Quantification of interstitial cells of Cajal and fibrosis during gastric per-oral endoscopic myotomy and its association with clinical outcomes

Background and study aims Alterations to interstitial cells of Cajal (ICC) and collagen fibrosis have been implicated in the pathogenesis of gastroparesis. We aimed to evaluate the feasibility and safety of pyloric muscle sampling during gastric peroral endoscopic myotomy (G-POEM) and the association between pyloric ICC density and degree of fibrosis with clinical outcomes. Patients and methods This was a single-center prospective study of gastroparetic patients who underwent G-POEM and intraprocedural pyloric muscle biopsies between January 2022 and April 2023. ICC count was estimated using CD117 stain and trichome for collagen fibrosis. Clinical response to G-POEM was defined as an improvement of ≥ 1 point on the Gastroparesis Cardinal Symptom Index. Results Fifty-six patients (median age 60 years, 71.4% women) underwent G-POEM (100% technical success; 71.4% clinical response). ICC depletion (< 10/high-power field) and fibrosis were encountered in 70.4% and 75% of the cases, respectively. There was no difference in mean ICC count between G-POEM responders vs. non-responders (7±3.6 vs. 7.7±3.3; P = 0.9). There was no association between ICC density or degree of fibrosis with the etiology of gastroparesis, duration of symptoms, gastric emptying rate, or pyloric impedance planimetry. Patients who did not respond to G-POEM had a significantly higher degree of moderate/severe fibrosis when compared with those who responded (81.3% vs. 25%; P = 0.0002). Conclusions Pyloric muscle biopsies during G-POEM was feasible and safe. ICC depletion and pyloric muscle fibrosis are common in gastroparetic patients. The degree of fibrosis may be related to pyloric dysfunction and clinical response to G-POEM. Additional studies are needed to confirm these results.

Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video)

BACKGROUND AND AIMS

Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs.

METHODS

This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line.

RESULTS

One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions.

CONCLUSIONS

The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).

Endoscopic blind limb reduction with septotomy: a novel endoscopic approach to candy cane syndrome after Roux-en-Y gastric bypass

Video 1The endoscopic blind limb reduction with septotomy procedure.

The CRAVE and ARGE scales for motivation states for physical activity and sedentarism: Brazilian Portuguese translation and single-item versions

Motivation states for physical activity and sedentarism potentially vary from moment to moment. The CRAVE scale (Cravings for Rest and Volitional Energy Expenditure) was developed to assess transient wants and desires to move. Three studies were conducted with the aims of: (1) translating and validating the scale in Brazilian Portuguese, (2) examining changes with exercise, and (3) determining the best single-item for Move and Rest subscales for English and Portuguese. In Study 1, six bilingual speakers translated the scale into Brazilian Portuguese [named Anseios por Repouso e Gastos com Energia (ARGE)]. The ARGE had good content validity coefficients across three dimensions (0.89-0.91), as determined by three independent, bilingual referees. 1,168 participants (mean age = 30.6, SD = 12.2) from across Brazil completed an online version of the ARGE. An Exploratory Factor Analysis found two clear, oblique, and inversely related factors (Move and Rest; GFI = 1.00, RMSR = 0.03). Reliability was good (Cronbach α's: 0.93 and 0.92). Two models of the scale (10 vs. 13 items) were compared with Confirmatory Factor Analysis. The previously validated version using 10 scored items (GFI = 1.00, RMSEA = 0.07, RMSR = 0.02) outperformed the version scored with 13 items. State anxiety and exercise behavior had small associations with Move and Rest (-0.20 to 0.26). In Study 2, ARGE Move scores had high correspondence post-session (ICC = 0.83) for 9 women performing short Sprint Interval Training (sSIT; 6 sessions). Large, but non-significant, effects were detected for changes in motivation states with sSIT. In Study 3, IRT analyses found that for the United States sample, "be physically active" and "be still" were the most representative items for Move and Rest, respectively, while for the Brazil sample they were "exert my muscles" and "be a couch potato." Overall, it was found that: (A) the ARGE scale demonstrated good psychometric properties, (B) the original scoring (with 10 items) resulted in the best model, (C) it had small associations with exercise behavior, and (D) the subscales were reduced to single items that varied by country, indicating potential cultural differences in the concept of motivation states for physical activity.

