Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Prophylactic colonic endoscopic submucosal dissection (ESD) defect closure may reduce delayed adverse events (DAEs) such as bleeding and perforation associated with ESD and facilitate same day discharge. We compared the effect of colonic ESD defect closure (closed group) with no closure (open group) on DAEs and overnight hospital admission. METHODS:We performed a Western multicenter retrospective study on patients who underwent colon ESD. Rectal lesions were excluded. DAEs were defined as adverse events within 2 weeks of ESD. Primary outcome measures were DAEs and overnight hospital admission. Multivariate analyses were performed. RESULTS:560 patients underwent colon ESD and 364 (71.8%) patients had complete defect closure. Closed group had a significantly lower rate of delayed bleeding (1.7% vs 5.6%, p = 0.03) compared to open group. Multivariate analysis with adjusted odds ratios (aOR) revealed right sided polyps (aOR = 7.0) and anticoagulation/antiplatelet agents (aOR = 6.6) increased the risk while defect closure (aOR = 0.2) decreased the risk of delayed bleeding. Defect closure amplified the reduction in risk of delayed bleeding (2.4% vs 10.4%, p = 0.014) for right-sided polyps. Malignant polyps significantly increased the risk of delayed perforation (aOR = 3.3) and overnight hospitalization (aOR = 2.9). Defect closure (aOR = 0.6), traction use (aOR = 0.6) and topical hemostatic agent use (aOR = 0.4) significantly reduced the risk of overnight hospitalization. CONCLUSION/CONCLUSIONS:Prophylactic closure of colon ESD defects was associated with a significant reduction in delayed bleeding with number needed to treat (NNT) of 25.6 (especially for right sided polyps, NNT 12.5), and post-procedural overnight hospitalization. Prospective studies are needed to further validate these results.

Malignancy associated with ileal neobladders or ileal conduits in postradical cystectomy patients is rare. Yet, recurrent urothelial carcinoma or new primary cancers, such as adenocarcinoma, enteric type (EA), are potential complications that pose significant clinical challenges. This study aimed to evaluate the incidence, clinical outcomes, and management strategies for malignancies in patients with ileal neobladders or ileal conduits. A retrospective review was conducted at 3 large academic institutions, identifying 10 cases of malignant tumors arising in ileal neobladders or ileal conduits over a period of 10 years. The study cohort included 9 male and 1 female patient aged 56 to 92 years (mean age = 68.2 y). Data on clinical presentation, management, pathology, and outcomes were collected, with a focus on recurrence and disease-specific survival rates. Seven of 10 patients (all males) were initially diagnosed with invasive high-grade urothelial carcinoma (IHGUC), whereas 3 patients had a history of bladder augmentation with colonic tissue (BA) for benign etiologies. Of patients with IHGUC, 2 patients received neoadjuvant chemotherapy, 1 received a combination of chemotherapy agents, and 3 patients underwent intravesical BCG therapy. All IHGUC exhibited conventional morphology without divergent differentiation. Pathologic staging of the cystectomy for IHGUC ranged from pTa to pT3a, with 4 cases showing lymph node metastasis. IHGUC recurrence was detected in 6 of 7 patients with a latency period range of 7 months to 6.7 years (mean 37 mo) and all tumors again exhibiting conventional morphology without divergent differentiation. IHGUC recurrence demonstrated a pathologic stage ranging from pT2 to pT4, and 5 died (mean = 4.2 mo), whereas 1 patient remains alive and on surveillance. EA occurred in 4 patients, including 3 BA patients and 2 foci in 1 patient with a neobladder for IHGUC. Staging of patients with EA ranged from pTis to pT2 developing 31 to 55 years postsurgery. Three of 5 EA cases were associated with a precursor lesion including 2 tubular adenoma with high-grade dysplasia, and 1 sessile serrated lesion with dysplasia. EA patients had relatively favorable outcomes compared with IHGUC patients,  with all surviving patients currently on surveillance though with one case demonstrating nodal metastasis. Although rare, malignancies in ileal neobladders or ileal conduits are a serious complication. Although IHGUC recurrence often leads to poor survival, EA patients-especially those with prior bladder augmentation-seem to be associated with better survival outcomes. The long latency period for IHGUC recurrence and the favorable prognosis for EA underscore the need for vigilant long-term surveillance.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Histiocytoses are diverse hematopoietic diseases with disabling neurologic involvement. Recently, targeted mitogen-activated protein kinase pathway inhibitors have been used with clinical and radiologic response; however, some patients are unable to tolerate these treatments or have isolated and/or refractory neurologic, ocular, or head and neck (NOHN) disease. Intra-arterial administration of chemotherapy has conferred favorable responses in various neoplasms; however, treatment and outcomes across histiocytosis subtypes have not been examined. METHODS:Patients with biopsy-proven histiocytosis involving NOHN structures underwent an outpatient interventional procedure with angiography, selective catheterization, and intra-arterial infusion of melphalan, with target arteries depending on the site of disease. Patients were followed with radiologic (i.e., PET/CT, CT, MRI, or ophthalmic ultrasound and optical coherence tomography) and quantified functional assessments (i.e., vision, speech, or balance) as appropriate. Complete or partial radiologic and functional response rates were captured as well as frequency of subsequent progression. RESULTS:Eighteen patients underwent 74 total treatment instances. For 14 patients with radiologically evaluable tumorous disease, 10 (71%) had partial or complete response and the remaining 4 had stable disease; 3 of 14 (21%) had subsequent radiologic progression. Of 13 functionally evaluable patients, including 6 with neurodegenerative histiocytosis, 12 (92%) experienced functional improvement; 7 of 13 (54%) had subsequent functional worsening consistent with disease progression. There were no intraprocedural complications; 3 patients required hospitalization following treatment, including 1 patient with allergic reaction to melphalan. DISCUSSION/CONCLUSIONS:For patients with tumorous and neurodegenerative histiocytosis, intra-arterial melphalan represents a safe and highly effective treatment with potential to improve neurologic function. Additional study may clarify patients most suitable for this intervention. This novel treatment modality may represent a practice-changing innovation for refractory histiocytosis involving neurologic and ocular structures, as well as neurodegenerative forms. The treatment delivery form is novel, and future work should be directed at studying the efficacy of this modality to other forms of neurologic, ocular, head, and neck cancers. CLASSIFICATION OF EVIDENCE/METHODS:This study provides Class IV evidence that in patients with tumorous or neurodegenerative histiocytosis, selective angiographic catheterization and intra-arterial infusion of melphalan result in radiologic and functional improvement.

