Primary Gastric Synovial Sarcoma Diagnosed by Endoscopic Surveillance of a Gastric Ulcer

Primary gastric synovial sarcoma is rare and challenging to diagnose. We present a case of a gastric ulcer that was diagnosed as primary gastric synovial sarcoma only after surveillance endoscopy with repeat biopsies. The diagnosis was established with the identification of the pathognomonic chromosomal translocation t(X;18)(p11;q11). The patient was treated with wedge resection and has remained disease-free on surveillance imaging and endoscopy. This case demonstrates the difficulty in diagnosing primary gastric synovial sarcoma and the benefits of early disease detection.

Confirmed Envenomation by Androctonus amoreuxi (Egyptian Yellow Fat Tail Scorpion)

In the United States, envenomations by native scorpion species such as Centruroides are common and generally well-tolerated. On the contrary, Androctonus species envenomations are exceedingly rare outside the Middle East and North Africa but are particularly deadly. We report a case of envenomation by an Egyptian Yellow Fat Tail (Androctonus amoreuxi) scorpion and the subsequent clinical course. A hobbyist and dangerous scorpion collector was stung by his pet Androctonus amoreuxi, purchased online. Our patient rapidly developed severe localized pain followed by systemic effects, including tachycardia, hypertension, tachypnea, anxiety, GI symptoms, diplopia, dyspnea, profound myalgias, and intense paresthesias. Ultimately, he was diagnosed with a grade 2-to-3 scorpion envenomation based upon evidence of autonomic hyperactivity and cranial nerve dysfunction. He never progressed to cardiopulmonary compromise;neither dobutamine nor antivenom was administered, and he improved with supportive care alone. Case details were verified in person and via electronic medical record review.

Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals

BACKGROUND In resource-limited countries,risk stratification can be used to optimize colorectal cancer screening.Few prospective risk prediction models exist for advanced neoplasia(AN)in true average-risk individuals.AIM To create and internally validate a risk prediction model for detection of AN in METHODS Prospective study of asymptomatic individuals undergoing first screening colonoscopy.Detailed characteristics including diet,exercise and medications were collected.Multivariate logistic regression was used to elucidate risk factors for AN(adenoma≥1 cm,villous histology,high-grade dysplasia or carcinoma).The model was validated through bootstrapping,and discrimination and calibration of the model were assessed.RESULTS 980 consecutive individuals(51%F;49%M)were enrolled.Adenoma and AN detection rates were 36.6%(F 29%:M 45%;P<0.001)and 5.1%(F 3.8%;M 6.5%)respectively.On multivariate analysis,predictors of AN[OR(95%CI)]were age[1.036(1.00-1.07);P=0.048],BMI[overweight 2.21(0.98-5.00);obese 3.54(1.48-8.50);P=0.018],smoking[<40 pack-years 2.01(1.01-4.01);≥40 pack-years 3.96(1.86-8.42);P=0.002],and daily red meat consumption[2.02(0.92-4.42)P=0.079].Nomograms of AN risk were developed in terms of risk factors and age separately for normal,overweight and obese individuals.The model had good discrimination and calibration.CONCLUSION The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West.Age,smoking,and BMI are important predictors of AN,with obesity being particularly powerful.Though external validation is needed,this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.

Reintervention with Transcatheter and Surgical Aortic Valves: A Systematic Review and Meta-Analysis

Background: Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. Methods: We performed a systematic review and meta-analysis of all published studies with ≥5years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). Randomized controlled trials (n = 4) and propensity-matched observational studies (n = 1) involving all surgical risk categories were included. The primary endpoint was the composite of aortic valve reintervention and death. Results: The meta- analysis included 4145 patients: 2101 underwent TAVR (mean age 81.7 ± 6.7 years, 54% male) and 2044 SAVR (mean age 81.8 ± 6.6 years, 54% male). All TAVR procedures were performed with early generations of THV. At a median follow-up of 5 years (range 5 - 6 years), TAVR had higher reintervention rates (odds ratio (OR) 3.33;95% CI: [1.78, 6.24], p < 0.001, I2 = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I2 = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I2 = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. Conclusion: Despite comparable short and medium-term results, TAVR with early-generation THV has higher rates of reintervention and the composite of reintervention and death. Further studies employing newer definitions of structural valve deterioration and bioprosthetic valve failure are needed to assess whether technological enhancements in THV technology will improve long-term outcomes.

Antithrombotic therapy in patients with COVID-19:indications,pharmacotherapy and controversy

Hypercoagulability associated with COVID-19 infection increases risks for either venous or arterial thrombotic events(ATEs)or both.1 For hospitalised patients with COVID-19,the incidence of venous thromboembolism(VTE)was 4.5%2;the rate among patients with crit-ical illness was 27.9%as compared with those not critically ill(7.1%).The exact mechanism of COVID-19-related thrombotic events is unclear.However,it may partially be related to Virchow triad:alternation of blood flow(stasis),vascular endothelial injury by SARS-CoV 2 virus and alteration of the constituents of the blood including inherited or acquired hypercoagulable state.Therefore,it is a challenge to evaluate the thromboembolic risk,select an appropriate antithrombotic agent and decide on the doses and duration of therapy in these patients.Several international and American societies have published clinical guidelines that reviewed evaluation of coagulation abnormalities in patients with COVID-19.3-6 To balance the risk of bleeding and preventing or treating thromboembolic events,a simplified practical summarisation is needed.

Vaccine booster efficiently inhibits entry of SARS-CoV-2 omicron variant

The newly emerged omicron strain of SARS-CoV-2 is spreading fast globally,replacing the previously dominant delta strain in many parts of the world[1].Compared to the early prototypic strains,the delta strain evades the human immune system more easily,causing many breakthrough infections in vaccinated people[2].It is imperative to understand in a timely fashion whether the omicron strain escapes immune surveillances.The information will be critical for public health measures.