Utilizing Deep Learning and Computed Tomography to Determine Pulmonary Nodule Activity in Patients With Nontuberculous Mycobacterial-Lung Disease

PURPOSE

To develop and evaluate a deep convolutional neural network (DCNN) model for the classification of acute and chronic lung nodules from nontuberculous mycobacterial-lung disease (NTM-LD) on computed tomography (CT).

MATERIALS AND METHODS

We collected a data set of 650 nodules (316 acute and 334 chronic) from the CT scans of 110 patients with NTM-LD. The data set was divided into training, validation, and test sets in a ratio of 4:1:1. Bounding boxes were used to crop the 2D CT images down to the area of interest. A DCNN model was built using 11 convolutional layers and trained on these images. The performance of the model was evaluated on the hold-out test set and compared with that of 3 radiologists who independently reviewed the images.

RESULTS

The DCNN model achieved an area under the receiver operating characteristic curve of 0.806 for differentiating acute and chronic NTM-LD nodules, corresponding to sensitivity, specificity, and accuracy of 76%, 68%, and 72%, respectively. The performance of the model was comparable to that of the 3 radiologists, who had area under the receiver operating characteristic curve, sensitivity, specificity, and accuracy of 0.693 to 0.771, 61% to 82%, 59% to 73%, and 60% to 73%, respectively.

CONCLUSIONS

This study demonstrated the feasibility of using a DCNN model for the classification of the activity of NTM-LD nodules on chest CT. The model performance was comparable to that of radiologists. This approach can potentially and efficiently improve the diagnosis and management of NTM-LD.

Whole-lesion assessment of volume and signal changes after sclerotherapy of extremity venous malformations

PURPOSE

To investigate quantitative changes in MRI signal intensity (SI) and lesion volume that indicate treatment response and correlate these changes with clinical outcomes after percutaneous sclerotherapy (PS) of extremity venous malformations (VMs).

METHODS

VMs were segmented manually on pre- and post-treatment T2-weighted MRI using 3D Slicer to assess changes in lesion volume and SI. Clinical outcomes were scored on a 7-point Likert scale according to patient perception of symptom improvement; treatment response (success or failure) was determined accordingly.

RESULTS

Eighty-one patients with VMs underwent 125 PS sessions. Treatment success occurred in 77 patients (95 %). Mean (±SD) changes were -7.9 ± 24 cm3 in lesion volume and -123 ± 162 in SI (both, P <.001). Mean reduction in lesion volume was greater in the success group (-9.4 ± 24 cm3) than in the failure group (21 ± 20 cm3) (P =.006). Overall, lesion volume correlated with treatment response (ρ = -0.3, P =.004). On subgroup analysis, volume change correlated with clinical outcomes in children (ρ = -0.3, P =.03), in sodium tetradecyl sulfate-treated lesions (ρ = -0.5, P =.02), and in foot lesions (ρ = -0.6, P =.04). SI change correlated with clinical outcomes in VMs treated in 1 PS session (ρ = -0.3, P =.01) and in bleomycin-treated lesions (ρ = -0.4, P =.04).

CONCLUSIONS

Change in lesion volume is a reliable indicator of treatment response. Lesion volume and SI correlate with clinical outcomes in specific subgroups.

Erdheim-Chester Disease Occult on Radiographs and CT but Visible on MRI and PET

BACKGROUND Erdheim-Chester disease (ECD) is a rare neoplasm of histiocytes that is characterized by prominent involvement of the long bones. Approximately 1500 cases have been reported since the disease was first described in 1930. The imaging appearance of ECD can be highly variable given the numerous systems it can affect. In this case report we discuss a patient whose ECD was occult on multiple imaging modalities. CASE REPORT We report the case of a 60-year-old woman who presented with sub-acute left knee and calf pain that led to an MRI. She was found to have innumerable marrow-replacing lesions in the axial and appendicular skeleton visualized on the initial MRI, as well as on an ¹⁸F-FDG PET/CT scan. The patient did not have extraosseous abnormal uptake on the PET/CT. Subsequently, a lesion from the left iliac bone was histologically confirmed as ECD on the basis of positive staining for CD68 and CD163 and negative staining for CD1a. Osseous lesions in ECD have a distinct imaging appearance and are typically detected by radiography and bone scintigraphy, among other modalities; however, the lesions in this case were unexpectedly absent from those studies. CONCLUSIONS If there is a high degree of suspicion for ECD, 18F-FDG PET/CT and/or MRI may be necessary for adequate visualization of bone lesions, given that those lesions can have an infiltrative nature that may be difficult to image with other anatomic imaging modalities. Use of 18F-FDG PET/CT and/or MRI may also lead to adequate guidance of confirmatory biopsy.