Ultrasound Assisted Endoscopic Gastric Bypass (USA-EGB): a potential endoscopic alternative to surgical bypass, a pre-clinical proof of concept study

Background and study aims Endoscopic weight loss procedures have gained traction as minimally invasive options for the primary treatment of obesity. Thus far, we have developed endoscopic procedures that reliably address gastric restriction but result in significantly less weight loss than surgical gastrointestinal bypass. The goal of this nonsurvival study was to assess the technical feasibility of an endoscopic procedure, that incorporates both gastric restriction and potentially reversible gastrointestinal bypass. Methods Ultrasound-assisted endoscopic gastric bypass (USA-EGB) was performed in three consecutive live swine, followed by euthanasia and necropsy. Procedure steps were: 1) balloon-assisted enteroscopy that determines the length of the bypassed limb; 2) endoscopic ultrasound-guided gastroenterostomy that creates a gastrointestinal anastomosis using a lumen apposing metal stent; 3) endoscopic pyloric exclusion that disrupts transpyloric continuity resulting in complete gastrointestinal bypass; and 4) gastric restriction that reduces gastric volume. Results Complete gastrointestinal bypass and gastric restriction was achieved in all three swine. The mean total procedure time was 131 minutes (range 113-143), mean length of the bypassed limb was 92.5 cm and 180 cm, using short and long overtubes, respectively. There were no significant complications. Conclusions We successfully described USA-EGB in three consecutive live swine. Further studies are needed to access the procedures safety, efficacy, and clinical use.

Arrythmic storm in patients with and without a myocardial infarction

Introduction

Available data on arrhythmic storm (AS) is frequently obtained from retrospective observational series of patients who carry an implantable cardioverter defibrillator or who undergo ablation, and typically, patients with ST-elevation myocardial infarction (STEMI) as the cause of the AS are excluded. Therefore, this selection bias limits the evidence regarding mortality and prognosis of patients with AS due to STEMI.

Purpose

Describe and compare the epidemiological and clinical characteristics, treatment, and outcomes of patients admitted for AS in the Acute Coronary Care Unit due to STEMI and other causes.

Methods

Between 2006 and 2020, 187 episodes of AS in 165 patients were identified in two third level hospitals. There were 40 patients with STEMI and 147 patients with other causes of AS. Clinical characteristics, treatment and outcome were analysed.

Results

Baseline characteristics are depicted in Figure 1. Risk profile of patients without STEMI was worse (they were older, had more often hypertension, and thyroid disturbances, and had worse NYHA class). Patients with STEMI were more frequently smokers. Ejection fraction was higher among STEMI patients.

Predisposing features for AS (apart from myocardial ischemia) were also different. Ion disturbances were more common among STEMI patients (37.4% vs 67.5%, p=0.001). Heart failure or cardiogenic shock (27.9% vs 40.0%, p=0.140), infection (12.2% vs 7.5%, p=0.399) and bradycardia with acquired long QT syndrome (10.2% vs 10.0%, p=0.695) were similar in both groups. There were two episodes of myocarditis in patients without STEMI.

The predominant arrythmia was also different. Ventricular fibrillation was more common in STEMI patients (4.8% vs 72.5%) while monomorphic ventricular tachycardia was more frequent patients without STEMI (80.3% vs 7.5%, p&lt;0.001).