Marijuana use is common and increasing due to decriminalization, legalization, and expansion of medical use. As a result, the proportion of vascular patients with marijuana is also expected to increase, raising questions if cannabis use affects the incidence and outcomes of vascular disease. Active ingredients of cannabis have been shown to interact with receptors found on vascular endothelium, promoting oxidative stress and endothelial dysfunction. However, current clinical studies have yet to demonstrate a relationship between marijuana use and atherosclerosis. Nonetheless, cannabis arteritis is a rare condition where cannabis is hypothesized to induce vascular inflammation. Future research with high-quality studies is needed to clarify the impact of marijuana use on vascular diseases.

Breast cancer screening recommendations have been established historically for women, but, have been less clearly outlined for men. For average-risk men and younger men less than 25 year of age, imaging is not usually appropriate as a screening test for breast cancer. For men of higher-than-average risk, screening with mammography as annual surveillance imaging is usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

This study aimed to assess factors impacting obstetric triage time to disposition. The primary and secondary hypotheses were that high-risk patients and patients evaluated during periods with less staffing would experience prolonged length of stay (LOS), respectively.This single-site, retrospective cohort study analyzed 9,704 obstetric triage visits of 6,182 patients between January 1, 2022, to February 28, 2023. Inclusion criteria included patients 18 years or older with one or more evaluations. Exclusion criteria included scheduled admissions, unknown chief complaints, triage time under 10 minutes, and patients under 18 years old. A total of 6,612 visits representing 4,390 patients were included. The visits were stratified by disposition: admission versus nonadmission (transfer or discharge). Descriptive statistics analyze continuous variables. Frequencies and percentages were calculated for categorical variables. SAS was used for chi-square or Fisher's exact test for categorical variables and the two-sample t-test or Mann-Whitney test for continuous data. Statistical significance was p-value < 0.05.Of 6,612 visits, 3,475 admissions, and 3,137 nonadmissions occurred. The most common chief complaints were contractions (42%), amniotic fluid index evaluation (18%), and preeclampsia evaluation (8%). Admitted compared with nonadmitted patients had shorter LOS (64 minutes vs. 185 minutes, p < 0.001). Admitted compared with nonadmitted patients had shorter LOS by chief complaint, gestational age, high-risk maternal-fetal medicine status, time of day, and day of the week (all p < 0.001).Nonadmitted, maternal-fetal medicine and preterm patients evaluated during daytime and weekdays had significantly longer LOS. Vulnerable populations and target times for triage workflow improvement were identified. · Patient and unit factors influenced LOS.. · Nonadmitted patients had triple the LOS.. · High-risk patients had longer LOS.. · Daytime and weekday visits had longer LOS..