Allison Schulman

18F-FDG PET/CT for the assessment of myocardial sarcoidosis

Cardiac involvement portends a poor prognosis in patients with sarcoidosis. However, due to the nonspecific clinical manifestations of the disease, patchy myocardial involvement, and the limited diagnostic yield of diagnostic tests, early diagnosis of cardiac sarcoidosis has been exceedingly difficult. As a result, there is no standardized approach for the early diagnosis of cardiac sarcoidosis. Imaging modalities that can both identify disease and predict response to therapy are paramount to improve management of cardiac sarcoidosis. 18F-FDG PET has many practical advantages in assessing disease activity and monitoring treatment response in patients with cardiac sarcoidosis. Accumulating data support the growing role of 18F-fluorodeoxyglucose (18F-FDG) PET in the diagnosis and risk stratification of patients with cardiac sarcoidosis.

Use of helical CT is associated with an increased incidence of postoperative pulmonary emboli in cancer patients with no change in the number of fatal pulmonary emboli.

BACKGROUND Multidetector computed tomography (MDCT) scanning technology has increased the ease with which pulmonary emboli (PE) are evaluated. Our aim was to determine whether the incidence and severity of postoperative PE have changed since adoption of multidetector computed tomography. STUDY DESIGN A prospective postoperative morbidity and mortality database from a single institution was used to identify all cancer patients who experienced a PE within 30 days of thoracic, abdominal, or pelvic operations. The incidence, type (central, segmental, and subsegmental), and severity of PE were examined. RESULTS A total of 295 PE were documented among 47,601 postoperative cancer patients. The incidence of PE increased yearly from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 patients in 2005 (p < 0.0001). This corresponded to an increasing number of CT scans of the chest performed (6.6 CT scans per 1,000 postoperative patients in 2000 versus 45 in 2005; p < 0.0001). The increased incidence was because of a 7.8% (CI, 4.0 to 11.7) and 5.4% (CI, 4.1 to 6.7) average annual increase in segmental and subsegmental PE, respectively. There was no change in the number of central (0.1%; CI, -1.0 to 1.12) PE. Overall incidence of fatal PE was 0.4 and did not change during the time period (p = 0.3). A central PE was more commonly associated with hypoxia, ICU admission, and 30-day mortality (33% versus 5% for peripheral; p = 0.02). CONCLUSIONS Chest CT scans are being performed more frequently on postoperative cancer patients and have resulted in an increased diagnosis of peripheral PE. The clinical significance of, and optimal treatment for, diagnosed subsegmental PE are incompletely defined.

Postoperative venous thromboembolism predicts survival in cancer patients.

Objectives:To determine whether a postoperative venous thromboembolism (VTE) is associated with a worse prognosis and/or a more advanced cancer stage and to evaluate the association between a postoperative VTE and cancer-specific survival when known prognostic factors, such as age, stage, cancer type, and type of surgery, are controlled. Context:It is unknown whether oncology patients who develop a venous thromboembolism after a complete curative resection are at the same survival disadvantage as oncology patients with a spontaneous VTE. Methods:A retrospective case control study was conducted at Memorial Sloan-Kettering Cancer Center. Years of study: January 1, 2000, to December 31, 2005. Median follow-up: 24.9 months (Interquartile range 13.0, 43.0). All cancer patients who underwent abdominal, pelvic, thoracic, or soft tissue procedures and those who developed a VTE within 30 days of the procedure were identified from a prospective morbidity and mortality database. Overall survival (OS) was calculated for the entire cohort. In the matched cohort, OS and disease-specific survival (DSS) were calculated for stages 0 to 3 and stages 0 to 2. Results:A total of 23,541 cancer patients underwent an invasive procedure and 474 (2%) had a postoperative VTE. VTE patients had a significantly worse 5-year OS compared to no-VTE patients (43.8% vs 61.2%; P < 0.0001); 205 VTE patients (stages 0–3) were matched to 2050 controls by age, sex, cancer type, stage, and surgical procedure. In this matched analysis, VTE patients continued to demonstrate a significantly worse prognosis with an inferior 5-year OS (54.7% vs 66.3%; P < 0.0001) and DSS (67.8% vs 79.5%; P = 0.0007) as compared to controls. The survival difference persisted in early stage disease (stage 0–2), with 5-year DSS of 82.9% versus 87.3% (P = 0.01). Conclusions:Postoperative VTE in oncology patients with limited disease and a complete surgical resection is associated with an inferior cancer survival. A postoperative VTE remains a poor prognostic factor, even when controlling for age, stage, cancer type, and surgical procedure further supporting an independent link between hypercoagulability and cancer survival.