STEMI patients had worse levels of pH (7.40 vs 7.25, p&lt;0.001) and lactate (2.25mmol/L vs 5.56mmol/L, p&gt;0.001) and required inotropics and vasopressors more frequently due to haemodynamic instability (15.0% vs 77.5%, p&lt;0.001), mechanical support with intra-aortic balloon pump (5.4 vs 57.5%, p&lt;0.001), ECMO (2.0% vs 7.5%, p=0.082), and other mechanical assist devices (0 vs 10.0%, p&lt;0.001), and oral intubation (23.8% vs 90.0%, p&lt;0.001).

Pharmacologic treatment is described in Figure 2.

Obviously, STEMI patients required more often percutaneous coronary intervention (8.2% vs 87.5%, p&lt;0.001) and less frequently ventricular ablation (50.3% vs 0, p&lt;0.001). Therapeutic hypothermia was more commonly used in STEMI patients due to out of hospital cardiac arrest (2.0% vs 52.5%, p&lt;0.001).

In-hospital mortality was higher in STEMI patients (11.6% vs 42.5%, p&lt;0.001).

Conclusion

Despite a worse cardiovascular profile in patients without STEMI, AS is associated with a worse haemodynamic situation and mortality in STEMI patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Beca para la Formaciόn e Investigaciόn en Cuidados Críticos Cardiolόgicos concedida por la Asociaciόn de Cardiopatía Isquémica y Cuidados Críticos Cardiolόgicosde la SEC Figure 1. Baseline CharacteristicsFigure 2. Pharmacological treatment

Search for γ-Ray Line Signals from Dark Matter Annihilations in the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

Spectral lines are among the most powerful signatures for dark matter (DM) annihilation searches in very-high-energy γ rays. The central region of the Milky Way halo is one of the most promising targets given its large amount of DM and proximity to Earth. We report on a search for a monoenergetic spectral line from self-annihilations of DM particles in the energy range from 300 GeV to 70 TeV using a two-dimensional maximum likelihood method taking advantage of both the spectral and spatial features of the signal versus background. The analysis makes use of Galactic center observations accumulated over ten years (2004-2014) with the H.E.S.S. array of ground-based Cherenkov telescopes. No significant γ-ray excess above the background is found. We derive upper limits on the annihilation cross section ⟨σv⟩ for monoenergetic DM lines at the level of 4×10^{-28}  cm^{3} s^{-1} at 1 TeV, assuming an Einasto DM profile for the Milky Way halo. For a DM mass of 1 TeV, they improve over the previous ones by a factor of 6. The present constraints are the strongest obtained so far for DM particles in the mass range 300 GeV-70 TeV. Ground-based γ-ray observations have reached sufficient sensitivity to explore relevant velocity-averaged cross sections for DM annihilation into two γ-ray photons at the level expected from the thermal relic density for TeV DM particles.

H.E.S.S. Limits on Linelike Dark Matter Signatures in the 100 GeV to 2 TeV Energy Range Close to the Galactic Center

A search for dark matter linelike signals iss performed in the vicinity of the Galactic Center by the H.E.S.S. experiment on observational data taken in 2014. An unbinned likelihood analysis iss developed to improve the sensitivity to linelike signals. The upgraded analysis along with newer data extend the energy coverage of the previous measurement down to 100 GeV. The 18 h of data collected with the H.E.S.S. array allow one to rule out at 95% C.L. the presence of a 130 GeV line (at l=-1.5°, b=0° and for a dark matter profile centered at this location) previously reported in Fermi-LAT data. This new analysis overlaps significantly in energy with previous Fermi-LAT and H.E.S.S.

RESULTS

No significant excess associated with dark matter annihilations was found in the energy range of 100 GeV to 2 TeV and upper limits on the gamma-ray flux and the velocity weighted annihilation cross section are derived adopting an Einasto dark matter halo profile. Expected limits for present and future large statistics H.E.S.S. observations are also given.

