Citations

Acquired angioedema due to C1-inhibitor deficiency (AAE-C1INH) is a rare condition characterized by the localized swelling of the deeper skin layers and mucous membranes, especially the face, lips, tongue, throat, and gastrointestinal tract. AAE-C1INH is strongly associated with lymphoproliferative disorders, although it can also be linked to autoimmune conditions, solid tumors, infections, or even occur without an identifiable cause. We present the case of a 45-year-old female patient with complaints of recurrent abdominal pain, bloating, and joint swelling. Laboratory testing showed decreased C1q and C4 complement levels, and C1 esterase inhibitor levels, indicative of AAE-C1INH. Further work up confirmed a diagnosis of extranodal marginal zone lymphoma with involvement of the bone marrow and spleen. Treatment with rituximab led to resolution of angioedema symptoms and almost complete remission of underlying lymphoma. This case underscores the importance of evaluating an underlying lymphoproliferative disorder in AAE-C1INH. Therefore, the early participation of a multidisciplinary team including specialists in immunology, hematology, and oncology is necessary for appropriate management.

Hepatic hydrothorax (HH) is a rare but serious complication of end-stage liver disease that is often refractory to conventional medical and procedural management. This case report describes a 75-year-old woman with HH secondary to cirrhosis from metabolic-associated steatotic liver disease. Her clinical course was marked by recurrent hospitalizations, refractory right-sided pleural effusion, and multiple unsuccessful interventions including diuretics, serial thoracenteses, an indwelling pleural catheter, and chemical pleurodesis. Notably, the persistence of pleural fluid despite resolution of ascites ultimately led to the formation of a thoracic fistula, with pleural drainage volumes exceeding 4 L/day. Further invasive procedures, such as transjugular intrahepatic portosystemic shunt or liver transplantation, were declined by the patient. She was enrolled in Mayo Clinic’s hospital-at-home (HaH) program, where continuous intravenous octreotide was initiated at a dose of 25 mcg/h. This resulted in a significant reduction in pleural output—from over 4000 mL to less than 100 mL daily. After clinical stabilization, the patient transitioned to subcutaneous octreotide and remained clinically stable for over 6 months, with improved quality of life and no significant adverse effects. To our knowledge, this is the first reported case of continuous intravenous octreotide infusion for HH administered safely in a home-based acute care setting. This case underscores the potential therapeutic role of octreotide in managing refractory HH and highlights the feasibility of delivering complex cirrhosis-related care through a HaH model with multidisciplinary collaboration. Further research is warranted to assess the long-term efficacy, safety, and cost-effectiveness of octreotide in this context and to explore broader application in home hospital environments.

Background: Transcatheter aortic valve replacement (TAVR) is a well-established therapeutic option for all risk patients with symptomatic severe aortic stenosis (AS). While TAVR primarily addresses AS, its benefits extend beyond the valve itself. Recent studies suggest possible restoration of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) following TAVR. This study aims to assess changes in LV GLS in patients undergoing TAVR, which may serve as a subclinical indicator of improved LV mechanics. Materials and Methods: This retrospective study included patients with severe AS who underwent TAVR at the American University of Beirut Medical Center from January 2017 to January 2023. Baseline and 1-year echocardiography parameters were compared, and GLS was calculated to assess the impact of TAVR on LV function. Results: A total of 80 patients (mean age: 81.3 ± 7.8 years; 38.8% of women; 88.8% hypertensive) who underwent TAVR for severe AS were included in the final analysis. One-year post-TAVR, echocardiographic studies showed a significant reduction in interventricular septum diameter (13.3 ± 2.3 mm vs. 12 ± 1.8 mm, P < 0.001) and LV mass index (LVMI) (113.6 ± 26.6 g/m 2 vs. 96 ± 30.3 g/m 2 , P < 0.001). LVEF showed a modest improvement (59.2 ± 12.3% vs. 62.1 ± 7.6%, P < 0.01). LV GLS significantly improved from −16.8 ± 4.6% to −19.2 ± 3.3% ( P < 0.001). Baseline LVMI, LVEF, and GLS correlate with the GLS change (ΔGLS) post-TAVR. Conclusion: GLS significantly improves 1 year after TAVR, indicating an overall improvement in LV performance. The degree of improvement in GLS correlates with baseline LVMI and systolic function.