The Impact of Intragastric Balloons on Obesity-Related Co-Morbidities: A Systematic Review and Meta-Analysis.

ObjectivesTherapies less invasive than surgery and more effective than lifestyle and pharmacotherapy are needed to contend with the obesity epidemic. Intragastric balloons (IGBs) are a minimally invasive endoscopic weight loss method recently approved for use in the US. The purpose of the study is to assess the effect of IGBs on metabolic outcomes associated with obesity.MethodsMEDLINE, Embase, and Cochrane Database were searched through July 2016. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. Primary outcomes included the change from baseline in metabolic parameters. Secondary outcomes included resolution and/or improvement in metabolic co-morbidities and association with baseline parameters.Results10 randomized controlled trials (RCT) and 30 observational studies including 5,668 subjects were analyzed. There was moderate-quality evidence for improvement in most metabolic parameters in subjects assigned to IGB therapy as compared to conventional non-surgical therapy in RCTs: mean difference (MD) in fasting glucose change: −12.7 mg/dl (95% confidence interval (CI) −21.5, −4); MD in triglycerides: −19 mg/dl (95% CI −42, 3.5); MD in waist circumference: −4.1 cm (95% CI −6.9, −1.4); MD in diastolic blood pressure: −2.9 mm Hg (95% CI −4.1, −1.8). The odds ratio for diabetes resolution after IGB therapy was 1.4 (95% CI 1.3, 1.6). The rate of serious adverse events was 1.3%.ConclusionsIGBs are more effective than diet in improving obesity-related metabolic risk factors with a low rate of adverse effects, however the strength of the evidence is limited given the small number of participants and lack of long-term follow-up.

Opened Proton Pump Inhibitor Capsules Reduce Time to Healing Compared With Intact Capsules for Marginal Ulceration Following Roux-en-Y Gastric Bypass

BACKGROUND & AIMS Marginal ulceration, or ulceration at the gastrojejunal anastomosis, is a common complication of Roux‐en‐Y gastric bypass (RYGB). Acidity likely contributes to the pathophysiology, and proton pump inhibitors (PPIs) frequently are prescribed for treatment. However, patients with gastric bypass only have a small gastric pouch and rapid small‐bowel transit, which limits the opportunity for capsule breakdown and PPI absorption. Soluble PPIs (open capsules [OCs]) might be absorbed more easily than intact capsules (ICs). We compared time to ulcer healing, number of endoscopic procedures, and use of health care for patients with marginal ulceration who received PPIs in OC vs IC form. METHODS We performed a retrospective study of 164 patients diagnosed with marginal ulceration who underwent RYGB at the Brigham and Womens Hospital from 2000 through 2015. Patients received high‐dose PPIs and underwent repeat endoscopy every 3 months until ulcer healing was confirmed. We used time‐to‐event analysis with a Cox proportional hazards model to evaluate the association between mode of PPI administration and time to ulcer healing, in addition to Cox multivariate regression analysis. Total charge (procedural and maintenance) was determined by comparison of categorized charges incurred from time of ulcer diagnosis to resolution. The primary outcome was time to healing of marginal ulceration in RYGB patients receiving high‐dose PPIs in OC vs IC form. RESULTS A total of 162 patients were included (115 received OC and 49 received IC). All patients were followed up until ulcer healing was confirmed. The median time to ulcer healing was 91.0 days for the OC group vs 342.0 days for the IC group (P < .001). OC was the only independent predictor of time to ulcer healing (P < .001) when we controlled for known risk factors. The number of endoscopic procedures (P = .02) and overall health care utilization (P = .05) were lower in the OC than the IC group. CONCLUSIONS Patients with marginal ulceration after RYGB who receive OC PPIs have shorter ulcer healing times, fewer endoscopic procedures, and use less health care resources compared with patients who receive IC PPIs. Given these results and the high prevalence of marginal ulceration in this patient population, the use of OC PPIs is a low‐risk, low‐cost alternative that should be considered.