Safety and efficacy of dynamic catheter-directed cerebral digital subtraction angiography for diagnosis of bowhunter syndrome spectrum disorders: A systematic review of the literature

INTRODUCTION

Dynamic catheter-directed cerebral digital subtraction angiography (dcDSA) is the gold standard for diagnosing dynamic vascular occlusion syndromes such as bowhunter syndrome (BHS). Nonetheless, concerns about its safety exist and no standardized protocols have been published to date.

METHODS

We describe our methodology and insights regarding the use of dcDSA in patients with BHS. We also perform a systematic literature review to identify cases of typical and atypical presentations of BHS wherein dcDSA was utilized and report on any procedural complications related to dcDSA.

RESULTS

Our study included 104 cases wherein dcDSA was used for the diagnosis of BHS. There were 0 reported complications of dcDSA. DcDSA successfully established diagnosis in 102 of these cases. Thirty-eight cases were deemed atypical presentations of BHS. Fourteen patients endorsed symptoms during neck flexion/extension. In eight cases, there was dynamic occlusion of bilateral vertebral arteries during a single maneuver. Three patients had multiple areas of occlusion along a single vertebral artery (VA). An anomalous entry of the VA above the C6 transverse foramen was observed in four patients. One patient had VA occlusion with neutral head position and recanalization upon contralateral lateral head tilt.

CONCLUSION

Our study highlights the safety and diagnostic benefits of dcDSA in characterizing the broad spectrum of BHS pathology encountered in clinical practice. This technique offers a powerful means to evaluate changes in cerebral blood flow and cervical arterial morphology in real time, overcoming the constraints of static imaging methods. Our findings pave the way for further studies on dcDSA to enhance cross-sectional imaging methods for the characterization of BHS and other dynamic vascular occlusion syndromes.

Direct superficial temporal artery access for middle meningeal artery embolization

Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.

Initial clinical experience with the Bendit steerable articulating tip microcatheter for intracranial access and intervention

BACKGROUND

The increasing complexity and sophistication of neurovascular implants and other therapeutic devices depend on access and delivery systems. Advancements in access technologies are required to improve minimally invasive endovascular procedures. Steerable catheters have been available in other disciplines, however, their implementation in neurovascular interventions has been a barrier previously due to issues with miniaturization and vascular caliber/complexity.

METHODS

A retrospective review of the neurovascular stroke database was conducted in accordance with local IRB to identify patients that received neurointerventional endovascular procedures using a novel first iteration 0.021'' microcatheter with controlled articulating tip flexion. Indications, management, demographics, comorbidities, and clinical and technical outcomes were recorded and analyzed. Primary operator feedback on the novel catheter was collected and reviewed.

RESULTS

Ten consecutive patients receiving treatment that involved a novel steerable 0.021'' microcatheter were identified and analyzed. No complications were reported. Novel useful features of the catheter were reported on a case-by-case basis.

CONCLUSIONS

Initial clinical experience with the controlled articulation that permits flexion at the tip of the microcatheter demonstrated it to be safe. Access to difficult proximal origin curves, and distal clinoidal/ophthalmic segment anatomy may be improved due to the high torque transmission, and acute angulation of this microcatheter. Further experience with the delivery of therapeutic devices will be necessary to better understand the potential role that the present catheter may play in modern neurointerventional procedures.

