Hidden local recurrence of colorectal adenocarcinoma diagnosed by endoscopic ultrasound: A case series

BACKGROUND

Almost half of the patients with colorectal cancer (CRC) will experience local-regional recurrence after standard surgical excision. Many local recurrences of colorectal cancer (LRCC) do not grow intraluminally, and some may be covered by a normal mucosa so that they could be missed by colonoscopy. Early detection is crucial as it offers a chance to achieve curative reoperation. Endoscopic ultrasound (EUS) is mainly used in CRC staging combined with cross-section imaging study. EUS can provide an accurate assessment of sub-mucosal lesions by demarcating the originating wall layer and evaluating its echostructure. EUS fine-needle aspiration (FNA) provides the required tissue examination and confirms the diagnosis.

CASE SUMMARY

We report a series of five cases referred to surveillance for LRCC with negative colonoscopy and/or negative endoscopic biopsies. EUS-FNA confirmed LRCC implanted deep into the third and fourth wall layer with normal first and second layer.

CONCLUSION

Assessment for LCRR is still problematic and may be very tricky. EUS and EUS-FNA may be useful tools to exclude local recurrence.

Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021

People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.

Role of EUS in detection of liver metastasis not seen by computed tomography or magnetic resonance imaging during staging of pancreatic, gastrointestinal, and thoracic malignancies

Background and Objectives:

Liver metastases might not be detected by computed tomography (CT) and magnetic resonance imaging (MRI) due to their small size, but they can be detected by EUS. Furthermore, EUS-FNA has a significant impact on improving the diagnostic accuracy of EUS. The purpose of this study was to assess the feasibility of EUS in detection of occult small hepatic focal lesions at the time of primary tumor staging, not seen by CT or MRI.

Methods:

This prospective study included 730 patients who underwent EUS for staging or sampling of gastrointestinal, pancreatic, or thoracic malignancy. The liver was examined thoroughly for detection of occult lesions. CT or MRI was done within 1 week of EUS examination.

Results:

EUS examination of the liver detected focal lesions in 150 patients (20.5%) and metastases in 118 patients (16.2%); meanwhile, CT and MRI detected focal lesions in 99 patients (13.6%) and metastases in 82 patients (11.2%). EUS missed focal lesions in 7 patients, 6 of which were liver metastases (1.0% and 0.8%, respectively), while CT and MRI missed focal lesions in 58 patients, 42 of which were metastases (7.9% and 5.8%, respectively), which were detected by EUS.

Conclusion:

Thorough dedicated EUS examination of the liver is a feasible useful tool for detection of small hepatic lesions missed by CT and MRI. It is not considered an extra financial burden to the patient or health-care system because those patients are indicated for EUS examination for evaluation of their original lesion in the first place. Furthermore, EUS-FNA can add another advantage in diagnosing the etiology of such lesions.

Effect of high-flow vs. low-flow nasal plus mouthguard oxygen therapy on hypoxaemia during sedation: a multicentre randomised controlled trial

Whether high-flow vs. low-flow nasal oxygen reduces hypoxaemia for sedation during endoscopic retrograde cholangiopancreatography is currently unknown. In this multicentre trial, 132 patients ASA physical status 3 or higher, BMI > 30 kg.m^-2 or with known or suspected obstructive sleep apnoea were randomly allocated to high-flow nasal oxygen up to 60 l.min^-1 at 100% F_I O₂ or low-flow nasal oxygen at 4 l.min^-1 . The low-flow nasal oxygen group also received oxygen at 4 l.min^-1 through an oxygenating mouthguard, totalling 8 l.min^-1 . Primary outcome was hypoxaemia, defined as S_p O₂ < 90% regardless of duration. Hypoxaemia occurred in 7.7% (5/65) of patients with high-flow and 9.1% (6/66) with low-flow nasal oxygen (percentage point difference -1.4%, 95%CI -10.9 to 8.0; p = 0.77). Between the groups, there were no significant differences in frequency of hypoxaemic episodes; lowest S_p O₂ ; peak transcutaneous carbon dioxide; hypercarbia (transcutaneous carbon dioxide > 2.66 kPa from baseline); requirement of chin lift/jaw thrust; nasopharyngeal airway insertion; bag-mask ventilation; or tracheal intubation. Following adjustment for duration of the procedure, the primary outcome remained non-significant. In high-risk patients undergoing endoscopic retrograde cholangiopancreatography, oxygen therapy with high-flow nasal oxygen did not reduce the rate of hypoxaemia, hypercarbia or the need for airway interventions, compared with combined oral and nasal low-flow oxygen.