H. Pylori as a predictor of marginal ulceration: A nationwide analysis

Helicobacter pylori has been implicated as a risk factor for development of marginal ulceration following gastric bypass, although studies have been small and yielded conflicting results. This study sought to determine the relationship between H. pylori infection and development of marginal ulceration following bariatric surgery in a nationwide analysis.

EUS-guided portal pressure measurement using a digital pressure wire with real-time remote display: a novel, minimally invasive technique for direct measurement in an animal model.

BACKGROUND AND AIMS Hepatic venous pressure gradient (HVPG) currently serves as a surrogate for portal pressure measurement but has many limitations. We developed a novel technique for rapid and direct portal pressure measurements using a digital pressure wire delivered through an EUS-guided 22-gauge FNA needle. Our aims were to evaluate (1) the short-term safety and technical feasibility, (2) procedural duration and subjective workload assessment, and (3) accuracy compared with a transjugular criterion standard approach. METHODS The subjects were Yorkshire pigs, weighing 40 to 55 kg. The portal vein was identified by using a linear array echoendoscope and accessed with a commercially available 22-gauge FNA needle preloaded with a digital pressure wire. Access was confirmed by portal venography. Mean digital pressure measurements were recorded over 30 to 60 seconds, and the National Aeronautics and Space Administration Task Load Index was scored. The control measurements were conventional transjugular catheterization with a balloon occlusion catheter to obtain free and wedged hepatic pressures, with subsequent HVPG calculation. RESULTS The total time required for EUS identification and needle access of the portal vein, venography, and digital pressure measurement was less than 5 minutes in 5 of 5 pigs. The National Aeronautics and Space Administration Task Load Index scores revealed a low subjective workload. Baseline portal pressure measurements via EUS ranged from 5 mm Hg to 10 mm Hg (mean, 6.4 mm Hg). HVPG measurements were consistently ±1 mm Hg of portal pressure. CONCLUSIONS This study is the first report of direct EUS-guided portal pressure measurements by using a digital pressure wire. This method is routinely performed in minutes and provides real-time pressure tracings via wireless transmission. This novel approach for direct portal pressure measurement has the potential to replace traditional indirect HVPG measurements.

Hospitalizations for Acute Myocardial Infarction Are Decreased Among Patients with Inflammatory Bowel Disease Using a Nationwide Inpatient Database.

Background:Questions remain regarding the true prevalence of cardiovascular events such as myocardial infarction (MI) among patients with inflammatory bowel disease (IBD). Using the Nationwide Inpatient Sample (NIS), we aimed to compare the proportion of hospitalizations for acute MI among patients with IBD with that of the general population. Methods:This study used data from years 2000 to 2011 in Nationwide Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. International Classification of Diseases, Ninth Revision, Clinical Modification discharge codes were used to identify adult patients with discharge diagnoses of IBD (ulcerative colitis or Crohns disease), acute MI, and multiple comorbid risk factors for cardiovascular disease. The independent effect of a diagnosis of IBD on risk of acute MI was examined using a multivariable logistic regression model controlling for multiple confounders. Data were analyzed using SAS survey procedures and weighted to reflect national estimates. Results:We identified 567,438 hospitalizations among patients with IBD and 78,121,000 hospitalizations among the general population. Patients with IBD were less likely to be hospitalized for acute MI than patients in the general population (1.3% versus 3.1%, P < 0.001). In adjusted analyses, the odds of hospitalization for acute MI among patients with IBD were decreased when compared with the general population (odds ratio, 0.51; 95% confidence interval, 0.50–0.52). Conclusions:Despite prior reports of a potentially increased risk of acute MI among patients with IBD, in a nationwide inpatient database, lower rates of acute MI were demonstrated in the IBD population when compared with the general population.

