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Dysregulation, Catastrophic Reactions, and the Anxiety Disorders

Walkup, John T; Friedland, Susan J; Peris, Tara S; Strawn, Jeffrey R
Normal developmental activities (eg, going to school, raising a hand in class, and managing typical life uncertainties) are 'triggers' for children and adolescents with anxiety disorders. To cope, children with anxiety avoid; however, when avoidance of developmentally appropriate activities is not possible, catastrophic responses can ensue. If these catastrophic reactions result in successful avoidance, they are likely to recur leading to a generalized pattern of dysregulated behavior. Interventions include treating anxiety disorder symptoms to remission. For parents the goal is to challenge their child to engage in important developmental activities, reward positive coping and avoid reinforcing avoidance behavior.
PMID: 33743949
ISSN: 1558-0490
CID: 4822062

A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions

Ichkhanian, Y; Vosoughi, K; Diehl, D L; Grimm, I S; James, T W; Templeton, A W; Hajifathalian, K; Tokar, J L; Samarasena, J B; Chehade, N El Hage; Lee, J; Chang, K; Mizrahi, M; Barawi, M; Irani, S; Friedland, S; Korc, P; Aadam, A A; Al-Haddad, M A; Kowalski, T E; Novikov, A; Smallfield, G; Ginsberg, G G; Oza, V M; Panuu, D; Fukami, N; Pohl, H; Lajin, Michael; Kumta, N A; Tang, S J; Naga, Y M; Amateau, S K; Brewer, G O I; Kumbhari, V; Sharaiha, R; Khashab, Mouen A
BACKGROUND:Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA. METHODS:Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE). RESULTS:A total of 95 patients (mean age 65.5 ± 12.6 year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4 mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8 min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention. CONCLUSIONS:Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.
PMID: 32180001
ISSN: 1432-2218
CID: 4361142

716 NON-EXPOSURE FULL-THICKNESS RESECTION OF COLONIC LESIONS IN THE U.S: THE FTRD EXPERIENCE [Meeting Abstract]

Ichkhanian, Y; Vosoughi, K; Sharaiha, R Z; Hajifathalian, K; Tokar, J L; Templeton, A W; James, T W; Grimm, I S; Mizrahi, M; Samarasena, J B; Chehade, N E; Lee, J; Chang, K J; Barawi, M; Irani, S S; Friedland, S; Korc, P; Aadam, A A; Al-Haddad, M A; Kowalski, T E; Novikov, A A; Diehl, D L; Smallfield, G; Ginsberg, G G; Oza, V; Pannu, D; Fukami, N; Pohl, H; Lajin, M; Kumta, N A; Tang, S J; Amateau, S K; Ngamruengphong, S; Kumbhari, V; Brewer, Gutierrez O I; Khashab, M A
Background: The full-thickness resection device (FTRD)was recently introduced in the US and has made endoscopic resection of difficult lesions and those with deep wall origin/infiltration possible using non-exposure resection technique. Although initial studies were promising, outcome results of FTRD in the literature are scarce.
Aim(s): To study the feasibility, effciacy, and safety of FTRD for the resection of colonic lesions.
Method(s): Patients who underwent endoscopic full-thickness resection (EFTR)using the FTRD for lower GI lesions at 24 U.S. tertiary-care centers between 10/17 and 10/18 were included in this retrospective study. Outcomes were technical success (defined as en-block resection)and R0 histologic margin. Chi square test was used to assess the association between lesion type, size, and location with the two outcomes.
Result(s): A total of 79 patients (mean age 65 yr, 39.2% F)underwent resection of colonic lesions using the FTRD. The most common indication was difficult adenoma (defined as non-lifting, recurrent, residual or involving appendiceal orifice/diverticular opening)in 48 (60.8 %)patients, followed by adenocarcinoma in 17 (21.5%), and sub-epithelial lesions in 10 (12.7 %). Lesion location was in the proximal colon in 46 (58.2%)patients, followed by distal colon in 17 (21.5%), and rectum in 16 (20.3%). Mean pre-resection lesion diameter and total procedure time were 15.3 +/- 6.5 mm and 63 +/-32 min, respectively. Majority of patients underwent MAC sedation and received no prophylactic antibiotics. Most patients, 72.2%, were discharged post-procedurally. Technical success was achieved in 67 (84.8 %)patients. For the 12 patients with technical failure, 5 underwent hot snare resection, 2 endoscopic submucosal dissection, 1 was managed surgically, while 4 had no further interventions. R0 resection was achieved in 88.9% of patients. A total of 9 (11.4%)adverse events occurred. Mild, moderate, and severe AE had a frequency of 6 (7.6%), 1 (1.3%), and 2 (2.5%), respectively. Most common AE was FTRD mechanical failure in 5 cases (6.3%), with one leading to perforation requiring surgery (severe event). Bleeding was reported in 3 cases (3.8%), with one case requiring endoscopic intervention 2-days post-procedure. One patient, despite being on pre and post procedure antibiotics, developed appendicitis 10-days post-procedure and was managed surgically (severe event). Technical success and R0 resection were not significantly associated with lesion type, size, or location.
Conclusion(s): Results from this first U.S multicenter study suggest that EFTR is a feasible, safe, and effective technique for EFTR of difficult colonic lesions. Surgical management can be avoid in the vast majority of cases. Although adverse events are not uncommon, severe complications are rare. [Figure presented][Figure presented]
Copyright
EMBASE:2002059159
ISSN: 0016-5107
CID: 3934902