Comparative Efficacy of Endoscopic Assist Devices on Colonic Adenoma Detection: A Systematic Review With Network Meta-analysis

BACKGROUND AND AIMS

Numerous endoscopic assist devices exist, yet data surrounding their comparative efficacy is lacking. We conducted a systematic review with network meta-analysis to determine the comparative efficacy of endoscopic assist devices on colonic adenoma detection.

METHODS

A systematic search was performed using multiple electronic databases through July 2020, to identify all randomized controlled trials and dual-arm observational studies compared with either other endoscopic assist devices and/or standard colonoscopy. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included polyp detection rate (PDR), serrated adenoma detection rate (SADR), right-sided adenoma detection rate (RADR), and proximal adenoma detection rate (PADR).

RESULTS

Fifty-seven studies (31,051 patients) met inclusion criteria and were analyzed. Network meta-analysis identified an enhanced ADR among (clear) cap [odds ratio (OR): 2.69, 95% confidence interval (CI): 1.45-4.99], endocuff, (OR: 4.95, 95% CI: 3.15-7.78), and endoring (OR: 3.68, 95% CI: 1.47-9.20)-with no significant difference amongst any particular device. Similar findings for PDR were also seen. Enhanced SADR was identified for endocuff (OR: 9.43) and endoring (OR: 4.06) compared with standard colonoscopy. Enhanced RADR (OR: 5.36) and PADR (OR: 3.78) were only identified for endocuff. Endocuff comparatively demonstrated the greatest ADR, PDR, and SADR, but this was not significant when compared with the other assist devices. Subgroup analysis of randomized controlled trials identified enhanced PDR and ADR for both cap and endocuff.

CONCLUSIONS

Endoscopic assist devices displayed increased ADR and PDR as compared with standard colonoscopy and thus should be widely adopted. A nonsignificant trend was seen toward higher efficacy for the endocuff device.

Real-world prevalence of endoscopic findings in patients with gastroesophageal reflux symptoms: a cross-sectional study

Background and study aims  Data regarding endoscopic findings and symptom correlation in patients with gastroesophageal reflux disease (GERD) symptoms are largely limited to single-center experiences. We performed a nationwide study to examine the association between patient-reported GERD symptoms and clinically relevant endoscopic findings. Patients and methods  Using the National Endoscopic Database, we retrospectively identified all esophagogastroduodenoscopies (EGDs) performed for GERD symptoms from 2000 to 2014. Patients were categorized into three symptom groups: 1) typical reflux only (R); 2) airway only (A); and 3) both R and A (R + A). Outcomes were the point prevalence of endoscopic findings in relation to patient-reported GERD symptom groups. Statistical analyses were performed using R. Results  A total of 167,459 EGDs were included: 96.8 % for R symptoms, 1.4 % for A symptoms, and 1.8 % for R + A symptoms. Of the patients, 13.4 % had reflux esophagitis (RE), 9.0 % Barrett's esophagus (BE), and 45.4 % hiatal hernia (HH). The R + A group had a significantly higher point prevalence of RE (21.6 % vs. 13.3 % and 12 %; P  < 0.005) and HH (56.9 % vs. 45.3 % and 38.3 %; P  < 0.005) compared to the R or A groups, respectively. The R group had a significantly higher point prevalence of BE compared to the A or R + A groups, respectively (9.1 % vs. 6.1 % and 6.1 %, P  < 0.005). Conclusions  On a national level, patients experiencing R + A GERD symptoms appear more likely to have RE and HH, while those with only R symptoms appear more likely to have BE. These real-world data may help guide how providers and institutions approach acid-suppression therapy, set thresholds for recommending EGD, and develop management algorithms.

Colorectal Cancer Screening Guidelines Are Primarily Based on Low-Moderate-Quality Evidence

BACKGROUND

Owning to colorectal cancer's (CRC) high mortality, multiple societies developed screening guidelines.

AIMS

We aimed to assess the overall quality of CRC screening guidelines.