Detection of Free Peritoneal Cancer Cells in Gastric Cancer Using Cancer-Specific Newcastle Disease Virus

IntroductionCytologic detection of peritoneal gastric cancer cells by Papanicolaou staining offers important prognostic information but has low sensitivity. We evaluated a novel detection technique using Newcastle disease virus expressing the enhanced green fluorescent protein (NDV-GFP) gene.MethodsNDV-GFP was tested on MKN-1 human gastric adenocarcinoma cells plated upon rat hepatocytes to determine tumor-specific infection and GFP expression. Malignant ascites infected with increasing doses of virus was evaluated for NDV-GFP dose determination. Peritoneal lavage samples from 30 patients with gastric adenocarcinoma undergoing staging laparoscopy were evaluated with NDV-GFP.ResultsNDV-GFP can specifically detect one MKN-1 cell among one million benign rat hepatocytes. NDV-GFP at 5 × 106 plaque-forming units (PFU) produced optimal GFP expression in malignant ascites. Noncancerous cells were non-GFP expressing. GFP-expressing cells counterstained positive for carcinoembryonic antigen expression, confirming their cancerous origin. Furthermore, in patients with advanced gastric cancer, GFP expression was markedly enhanced over cytology. Of six patients with M1 disease discovered during laparoscopy, only 50% were cytology positive. All six, however, were NDV-GFP positive. Cytology was positive in 9% of patients with T3 disease, 8% with N1 disease, and 50% with N2 disease. In contrast, NDV-GFP was positive in 95% of T3 patients and 100% of patients with N1 or N2 disease.ConclusionsNDV-GFP can specifically infect and detect peritoneal gastric cancer cells and offers a more sensitive method compared with conventional cytology. This novel modality may offer enhanced detection of intraperitoneal cancer spread and provide important prognostic information.

Abdominal pain in the roux-en-Y gastric bypass patient

INTRODUCTION Roux-en-Y gastric bypass (RYGB) is a common bariatric surgical procedure resulting in weight loss and resolution of comorbidities. It involves partitioning of the upper portion of the stomach to create a small gastric pouch, along with diversion of oral intake and biliopancreatic digestive enzymes to the distal small bowel, via creation of a Roux limb ( Figure 1 ). Abdominal pain is common in patients who have undergone RYGB, although existent literature is variably sparse. Numerous studies focus on conditions such as marginal ulceration, and fewer studies describe other causes ( 1,2 ). In a large retrospective study of 1,429 RYGB patients, over one-third presented with abdominal pain ( 3 ). Th is is likely an underestimate as this study was not performed in a closed setting, and oft entimes patients will be admitted to other hospitals or change health-care providers. A standard abdominal pain work-up evaluating potential etiologies unrelated to bariatric surgery should be pursued as appropriate, including but not limited to cardiovascular disease, pancreatitis, appendicitis, functional pain, splenic infarcts or abscesses, pulmonary processes, or vascular evaluation for what would be considered an atypical presentation. Th ese and other rare causes of abdominal pain that are not unique to gastric bypass will not be addressed in this review. A surgery specifi c work-up should also be pursued, with attention to unique diagnostic strategies and treatment plans. With this in mind, patient history and physical examination are oft en essential in making a diagnosis, with prioritization of diagnostic studies depending on initial presenting symptoms. Symptoms may be suggestive of a particular diagnosis, but they are seldom pathognomonic. Below, we discuss the most common diagnoses tied to type and location of abdominal pain; however, there is no doubt that there is overlap between symptoms and other diagnoses. We also propose a suggested treatment algorithm ( Figure 2 ) and management strategy ( Table 1 ), although additional studies are underway to solidify the approach.