OUTCOMES OF ENDOSCOPIC SUBMUCOSAL DISSECTION VERSUS SURGERY IN EARLY GASTRIC CANCER MEETING STANDARD AND EXPANDED INDICATIONS: A MULTICENTER NORTH AMERICAN COHORT [Meeting Abstract]

Kerdsirichairat, T; Wang, R; Aihara, H; Draganov, P V; Kumta, N A; Tomizawa, Y; Truong, C D; Lo, S K; Jamil, L H; Gaddam, S; Burch, M; Dhall, D; Perbtani, Y B; Yang, D; Bartel, M J; Goel, N; Reddy, S S; Farma, J M; Gong, Y; Ferri, L E; Chen, A; Chen, M; Chen, Y -I; Sethi, A; Ansari, N; Trapp, G; Schrope, B; Del, Portillo A; DeLatour, R; Park, K H; Khanna, L G; Melis, M; Newman, E; Hatzaras, I; James, T W; Grimm, I S; DeWitt, J M; Siegel, A B; Aadam, A A; Wang, A Y; Bechara, R; Abe, S; Wong, Kee Song L M; Brewer, Gutierrez O I; Montgomery, E; Johnston, F M; Duncan, M D; Canto, M I; Lennon, A M; Hanada, Y; Hwang, J H; Friedland, S; Ngamruengphong, S
Background: Prior data from Asian countries showed comparable outcomes of endoscopic submucosal dissection (ESD)vs surgery in patients with early gastric cancer (EGC)meeting standard and expanded criteria. Data from comparative studies using strict criteria in North American population are lacking.
Method(s): We conducted a multicenter retrospective study from 16 North American centers. All patient underwent ESD and/or gastrectomy for EGC between 12/2004 and 2/2018, with follow-up until 10/2018. Patients who did not meet either standard or expanded criteria, those with evidence of lymph node or distant metastasis at time of diagnosis, those without curative resection, and those with follow-up time of less than 6 months were excluded. Primary outcomes were overall survival (OS), cancer-specific survival (CSS)and recurrence-free survival (RFS). Kaplan-Meier using log-rank analysis was used to compare outcomes between ESD and surgery groups. Factors associated with outcomes were analyzed using Cox hazards regression and linear regression analyses.
Result(s): There were 393 patients with EGC who underwent ESD or gastrectomy from 14 US and 2 Canadian centers. Of these, 318 patients were excluded due to unfulfilled standard or expanded criteria (n=254), evidence of lymph node metastasis (n=1), no data on lymphovascular invasion (n=1), non-R0 resection (n=17)and follow-up time of less than 6 months (n=45). A total of 75 patients were analyzed (38 treated with ESD and 37 treated with surgery). Patients treated with surgery had a higher proportion of pedunculated lesions (P=0.02), undifferentiated tumors (P =0.01), EGCs fulfilling expanded criteria (P <0.0001)and longer follow-up time (P=0.0004)(Table 1). OS (P= 1.00), CSS (P=1.00)and RFS (P=1.00)were not statistically different between ESD vs surgery groups. There was no subsequent nodal or distant metastasis in either group. A single patient in the surgery group died of an etiology not related to gastric cancer at 7.9 years after gastrectomy. There were no deaths in the ESD group. One patient with moderately differentiated adenocarcinoma in the gastric antrum, treated with curative ESD, developed a gastric cardiac neuroendocrine tumor at 7.2 years (Table 2). The metachronous lesion was treated with a repeat curative endoscopic resection. There was no demographic, procedural or histological factor associated with OS, CSS or RFS.
Conclusion(s): The standard and expanded criteria for gastric ESD are clinically applicable to a North American population. ESD provides comparable oncologic outcomes and is thus an alternative treatment option to surgery. Recurrence after ESD is uncommon, and can be managed successfully using follow-up and repeat endoscopic treatment. [Figure presented][Figure presented]
Copyright
EMBASE:2002059404
ISSN: 0016-5107
CID: 3935402