METHODS

A systematic search was performed to review CRC screening guidelines for conflicts of interest (COI), recommendation quality and strength, external document review, use of patient representative, and recommendation age-as per Institute of Medicine (IOM) standards. In addition, recommendations were compared between guidelines/societies. Statistical analysis was conducted using R.

RESULTS

Twelve manuscripts were included in final analysis. Not all guidelines reported on COI, provided a grading method, underwent external review, or included patient representation. 14.5%, 34.2%, and 51.3% of recommendations were based on high-, moderate-, and low-quality evidence, respectively. 27.8%, 54.6%, and 17.5% of recommendations were strong, weak/conditional, and did not provide a strength, respectively. The proportion of high-quality evidence and strong recommendations did not significantly differ across societies, nor were significant associations between publication year and evidence quality seen (P = 0.4).

CONCLUSIONS

While the majority of the CRC guidelines contain aspects of the standards set forth by the IOM, there is an overall lack of adherence. As over 85% of recommendations are based on low-moderate quality evidence, further studies on CRC screening are warranted to improve the overall quality of evidence.

Identification of optimal therapeutic window for steroid use in severe alcohol-associated hepatitis: A worldwide study

BACKGROUND & AIMS

Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH.

METHODS

We performed a retrospective, international multicenter cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method.

RESULTS

In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p <0.001). Steroids only improved survival in patients with MELD scores between 21 (HR 0.61; 0.39-0.95; p = 0.027) and 51 (HR 0.72; 0.52-0.99; p = 0.041). The maximum effect of corticosteroid treatment (21-30% survival benefit) was observed with MELD scores between 25 (HR 0.58; 0.42-0.77; p <0.001) and 39 (HR 0.57; 0.41-0.79; p <0.001). No corticosteroid benefit was seen in patients with MELD >51. The type of corticosteroids used (prednisone, prednisolone, or methylprednisolone) was not associated with survival benefit (p = 0.247).

CONCLUSION

Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39.

LAY SUMMARY

Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90- or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51).

Global incidence, prevalence and features of primary sclerosing cholangitis: A systematic review and meta-analysis

BACKGROUND & AIMS

Primary sclerosing cholangitis (PSC) is an idiopathic, cholestatic liver disease with a diverse range of clinical manifestations. Inter-regional data on PSC are variable, but its global geoepidemiology has not been well-studied. We aimed to examine the worldwide incidence, prevalence and features of PSC and PSC-inflammatory bowel disease (PSC-IBD).

METHODS

A systematic search of multiple databases was conducted to identify all original, full-text studies until December 2020 with data regarding the incidence rate (IR) and/or prevalence of PSC. Outcomes were PSC IR, prevalence, features and IBD concurrence. Additionally, a meta-analysis of PSC IR was performed. The study was registered in PROSPERO (CRD42021224550).

RESULTS

Of the 1003 studies identified, 17 studies spanning three continents were included. PSC IR was 0.60 per 100 000 person-years (PY) (95% confidence interval: 0.37-0.88 per 100 000 PY). In pooled subgroup analysis for studies conducted in Europe and North America, PSC IR was 0.62 and 0.53 per 100 000 PY, respectively. PSC prevalence ranged 0-31.7 per 100 000 persons, with notable inter-regional differences. Mean age at PSC diagnosis was bimodally distributed, with relative peaks at 15 and 35 years. Mean concurrence of IBD with PSC was 50%, with 76% having ulcerative colitis, 17% Crohn's disease and 8% indeterminate/unspecified IBD.

CONCLUSION

While considerable heterogeneity exists in the geoepidemiology of PSC, overall, the classical dogmata of male predilection, bimodal distribution of mean age and high PSC-IBD concurrence appear to hold true. Despite a seemingly stable IR over time, further studies are needed to better understand the geoepidemiology of PSC.

