent predictive factor re-bleeding at 7 days for EGD (OR = 12.16, 95% CI = 1.51-97.75, P = 0.019). Bleeding refractory to endoscopic treatment with hemospray required radiological embolization in 9 instances, and surgery in 9 instances. Hemospray therapy was protective against need for embolization (p < 0.05). 2 patients underwent liver transplantation and there was a total of 5 deaths. Hepatic disease was an independent predictor of death (OR = 47.15, 95% CI = 2.42-916.89, P = 0.011)., Conclusion: Hemospray is effective in achieving immediate hemostasis but is plagued by high rates of rebleeding. Syncope is a predictor of rebleeding, and hepatic disease is a predictor of death in patients undergoing Hemospray therapy. Despite high rates of embolization and surgery, Hemospray may reduce need for embolization. Hemospray use during endoscopy should prompt physicians to consider early re-look endoscopy and more aggressive therapy., (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Implantation of drug-eluting stents (DES) is the dominant treatment strategy for patients with symptomatic coronary artery disease. However, the first-generation DES had substantial drawbacks, including delayed healing, local hypersensitivity reactions and neoatherosclerosis, which all led to a steady increase in major adverse cardiovascular events over time. Subsequently, newer-generation DES were introduced with thinner struts, different scaffold designs (to improve deliverability while maintaining radial strength), different durable and biodegradable polymers - and in some cases no polymer (to improve vascular biocompatibility) - and new antiproliferative drug types and doses. Currently, >30 different DES are commercially available in Europe, with fewer available in the USA but with many new entrants coming onto the US market in the next few years. Never before have cardiologists been faced with so many choices of stent, each with its own unique design. In this Review, we detail preclinical and pathology studies for each stent design, examining thromboresistance, speed of neointimal coverage and completeness of healing, including endothelialization. We conclude by discussing how these design characteristics might affect the potential for shortening the minimum duration of dual antiplatelet therapy needed after coronary intervention.

Left ventricular assist devices (LVADs) are associated with numerous short- and long-term complications, including infection. The impact LVAD infections have on clinical outcomes after transplantation is not well established. We sought to determine whether the presence of infection while on LVAD support negatively influences outcomes after cardiac transplantation. We searched electronic databases and bibliographies for full text studies that identified LVAD infections during support and also reported on posttransplant outcomes. A meta-analysis of posttransplant survival was conducted using a random effects model. Of 2,373 records, 13 bridge to transplant (BTT) cohort studies were selected (n = 6,631, 82% male, mean age 50.7 ± 2.7 years). A total of 6,067 records (91.5%) received transplant. There were 3,718 (56.1%) continuous-flow LVADs (CF-LVADs), 1,752 (26.4%) pulsatile LVADs, and 1,161 (17.5%) unknown type records. A total of 2,586 records (39.0%) developed LVAD infections. Patients with LVAD infections were younger (50.5 ± 1.5 vs. 51.3 ± 1.5, p = 0.02), had higher body mass indeices (BMIs) (28.4 ± 0.7 vs. 26.8 ± 0.4, p < 0.01), and longer LVAD support times (347.0 ± 157.6 days vs. 180.2 ± 106.0 days, p < 0.01). Meta-analysis demonstrated increased posttransplant mortality in those patients who had an LVAD infection (hazard ratio [HR] 1.30, 95% CI: 1.16-1.46, p < 0.001). Subgroup meta-analyses by continuous-flow and pulsatile device type demonstrated significant increased risk of death for both types of devices (HR 1.47, 95% CI: 1.22-1.76, p < 0.001 and 1.71, 95% CI: 1.19-2.45, p = 0.004, respectively). Patients who develop LVAD infections are younger, have higher BMIs and longer LVAD support times. Our data suggests that LVAD-related infections result in a 30% increase in postcardiac transplantation mortality. Strategies to prevent LVAD infections should be implemented to improve posttransplant outcomes in this high-risk population.

Background: Cirrhotic patients undergoing liver transplantation are at risk of cardiac complications. Brain natriuretic peptide (BNP) and amino terminal brain natriuretic peptide (NT-BNP) are used in cardiac risk stratification. Their significance in predicting mortality risk in cirrhotic patients during or after liver transplantation is unknown. We conducted a systematic review and meta-analysis to answer this question., Methods: An electronic search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (2005-September 2016), Google Scholar, and study bibliographies was conducted. Study quality was determined, and demographic and outcome data were gathered. Random effects meta-analyses of mortality-based BNP and NT-BNP level or presence of post-transplant heart failure were conducted., Results: Seven studies including 2,010 patients were identified. Demographics were similar between patients with high or low BNP or NT-BNP levels. Hepatitis C was the most prevalent etiology of cirrhosis (38%). Meta-analysis revealed a pooled relative risk of 3.1 (95% CI 1.9% to 5.0%) for post-transplant mortality based on elevated BNP or NT-BNP level. Meta-analysis also revealed a pooled relative risk of 1.6 (95% CI 1.3% to 2.1%) for post-transplant mortality if patients had demonstrated post-transplant heart failure., Conclusions: Our analysis suggests that BNP or NT-BNP measurement may help in risk stratification and provides data on post-operative mortality in cirrhotic patients undergoing liver transplantation. Discriminatory thresholds are higher in cirrhotic patients relative to prior studies with non-cirrhotic patients. However, the number of analyzed studies is limited, and our findings should be validated further through larger, prospective studies., Competing Interests: The authors have no conflicts to declare., (Copyright © 2019 Canadian Association for the Study of the Liver.)