Abstract Extracellular vesicles (EV) are phospholipid‐encapsulated nanoparticles secreted by cells into their surrounding environment. EVs can transfer a variety of biomolecules that mediate intercellular communication and play a key role in physiological and pathological processes. Therefore, EVs are emerging as new biomarkers for diseases, therapeutic targets, and drug delivery vehicles. The isolation and detection of EVs requires time‐consuming and labor‐intensive processes, first to extract EVs from biological and physiological fluids and then to detect EV‐associated molecules with high sensitivity. The methodologies and instruments commonly used for EV analysis are not widely accessible outside of dedicated research laboratories, creating practical barriers for the study of EV‐associated molecules in biology research and clinical applications. To bridge this gap, we developed a proof‐of‐concept digital microfluidic device that can automatedly extract EVs from 20 µL of culture and human plasma samples within 25 min and detect EV‐bound proteins (e.g PD‐L1) on‐chip using an electrochemical sensor. This work serves as a framework for the development of streamlined EV analysis in both research and diagnostics.

ABSTRACTCronkhite‐Canada Syndrome (CCS) is a rare non‐hereditary gastroenterological polyposis syndrome without a clear etiology. Myelodysplastic syndromes (MDS) are clonal hematological disorders. Immune dysregulation has been posited as a contributor to the development of both. A 70‐year‐old man developed chronic diarrhea, dysgeusia, and onycholysis. Endoscopic evaluation and testing to exclude hereditary polyposis syndromes resulted in a diagnosis of CCS. Approximately 1 year later, he was noted to have persistent anemia, which was ultimately diagnosed as MDS. He was evaluated with a myeloid disorder next‐generation sequencing panel and found to have mutations in IDH2, SRSF2, and JAK2. This is the second reported case characterizing concomitant MDS and CCS. This is the first case to report the development of MDS after the diagnosis and treatment of CCS. A successful management strategy for both disorders is outlined within this case report.

Abstract Postoperative pain control after total knee arthroplasty (TKA) remains challenging, particularly in patients utilizing chronic opioids preoperatively. Our study aimed to evaluate the effect of regional nerve blockade on perioperative pain control outcomes after TKA in patients using or not using chronic preoperative opioids. A retrospective review of our institutional database identified 434 chronic opioid patients defined as documented ongoing use greater than 3 months prior to contemporary TKA. Patients were 1:1 matched to nonopioid users based upon age, sex, body mass index, and regional block type (single-shot adductor canal block [ACB, 29%], 3-day ACB catheter [31%], or no block [41%]). All patients underwent primary TKA using periarticular injections and contemporary multimodal pain management. Immediate and 90-day postoperative outcomes, including Knee Osteoarthritis Outcome Score, Junior (KOOS, Jr), were compared via univariate analysis among the matched cohort and regional block type among chronic opioid patients. Chronic opioid patients demonstrated higher inpatient opioid use than controls (90 vs. 65 oral morphine equivalents [OMEs], respectively, p < 0.01), but no significant differences existed in length of stay (LOS), discharge pain scores, 90-day readmission or KOOS, Jr (all p ≥ 0.05). When comparing chronic opioid patients according to block type, those receiving no block had the highest LOS (1.6 days, p < 0.01), discharge pain score (5.0, p < 0.01), and inpatient opioid use (80 OMEs, p < 0.01) compared with either ACB. The subgroup receiving an ACB catheter demonstrated a significantly higher 90-day readmission rate (9%, p < 0.05). Patients utilizing chronic opioids preoperatively require more opioids in the immediate postoperative period after TKA compared with nonopioid users despite contemporary modalities. Nonetheless, the use of any type of ACB provides improved pain control in these patients.