COVID-19 Disease Outcomes: Does Gastrointestinal Burden Play a Role?

Background

The novel coronavirus disease 2019 presents an urgent threat to global health. As the epidemic grows, prognosis prediction is essential for monitoring risky patient. It is thus important to consider gastrointestinal manifestations and the duration of symptoms as predictors of prognosis. Our aim was to determine the correlation of gastrointestinal symptoms and laboratory markers with disease outcomes and whether symptom duration varies substantially between patients. We also undertook this study to determine the optimal time to predict COVID-19 outcome.

Patients and Methods

A total of 190 patients with polymerase chain reaction-confirmed COVID-19 were followed up until recovery. We proposed a correlation between gastrointestinal symptoms and disease severity (based on clinical data, and diagnostic investigations) to estimate the duration of symptoms as a predictor of COVID-19 prognosis.

Results

The prevalence of gastrointestinal symptoms was 49.5%, consisting mainly of diarrhea in 27.9% of patients. In addition, a longer disease duration and higher temperature were observed in patients with diarrhea. Symptom duration was variable, with a median of 12 days and a range of 1–55 days. Statistical analysis indicated that patients with a duration of symptoms ≥12 day had more severe symptoms and a worse prognosis. Patients who complained of diarrhea had 2.7 times the odds of a longer duration of symptoms, and those with a history of chronic lung disease have 7.2 times the odds of a longer duration of symptoms.

Conclusion

GIT manifestations (mainly diarrhea) and the duration of symptoms of COVID-19 provide prognostic evidence of COVID-19 outcomes, irrespective of earlier categorization by the World Health Organization. Thus, patients with mild symptoms who present with diarrhea and a duration of symptoms longer than 12 days are expected to have a worse prognosis.

Comparative study of tissue adhesive therapy versus band ligation in control of actively bleeding esophageal varices

BACKGROUND AND STUDY AIMS

Bleeding esophageal varices is a common life-threatening emergency that carries a significant morbidity and mortality. Acute variceal bleeding is considered active when spurting and/or oozing varix is seen at the time of endoscopy, or inactive in the presence of large esophageal varices with blood in the stomach with no other bleeding source at the time of endoscopy. Aim: comparing endoscopic variceal ligation (EVL) versus cyanoacrylate injection (CI) in active esophageal variceal bleeding control.

PATIENTS AND METHODS

a retrospective single tertiary center study from April 2014 to February 2018, including 401 patients with active esophageal variceal bleeding.

RESULTS

Endoscopic hemostasis was achieved by both endoscopic variceal ligation in 182 patients (91.9%) and cyanoacrylate injection in 197 patients (97.05%) without significant difference (P value 0. 15). Re-bleeding occurred more frequently in EVL group 20 patients (10.1%) compared to 14 patients (6.9%) in CI (P value 0.01). Early six-week Mortality was higher among EVL group (20.7%) compared to CI (17.2%) without statistical significance (P value 0.3).

CONCLUSION

Both EVL and CI are almost as effective in achieving endoscopic hemostasis. CI is more effective, feasible, and could be used as a salvage therapy and/or spared for risky active bleeding esophageal varices.

Cap-Assisted Technique versus Conventional Methods for Esophageal Food Bolus Extraction: A Comparative Study

BACKGROUND/AIMS

Food bolus impaction is the most common form of esophageal foreign body impaction observed in adults. Clinical guidelines recommend using the push technique or retrieval methods in such cases. The push technique can cause injuries in certain clinical situations. Notably, conventional retrieval methods are time and effort consuming. Cap-assisted endoscopic extraction of an impacted food bolus is an easy and effective technique; however, more data are needed for its validation. This study compared the capassisted extraction technique with conventional methods.