Do Water-aided Techniques Improve Serrated Polyp Detection Rate During Colonoscopy?: A Systematic Review With Meta-Analysis

BACKGROUND AND STUDY AIMS

The utility of water-aided techniques (WT): water exchange (WE) and water immersion (WI) have been studied extensively in the literature for improving colonoscopy outcome metrics such as adenoma detection rate. Serrated polyps owing to their location and appearance have a high miss rate. The authors performed a systematic review and meta-analysis of studies comparing WT with the standard gas-assisted (GA) method to determine if there was any impact on serrated polyp detection rate (SPDR) and sessile serrated polyp detection rate.

METHODS

The following databases were queried for this systematic review: Medline, EMBASE, Cochrane Library, CINAHL, and Web of Sciences. The authors only included randomized controlled trials (RCTs). The primary outcome was SPDR and secondary outcomes were sessile serrated polyp detection rate and cecal intubation rate. Risk ratios (RRs) were calculated for each outcome. A P-value <0.05 was considered to be statistically significant.

RESULTS

A total of 4 RCTs (5 arms) with 5306 patients (2571 in the GA group and 2735 in the WT group) were included. The SPDR was significantly increased for the WT group compared with GA (6.1% vs. 3.8%; RR, 1.63; 95% confidence interval, 1.24-2.13; P<0.001; I2=22.7%). A subgroup analysis for WE technique also demonstrated improved SPDR compared with the GA method (4.9% vs. 3.2%; RR, 1.57; 95% confidence interval, 1.15-2.14; P=0.004; I2=6.1%).

CONCLUSIONS

WT, particularly, the WE method results in improved SPDR. This technique should be encouraged in a clinical setting to detect these polyps to prevent interval colorectal cancer.

Blastomycosis in solid organ transplant recipients-A retrospective series from southeastern Wisconsin

Blastomycosis is a fungal infection caused primarily by Blastomyces dermatitis. The fungus is endemic to the Ohio, Mississippi, and St. Lawrence River areas of the United States. Organ transplant recipients are at risk of blastomycosis due to pharmacologic immunosuppression. Over a 20-year period, 30 cases of blastomycosis post-solid organ transplantation were identified at our center. The cumulative incidence of blastomycosis among SOT recipients was 0.99%. There was a male predominance (70% male) and a median age of 59 at the time of diagnosis. Regarding transplant type, 23 patients received kidney transplants, 4 received liver transplants, 2 received pancreas transplants and 1 received a heart transplant. Median time to blastomycosis identification post-transplant was 67.8 months (range: 1-188 months). Amphotericin B was used as initiation therapy in most cases, followed by itraconazole, voriconazole, or in select cases fluconazole or posaconazole maintenance therapy. Regarding comorbid conditions, 87% of patients had diabetes, 50% had congestive heart failure, and 20% had chronic pulmonary disease. Nine patients (30%) developed blastomycosis-related acute respiratory distress syndrome, 33% of these died with a median time to death of 22 days (range 20 days to 2 months); these were the only deaths attributable to blastomycosis.

Etiological Analysis of Reactive Gastropathy in an Urban Population

Background

Reactive gastropathy (RG) is an adaptive response to assaults of the gastric mucosa. Demographic information regarding RG as well as the coincidence of RG and gastrointestinal cancer are poorly characterized entities.

Objective

Herein, we aim to investigate relationships of RG to both modifiable and nonmodifiable risk factors, as well as conduct a stratified analysis by race in an ethnically diverse, urban population.

Methods

In this retrospective study, we queried an urban hospital inpatient pathology database searching for patients with surgical gastric biopsies positive for RG between March 25, 2015, and March 25, 2016. Of the 728 patients with a final diagnosis of RG, 292 were selected based on strict inclusion and exclusion criteria. We explored risk factors and conducted a stratified analysis for associations based on patient demographics.

Results

In this urban minority population, nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common medication associated with RG (Fig. 1), as well as the most common cause of RG, followed by chronic bile reflux. In addition, significant differences in demographics and gastropathic characteristics associated with RG, stratified by ethnicity, were found (Fig. 2). Notably, Hispanics, African Americans, and Caucasians had the highest rate of concomitant RG and diabetes, hypertension, and tobacco/alcohol use, respectively.