Search for Dark Matter Annihilations towards the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

The inner region of the Milky Way halo harbors a large amount of dark matter (DM). Given its proximity, it is one of the most promising targets to look for DM. We report on a search for the annihilations of DM particles using γ-ray observations towards the inner 300 pc of the Milky Way, with the H.E.S.S. array of ground-based Cherenkov telescopes. The analysis is based on a 2D maximum likelihood method using Galactic Center (GC) data accumulated by H.E.S.S. over the last 10 years (2004-2014), and does not show any significant γ-ray signal above background. Assuming Einasto and Navarro-Frenk-White DM density profiles at the GC, we derive upper limits on the annihilation cross section ⟨σv⟩. These constraints are the strongest obtained so far in the TeV DM mass range and improve upon previous limits by a factor 5. For the Einasto profile, the constraints reach ⟨σv⟩ values of 6×10^{-26}  cm^{3} s^{-1} in the W^{+}W^{-} channel for a DM particle mass of 1.5 TeV, and 2×10^{-26}  cm^{3} s^{-1} in the τ^{+}τ^{-} channel for a 1 TeV mass. For the first time, ground-based γ-ray observations have reached sufficient sensitivity to probe ⟨σv⟩ values expected from the thermal relic density for TeV DM particles.

Constraints on an annihilation signal from a core of constant dark matter density around the milky way center with H.E.S.S

An annihilation signal of dark matter is searched for from the central region of the Milky Way. Data acquired in dedicated on-off observations of the Galactic center region with H.E.S.S. are analyzed for this purpose. No significant signal is found in a total of ∼9  h of on-off observations. Upper limits on the velocity averaged cross section, ⟨σv⟩, for the annihilation of dark matter particles with masses in the range of ∼300  GeV to ∼10  TeV are derived. In contrast to previous constraints derived from observations of the Galactic center region, the constraints that are derived here apply also under the assumption of a central core of constant dark matter density around the center of the Galaxy. Values of ⟨σv⟩ that are larger than 3×10^{-24}  cm^{3}/s are excluded for dark matter particles with masses between ∼1 and ∼4  TeV at 95% C.L. if the radius of the central dark matter density core does not exceed 500 pc. This is the strongest constraint that is derived on ⟨σv⟩ for annihilating TeV mass dark matter without the assumption of a centrally cusped dark matter density distribution in the search region.

Search for photon-linelike signatures from dark matter annihilations with H.E.S.S

Gamma-ray line signatures can be expected in the very-high-energy (E(γ)>100 GeV) domain due to self-annihilation or decay of dark matter (DM) particles in space. Such a signal would be readily distinguishable from astrophysical γ-ray sources that in most cases produce continuous spectra that span over several orders of magnitude in energy. Using data collected with the H.E.S.S. γ-ray instrument, upper limits on linelike emission are obtained in the energy range between ∼ 500 GeV and ∼ 25 TeV for the central part of the Milky Way halo and for extragalactic observations, complementing recent limits obtained with the Fermi-LAT instrument at lower energies. No statistically significant signal could be found. For monochromatic γ-ray line emission, flux limits of (2 × 10(-7) -2 × 10(-5)) m(-2) s(-1) sr(-1) and (1 × 10(-8) -2 × 10(-6)) m(-2) s(-1)sr(-1) are obtained for the central part of the Milky Way halo and extragalactic observations, respectively. For a DM particle mass of 1 TeV, limits on the velocity-averaged DM annihilation cross section ⟨σv⟩(χχ → γγ) reach ∼ 10(-27) cm(3)s(-1), based on the Einasto parametrization of the Galactic DM halo density profile.

P2-09-10: Giant or Windmill? 18F-FDG-PET/CT Semi-Quantitative Parameters and Biological Prognostic Parameters in Women with Breast Cancer Treated with Neoadjuvant Chemotherapy: A Multicentric Study in La Mancha

Background: To analyze the possible predictive-prognostic value of 18F-FDG-PET/CT to evaluate response to primary preoperative neoadjuvant (NA) chemotherapy (CT) in women with breast cancer (BC) a multicenter study is being conducted in most Hospitals in Castilla - La Mancha (central Spain). As per protocol a PET/CT study has to be conducted prior to 1st cycle, after 2nd cycle and at the end of induction CT. We report here the initial results with the correlation between the PET/CT results and pathological-radiological-clinical findings prior to NA CT.