METHODS

This prospective observational multicenter study compared the success and en bloc removal rates, total procedure time, and adverse events in both techniques..

RESULTS

The study included 303 patients who underwent food bolus extraction. The push technique was used in 87 patients (28.7%) and a retrieval procedure in 216 patients (71.3%). Cap-assisted extraction was performed in 106 patients and retrieval using conventional methods in 110 patients. The cap-assisted technique was associated with a higher rate of en bloc removal (80.2% vs. 15%, p<0.01), shorter procedure time (6.9±3.5 min vs. 15.7±4.1 min, p<0.001), and fewer adverse events (0/106 vs. 9/110, p<0.001).

CONCLUSION

Cap-assisted extraction showed no adverse events, higher efficacy, and a shorter procedure time compared with conventional retrieval procedures.

Serum interleukin-17 in Egyptian children with systemic lupus erythematosus: is it related to pulmonary affection?

Objective Pulmonary involvement in paediatric systemic lupus erythematosus (pSLE) is not an uncommon finding; however, subclinical affection occurs more frequently. Many studies have reported that cytokine dysregulation as interleukin-17 (IL-17) over-expression plays a key role in the pathogenesis of systemic lupus erythematosus (SLE). We aim to assess serum levels of IL-17 A and their association with pulmonary involvement in children with SLE. Methods Serum IL-17A levels - determined by solid phase sandwich ELISA - were assessed in forty-two pSLE patients and compared to 45 age-matched healthy controls. All patients were subjected to pulmonary function tests to detect subclinical pulmonary affection. High-resolution CT (HRCT) chest scan was carried out in patients with abnormal pulmonary function tests (PFTs) and those with chronic respiratory symptoms. Results Abnormal PFTs were found in 73% of patients; of them, only 25% had abnormal findings in HRCT chest. Serum levels of IL-17 A were significantly elevated in pSLE patients as compared to healthy controls ( p < 0.001). The serum levels of IL-17 A had a highly significant positive correlation with SLEDAI ( r = 0.811 and p < 0.001) Strong negative correlation was found between serum levels of IL-17A with both FEV1 and FVC ( p < 0.05). Conclusions Serum IL-17A is elevated in pSLE patients, which correlates with disease activity. IL-17 seems to have a possible role in the pathogenesis of subclinical lung affection. Abnormal PFTS may be found in pSLE patients even with normal radiology.

Salivary gland composition of some Old World vector sand fly

The saliva of blood feeding arthropods has a variety of substances that are responsible for blood meal success. The composition and the influence of sand fly saliva vary considerably between species and even between populations of different geographical origin. In Old-World sand flies (Phlebotomus sp.) differences in protein components of the salivary gland homogenate were demonstrated between species and between colonies of the same species. We compared protein components in the salivary glands of sand flies vectors from different species and origins. The salivary gland homogenate (SGH) of laboratory reared Egyptian phlebotomine sand flies, P. papatasi, P. sergenti and P. langeroni Sinai and El-Agamy strains respectively were compared with Spanish naturally caught P. perniciosus and P. ariasi, which were collected from a farm 20 km southwest of Barcelona. Polyacrylamide gel electrophoresis (PAGE) (SDS-PAGE) was done for compareson. The electrophoresis profiles of SGH differed between all tested species. From 8-14 prominent proteins bands with molecular masses ranging from 8-70 kDa were visualized by Commassie blue gel code staining in each SGH. So, saliva composition varied between species and sub-species, and increased between different sub-genera and geographical areas. The data are important for the characterization of salivary proteins.