646 ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC NEOPLASIA: A LARGE MULTICENTER STUDY FROM NORTH AMERICA [Meeting Abstract]

Ngamruengphong, S; Ferri, L E; Aihara, H; Draganov, P V; Yang, D; Perbtani, Y B; Hanada, Y; Wong, Kee Song L M; Kumta, N A; Othman, M O; Mercado, M O; Javaid, H; Aadam, A A; Siegel, A B; James, T W; Grimm, I S; DeWitt, J M; Novikov, A A; Schlachterman, A; Kowalski, T E; Samarasena, J B; Hashimoto, R; Chehade, N E; Lee, J; Chang, K J; Su, B; Chen, A; Chen, M; Chen, Y -I; Ujiki, M; Mehta, A; Sharaiha, R Z; Carr-Locke, D L; Kumbhari, V; Khashab, M A; Khoshknab, M P; Wang, R; Kerdsirichairat, T; Tomizawa, Y; von, Renteln D; Bechara, R; Patel, N J; Fukami, N; Lazkowska, M; Sethi, A; Wang, A Y; Hwang, J H; Friedland, S; Kalloo, A N
Background: In Western countries, most patients with early gastric cancer (EGC)are still being treated with gastrectomy. Endoscopic submucosal dissection (ESD)is a widely accepted treatment option for EGC in Asia and has become increasingly performed in the West. To date, outcomes data on gastric ESD in the Western settings have been limited to small, single-center studies, with a lack of data coming from North America.
Aim(s): To evaluate gastric ESD outcomes across various centers in North America.
Method(s): This was a retrospective analysis of prospectively collected data on consecutive patients with gastric epithelial neoplasia who underwent ESD between 1/2008 to 10/2018 at 19 centers. Primary end point was the rate of en bloc resection. Secondary outcomes included: (1)rate of complete (R0)and curative resection, (2)adverse event rates, and (3)rates of recurrence and gastric cancer-related death.
Result(s): Of 253 patients who were referred for gastric ESD, ESD was not technically feasible in 6 cases (1 due to deeply invasive cancer and 5 due to severe submucosal fibrosis from prior endoscopic resection). In 247 patients (mean age 69 yrs; 56% male; 50% Caucasian), including 143 (58%)adenomas, 67 (27%)EGC, and 28 (11%)neuroendocrine tumors (NET), ESD was attempted. Median procedure time was 90 min (IQR 55 - 124). In 38% of cases, ESD was performed in an outpatient setting. En-bloc resection rates for all lesions, EGCs, adenomas, and NETs were 92%, 94%, 89%, and 90%, respectively. R0 resection rates for all lesions, EGC, adenomas, and NET were 81%, 76%, 87%, and 70%, respectively. Curative resection according to Japanese criteria was achieved in 76% (16/21)of EGCs fulfilling the standard criteria and 69% (25/36)of EGCs fulfilling the expanded criteria. Intraprocedural perforation occurred in 8%(n=21). Of these, all but two cases were treated successfully with endoscopic therapy. Two cases (0.8%)required surgery due to perforation, and both occurred during the early phase of the learning curve. Delayed bleeding occurred in 8 cases (3%). No delayed perforation or procedure-related deaths were observed. In the EGC cohort, local recurrence was observed in 4 cases (11%)and all were following non-curative resection. In the gastric adenoma group, there were 5 (6.7%)local recurrences after ESD (1.8% after R0 resection vs 44% after non-R0 resection, p=0.001). After a median follow-up of about 12 months post-operatively, no metastatic recurrences or gastric cancer-related deaths were observed.
Conclusion(s): This large multicenter study demonstrated high rates of en bloc and R0 resections of gastric neoplasia in North America, comparable to that of Eastern centers. We recommend ESD as treatment of choice for gastric neoplasia including lesions fulfilling standard and expanded criteria for EGC. [Figure presented][Figure presented]
Copyright
EMBASE:2002059003
ISSN: 0016-5107
CID: 3935422

Stimulant-Induced Punding and Stimulant Discontinuation-Induced Manic-Like Symptoms in a Preadolescent Male

Friedland, Susan; Kahlon, Sidra; Carlson, Gabrielle A; Greenhill, Laurence L
PMID: 31075054
ISSN: 1557-8992
CID: 4271472

Meta-Assurance: No Tic Exacerbation Caused by Stimulants [Editorial]

Friedland, Susan; Walkup, John T
PMID: 26299291
ISSN: 1527-5418
CID: 1742672