Aim: To analyze the correlation between 18F-FDG uptake assessed by PET/CT and histopathological and inmunohistochemical prognostic factors in BC prior to NA CT.

Material and methods: 68 women diagnosed of BC (36 with locally advanced BC) were prospectively evaluated. PET/CT was requested in the initial staging previous to NA CT. Clinical and metabolic stages were assessed according to TNM classification. All biological prognostic parameters, such as ER, PR, p53 and c-erbB-2 expression, proliferation rate (Ki-67), and grading (SBR) were determined from tissue of the primary tumour prior to NA CT. All patients underwent an 18F-FDG PET/CT with a dual-time-point acquisition performed in the early phase 1 h after FDG administration (PET-1) and in the delayed phase 3 h after FDG administration (PET-2). Both examinations were evaluated qualitatively and semiquantitatively with calculation of SUVmax values in PET-1 (SUV-1) and in PET-2 (SUV-2) and the percentage variation of the standard uptake values (retention index) between PET-1 and PET-2. Metabolic, clinical and biological parameters were correlated. Student, ANOVA and Bonferroni tests were used to compare the means, chi-score to compare proportions and Pearson correlation to compare two quantitative variables.

Results: A positive relationship was found between the SUVmax, tumour size, clinical and metabolic stages. SUV-1 and SUV-2 values showed significant statistical correlation (p&lt;0.05) with PET stage and tumour size assessed by PET. On the contrary, the retention index showed relation with clinical stage (p&lt;0.05). About the biological parameters, retention index showed the best results with positive and significant relation (p&lt;0.05) with histological grade, ER status, Ki-67 and c-erbB-2 expression. Isolated SUV values only showed significant relation to Ki-67 expression.

Conclusion: The retention index showed the best correlation with biological and clinical parameters compared to isolated SUVmax values. It may be useful as a predictive marker of tumor biological behavior. Nevertheless these are only the results of PET/CT prior to NA CT, with longer follow up we hopefully will be able to look at the correlation between PET/CT and radiological, clinical and pathological response after NA CT.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-10.

Search for a dark matter annihilation signal from the galactic center halo with H.E.S.S

A search for a very-high-energy (VHE; ≥100  GeV) γ-ray signal from self-annihilating particle dark matter (DM) is performed towards a region of projected distance r∼45-150  pc from the Galactic center. The background-subtracted γ-ray spectrum measured with the High Energy Stereoscopic System (H.E.S.S.) γ-ray instrument in the energy range between 300 GeV and 30 TeV shows no hint of a residual γ-ray flux. Assuming conventional Navarro-Frenk-White and Einasto density profiles, limits are derived on the velocity-weighted annihilation cross section (σv) as a function of the DM particle mass. These are among the best reported so far for this energy range and in particular differ only little between the chosen density profile parametrizations. In particular, for the DM particle mass of ∼1  TeV, values for (σv) above 3×10(-25)  cm(3) s(-1) are excluded for the Einasto density profile.

Monoamine oxidase inhibitory activity of some Hypericum species native to South Brazil

The total methanol crude extracts and petroleum ether, chloroform, and methanol fractions obtained from Hypericum species, H. caprifoliatum, H. carinatum, H. connatum, H. cordatum, H. myrianthum, H. piriai, H. polyanthemum and H. brasiliense, all native to South Brazil, were assayed for monoamine oxidase A (MAO A) and MAO B inhibitory activity in rat brain mitochondrial preparations at concentrations ranging from 1 to 20microg mL(-1). Three benzopyrans, HP1 (6-isobutyryl-5,7-dimethoxy-2,2-dimethylbenzopyran), HP2 (7-hydroxy-6-isobutyryl-5-methoxy-2,2-dimethylbenzopyran) and HP3 (5-hydroxy-6-isobutyryl-7-methoxy-2,2dimethylbenzopyran) isolated from H. polyanthemum were also tested at maximal concentrations of 150, 150 and 75/microM, respectively. The lipophilic extracts of H. polyanthemum, H. caprifoliatum and H. piriai displayed MAO A inhibitory activity greater than 50%. Among the benzopyrans, only HP3 showed significant activity, with an IC50 value of 22 microM. The total methanol crude extracts of aerial parts from H. carinatum, H. connatum, H. cordatum, H. polyanthemum and H. piriai were evaluated for antidepressant activity in the Porsolt's forced swimming test in Wistar rats (270 mg kg(-1) day(-1); i.p); however, none of them showed activity.