Immunomodulatory properties of sand fly saliva and its role on vertebrate host

The salivary glands of Phlebotomus papatasi and P. langeroni were investigated for their immunomodulatory properties on vertebrate hosts. Laboratory reared sand fly, were used for feeding on hamsters and for extraction of salivary gland. To determine the influence of the sand fly saliva homogenate (SGH) were performed ELISA using sera from injected hamsters by SGH. Frequent feeding of P. papatasi on hamsters were carried out to relate the anti-body titre with the biting rate. The mosquito Culex pipiens was allowed to feed on pre-exposed hamsters to P. papatasi bites. Antibodies correlated with the saliva of both species showed low titre and not related either to the time (after feeding and injection) or to the number of fed flies. Saliva of P. langeroni (non vector) recorded higher anti-body titre than P. papatasi. The preliminary experiment of the mosquitoes' feeding (C. pipiens) on pre-exposed hamsters on its saliva showed cross reactions between biting of mosquitoes and sand flies. More investigations are needed to study the effects of sand fly saliva on human immune responses to evaluate the fly salivary proteins as vaccines for leishmaniasis and to prevent or decrease the sand flies biting or probably mosquitoes.

Development of Leishmania major in the phlebotomine sandflies, Phlebotomus papatasi (Scopoli) and Phlebotomus langeroni (Nitzulescu)

Laboratory bred Phlebolomus papatasi and P. langeroni were examined for their susceptibility to develop Leishmania major promastigotes under laboratory conditions. Promastigotes were demonstrated in the gut of both species when they were given sugar 24 hr before or after an infective blood meal and in flies offered only an infective blood. The overall infection rate was slightly higher in P. langeroni than P. papatasi. Head promastigotes were detected in P. papatasi provided with sugar 24 hr before or after an infective blood meal. No head promastigotes were seen in flies offered only infective blood. In P. langeroni, head promastigotes were only seen in flies fed on sugar before or after an infective blood and maintained at 18 degrees C. Results indicate that sugar plays a major role in the migration of parasites from the gut to the head. Temperature may have a marginal effect on the migration process. Attempts to transmit L. major to hamster by the bite of infected P. papatasi were not successful.

Cognitive changes in acute schizophrenia with brief neuroleptic treatment

The authors studied 44 acutely decompensated, hospitalized schizophrenic patients who were placed on a double-blind basis for 10 days in three treatment groups: patients given high, moderate, and standard doses of haloperidol. To assess changes in the patients' concentration, abstract thinking, and ability to respond appropriately they administered two clinical rating scales and three psychological tests. Patients in all three treatment groups showed similar and significant improvements according to both clinical and psychological ratings after haloperidol administration. Normal control subjects showed no change in psychological test scores over time. The authors conclude that brief treatment with neuroleptics produces measurable improvement in schizophrenic thinking.

Haloperidol for acute schizophrenic patients. An evaluation of three oral regimens

The relative efficacy of three oral regimens of haloperidol was compared in a ten-day, double-blind study of 63 acutely ill schizophrenic patients newly admitted to the hospital. One group of patients received 20 mg of haloperidol on day 1, then increasing increments of 20 mg a day, reaching a maximum dosage of 100 mg daily on day 5. Another group received 10 mg of haloperidol on day 1, then increasing increments of 10 mg daily, reaching 100 mg daily on day 10. A third group of patients received a fixed dosage of 10 mg daily for ten days. Haloperidol was well tolerated by the patients; there were no serious adverse reactions. The data indicated that the regimens had similar therapeutic efficacy, suggesting that acutely ill schizophrenic patients respond to a wide range of doses of haloperidol but that onset of response and efficacy are not increased in most patients by providing a high initial loading dosage. Adequate, safe dosage must be determined in each case.

High vs standard dosage fluphenazine HCL in acute schizophrenia

This rater blind project compared the efficacy and safety of using an oral rapid or neuroleptization method (maximum 80 mg./day) versus fixed standard dosage (20 mg./day) fluphenazine, a commonly used neuroleptic. There were 32 hospitalized, acutely decompensated schizophrenic patients in the experiment; the study period for each patient was a maximum of 7 days. The data were collected using the Benjamin Proverb Test and rating scales for psychopathology and adverse effects. Data analysis by means of the analysis of covariance demonstrated few significant differences between the 2 treatment methods: both methods produced a similar reduction in psychopathological symptoms and incidence of adverse effects. The authors conclude that the rapid neuroleptization method is not superior to the fixed standard dosage method in treating acute schizophrenia.