Abstract Gastrointestinal (GI) endoscopy has evolved from a diagnostic tool into a therapeutic modality, leading to a higher incidence of bleeding complications during and after procedures. To address this issue, various hemostatic agents have been developed, including injectable, mechanical, thermal, and topical products. Topical hemostatic agents, available in powder or gel forms, can be used as standalone treatments or as adjuncts to traditional hemostatic therapies to control or prevent bleeding. This Technical and Technology Review examines the commercially available topical hemostatic agents used in endoscopy, specifically Purastat, TC-325 Hemospray, EndoClot PHS, Nexpowder, Ankaferd Blood Stopper, and CG GEL. A systematic literature review was conducted up to January 2025, focusing on randomized controlled trials (RCTs), meta-analyses, and observational studies. Each product was assessed for its composition, mechanism of action, regulatory status, mode of use, efficacy, safety, and financial considerations. Purastat showed 94% efficacy in acute GI bleeding, reducing delayed bleeding to 4.3% in endoscopic submucosal dissection (ESD) and endoscopic mucosal resection cases, with significantly lower thermal device usage. TC-325 Hemospray achieved 85%–98.5% primary hemostasis in upper and lower GI bleeding, with pooled hemostasis rates of 93.1% and rebleeding rates of 8.9%. It was also effective in malignancy-related bleeding, with hemostasis success up to 100%. EndoClot PHS demonstrated 76%–100% hemostasis efficacy, comparable with TC-325, with rebleeding rates of 24%–25%. It showed prophylactic potential post-ESD, with rebleeding rates of 7.3%–9.1%. Nexpowder achieved 94% hemostasis in refractory upper GI bleeds and reduced rebleeding in lower GI bleeds to 5.5% at 28 days. Ankaferd Blood Stopper demonstrated 73%–100% hemostasis across various GI bleeding sources, including peptic ulcers and malignancies, though further data on rebleeding are needed. Topical hemostatic agents offer effective options for managing GI bleeding. Products like Purastat, TC-325 Hemospray, EndoClot PHS, Nexpowder, Ankaferd Blood Stopper, and CG GEL have shown promising results in achieving hemostasis; however, further RCTs and cost-effectiveness analyses are needed to better establish their roles in endoscopic practice.

Background: The authors present a novel microsurgical model to investigate ischemia-reperfusion (I/R) injury in composite tissue (muscle/skin) using a musculocutaneous flap. I/R was induced in a rodent biceps femoris musculocutaneous flap through collateral ligation and arteriovenous clamping. The authors hypothesized that I/R flaps would show greater tissue damage compared with sham. Methods: Male rats were randomized into I/R ( n = 10) and sham ( n = 9) groups. The I/R group underwent flap elevation, collateral ligation, 3 hours of arteriovenous clamping, followed by reperfusion. The sham group had flap elevation only. Perfusion was monitored using laser-speckle imaging, and flap discoloration was assessed with blinded skin ischemia necrosis scores. Serum and the composite tissue (skin/muscle) were analyzed for injury on postoperative days (PODs) 1 or 3. Results: Clamping reduced perfusion ( P = 0.00), whereas unclamping increased perfusion ( P <0.00). Over time, flaps exposed to I/R were more ischemic (estimate, 0.39; P = 0.02). At POD1, the injury group had higher serum creatine kinase ( P = 0.04) and potassium ( P = 0.00) than the sham group. The injury group had more muscle apoptosis (34.7% versus 5.2%; P = 0.03), myonecrosis (30.3% versus 14.1%; P = 0.04), and inflammation (13.7% versus 4.9%; P = 0.02) than the sham group; myonecrosis and inflammation persisted into POD3. Skin apoptosis and inflammation were similar. Conclusions: This model reliably reproduces I/R injury with a 3-hour ischemic period followed by early reperfusion. Animals subjected to the authors’ technique showed greater tissue damage than the sham group, with muscle being more vulnerable than skin. Serum showed peak muscle injury at 24 hours, and histologic analysis showed myonecrosis and inflammation through 72 hours. This suggests that less than 24 hours’ reperfusion (eg, critical window) may serve as the optimal time for possible intervention. Clinical Relevance Statement: I/R injury is a complex phenomenon affecting vascular composite tissues. The mitochondrial superoxide dismutase may be more specific for I/R injury. There may be a critical window within which to mitigate injury (<24 hours after reperfusion). The authors’ model helps investigate muscle/skin I/R injury.