Background: Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are cutaneous hypersensitivityreactions that develop in response to specific triggers such as medications and certain infections. Vaccines, which undergo rigorous safety testing prior to use in humans, are a rare cause of SJS/TEN and little is known about the frequency of such events and corresponding pathogenesis., Objective: Herein, we discuss a case of suspected TEN in a 19-year-old woman who received the meningococcal B vaccine (the first report of such an association) and conduct a systematic review of the associated literature. We also discuss management of this patient with a single dose of etanercept., Methods: Relevant literature was searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method., Results: A total of 29 articles reporting EM, SJS, or TEN following vaccination were included from &gt;5 countries. Of the 29, 22 articles reported EM, 6/29 reported SJS, and 4/29 reported TEN (3 articlesreported cases of both EM and SJS/TEN)., Conclusions: We suggest consideration of vaccines as an etiology for cases of SJS or TEN that begin with an EM-like presentation, and provide further evidence for the use of etanercept as a viable treatment for TEN.

Oral submucous fibrosis (OSMF) is an oral precancerous condition characterized by inflammation and progressive fibrosis of the submucosal tissues resulting in marked rigidity and trismus. OSMF still remains a dilemma to the clinicians due to elusive pathogenesis and less well-defined classification systems. Over the years, many classification systems have been documented in medical literature based on clinical, histopathological, or functional aspects. However, none of these classifications have achieved universal acceptance. Each classification has its own merits and demerits. An attempt is made to provide and update the knowledge of classification system of OSMF so that it can assist the clinicians, beneficial in researches and academics in categorizing this potentially malignant disease for early detection, prompt management, and reducing the mortality. Along with this, pathogenesis and management have also been discussed., Competing Interests: There are no conflicts of interest.

Introduction: A child's intelligence quotient (IQ) is determined by both genetic and environmental factors that start from the prenatal period itself. There is a lack of data on the factors which influence IQ in Indian children; therefore, we conducted a multicenter questionnaire-based study to determine the environmental factors which influence IQ in Indian children., Participants and Methods: In this cross-sectional observational study, we recruited 1065 schoolchildren between the age of 12 and 16 years from 2 government and 13 private schools in 5 towns, 6 cities, and 2 villages across India. All the children were administered a questionnaire consisting of various environmental factors such as parents' education, occupation, income, and the physical activity of the students. IQ scores were assessed using Ravens Standard Progressive Matrices. An approximate IQ score was calculated using the score on the Ravens test. IQ scores were divided into three groups: below normal IQ (0-79), normal IQ (80-119), and high IQ (above 120). The data were analyzed using SPSS software., Results: In this study, it was observed that the environmental factors such as place of residence, physical activity, family income, parental education, and occupation of the father had an impact on the IQ of the children. Children living in cities ( P = 0.001), children having physical activity more than 5 h/weeks ( P = 0.001), children with parents having a postgraduate or graduate level of education ( P = 0.001), children whose father having a professional job ( P = 0.001), and those with a higher family income ( P = 0.001) were more likely to have high IQ., Conclusions: In the present study, we found that various environmental factors such as place of residence, physical exercise, family income, parents' occupation and education influence the IQ of a child to a great extent. Hence, a child must be provided with an optimal environment to be able to develop to his/her full genetic potential., Competing Interests: There are no conflicts of interest.

Paradoxical air embolism is a very rare complication associated with percutaneous nephrolithotomy (PCNL). Incidence may be higher if patients also suffer from a septal heart defect. We report the case of a 76-year old male who presented for PCNL treatment of a right kidney lower calyceal calculus. During the procedure, the patient developed signs and symptoms consistent with that of air embolism. Intraoperative echocardiography confirmed the diagnosis. Subsequent intraoperative and postoperative medical management was carried out and the patient was discharged after recovery three days later. This case highlights the importance of a rare but potentially fatal complication of PCNL.

Urachal neoplasms are rare entities which may be classified as cystic or non-cystic. Literature surrounding patient outcomes remains limited to non-cystic, urachal adenocarcinomas. Literature focusing on mucinous cystic neoplasms of the urachus is sparse. These mucinous cystic lesions may be subclassified as benign mucinous cystadenomas, mucinous cystic tumours of low malignant potential, and mucinous cystadenocarcinomas. Mucinous subtypes have the potential to behave aggressively and may result in pseudomyxoma peritonei. We describe here the case of a 37-year-old male with a mucinous cystic tumour of low malignant potential after prior right orchiectomy and left hydrocelectomy. This case raises the interesting possibility of multiple genitourinary neoplasms arising in a similar time frame.

The sedimentation and aggregation of cells within inkjet printing systems has been hypothesized to negatively impact printer performance. The purpose of this study was to investigate this influence through the use of neutral buoyancy. Ficoll PM400 was used to create neutrally buoyant MCF-7 breast cancer cell suspensions, which were ejected using a piezoelectric drop-on-demand inkjet printing system. It was found that using a neutrally buoyant suspension greatly increased the reproducibility of consistent cell counts, and eliminated nozzle clogging. Moreover, the use of Ficoll PM400 was shown to not affect cellular viability. This is the first demonstration of such scale and accuracy achieved using a piezoelectric inkjet printing system for cellular dispensing., (Copyright © 2012 Wiley Periodicals, Inc.)