Clinicoepidemiological study of imported malaria in travelers and immigrants to Madrid

BACKGROUND

The number of Spanish travelers visiting malaria endemic areas, and the number of immigrants from malarial countries arriving in Spain are continuously increasing. However, little information about imported cases in Spain is available.

METHODS

A prospective clinicoepidemiological study of imported cases of malaria diagnosed at a referral teaching hospital in Madrid, Spain.

RESULTS

Of the 160 patients, sixty (37.5%) were immigrants and 100 (62.5%) Spanish nationals. Malaria was acquired in Africa by 98.3% of immigrants and in 83.0% of travelers. Falciparum malaria accounted for 71.8% of the cases, P. vivax for 11.9%, P. ovale for 10.6% and P. malarie for 5. 0%. Eleven (6.9%) patients, all immigrants, were asymptomatic. Severe complications were recorded in 17 (10.6%): 7, severe anemia; 3, cerebral malaria; 2, renal failure; 1, spontaneous splenic rupture; 1, acute pulmonary edema; 1, sepsis; 1, acute cerebrovascular accident; and 1, disseminated intravascular coagulation. There were no fatal cases. Among the 100 Spanish nationals, 44% did not follow any prophylaxis, 29% followed a correct prophylaxis, 27% were considered defaulters, and 39% took self-treatment without cure.

CONCLUSIONS

There is a changing pattern of imported malaria in Madrid, with one third occurring in immigrants and two thirds in nationals. This data provides information about the reemergence of imported malaria to Europe.

Massive haemorrhage from rupture of a pancreatic pseudocyst after pentamidine-associated pancreatitis

A 40 year-old man with the acquired immunodeficiency syndrome who was treated with intravenous pentamidine suffered a massive spontaneous haemorrhage caused by rupture of a pancreatic pseudocyst after pentamidine-induced pancreatitis. The patient previously presented symptomatic hypoglycaemia, severe nephrotoxicity and hyperkalaemia, while not receiving any other drug but pentamidine. This is the first case reported of such a complication of pentamidine induced pancreatitis, and one of the few cases reported of the latter adverse event.

[Mortality in the under-65 years of age in a teaching internal medicine service]

The reports of patients under 65 years of age who died during the period 1982 to 1988 at an Internal Medicine Department in a University Hospital were analysed in a transversal study. There were 927 deaths, 815 being evaluable, and 160 (19.63%) of the patients were under 65 years old. The group in question had multiple diseases and admissions (15.72%). The most frequent diseases observed were neoplasia (31.64%), cirrhosis (17.08), ischemic cerebrovascular disease (11.39%), pneumonia (11.39%) and renal insufficiency (11.39%). Terminology such as cardio-respiratory arrest and "probably, possible or not confirmed" were found in 30.37% of the reports.

[An analysis of 14,000 patients admitted to an internal medicine service during 1982-1988]

We analysed the discharge reports of patients admitted during 1982-1988 to an internal medicine department of a university hospital. There were 927 deaths among 13,913 patients (6.66%); the median age of the persons admitted was 59.50 years while the median age of the patients who died was 72.87 years. Both groups suffered from several afflictions; the most frequent among the hospital-admission group being: blood hypertension, pneumonia, diabetes mellitus, and the group who eventually died: pneumonia, cerebrovascular and neoplastic disease.