Conclusion

Our study indicated that NSAID usage is the most common cause of RG, followed by bile reflux-mediated mucosal injury, in an ethnically diverse urban US-based population. Of note, few patients had intestinal metaplasia, suggesting it to be a slow or negligent sequela of RG.

Hidden dangers and updated labels on gastric balloons

In recent years, intragastric balloons (IGBs) have emerged as an efficacious, nonsurgical modality to treat obesity. We present a case in which an IGB caused a gastric ulcer, only unearthed after the novel technique of deflation and early retrieval.

Homomorphic Adenocarcinoma Metastases to the Liver: A Report of 2 Cases

Case series

Patients: Male, 51-year-old • Male, 46-year-old

Final Diagnosis: Metastatic hepatic malignancy

Symptoms: Weight loss

Medication: —

Clinical Procedure: Endoscopy

Specialty: Gastroenterology and Hepatology

Atherosclerotic cardiovascular disease in inflammatory bowel disease: The role of chronic inflammation

Inflammatory bowel disease (IBD) causes systemic vascular inflammation. The increased risk of venous as well as arterial thromboembolic phenomena in IBD is well established. More recently, a relationship between IBD and atherosclerotic cardiovascular disease (ASCVD) has been postulated. Systemic inflammatory diseases, such as rheumatoid arthritis and systemic lupus erythematosus, have well characterized cardiac pathologies and treatments that focus on prevention of disease associated ASCVD. The impact of chronic inflammation on ASCVD in IBD remains poorly characterized. This manuscript aims to review and summarize the current literature pertaining to IBD and ASCVD with respect to its pathophysiology and impact of medications in order to encourage further research that can improve understanding and help develop clinical recommendations for prevention and management of ASCVD in patients with IBD.

Pneumatosis Cystoides Intestinalis Identified on Screening Colonoscopy With Associated Pneumoperitoneum

Pneumatosis cystoides intestinalis (PCI) is defined by the presence of gas within the bowel wall. It is often asymptomatic and usually benign but may be associated with significant morbidity and mortality. In this patient, PCI was found incidentally on screening colonoscopy, and biopsy of the affected mucosa resulted in deflation of a cyst. Pneumoperitoneum was then identified on subsequent CT. Because pneumoperitoneum is associated with bowel perforation in most cases, it is often treated as an indication for operation. This case of benign and asymptomatic pneumoperitoneum was managed conservatively without complications. Clinicians should be able to identify PCI as a potentially benign finding on colonoscopy as well as a potentially benign cause of pneumoperitoneum. This understanding presents an opportunity to avoid the unnecessary morbidity and costs associated with surgical exploration or additional endoscopic procedures.

Are Quality Metrics in Inflammatory Bowel Disease Rooted on Substantial Quality Evidence? A Systematic Review

BACKGROUND AND AIMS

Quality metrics were established to develop standards to help assess quality of care, yet variation in inflammatory bowel disease (IBD) clinical practice exists. We performed a systematic review to assess the overall quality of evidence cited in formulating IBD quality metrics.

METHODS

A systematic search was performed on PubMed, MEDLINE, and EMBASE. All major national and international IBD societies were included. Quality metrics were assessed for evidence quality and categorized as category A (guideline based), category B (primarily retrospective and observational studies) or category C (expert opinion). Quality metrics were examined for the type of metric, the quality, measurability, review, existing conflicts of interest (COI), and patient participation of the metric. Statistical analysis was conducted in R.

RESULTS

A total of 143 distinct, and an aggregate total of 217 quality metrics were included and analyzed. 68%, 3.2%, and 28.6% of IBD quality metrics were based on low, moderate, and high quality of evidence, respectively. The proportion of high quality evidence across societies was significantly different (P <0.01). Five organizations included patients in quality metric development, three reported external review, not all reported measurable outcomes or stated the presence of a COI. Finally, 43% of quality metrics were published more than 5 years ago.

CONCLUSIONS

Quality metrics are important to standardize practice. As more than two-thirds of the quality metrics in IBD are based on low quality evidence, further studies are needed to improve the overall quality of evidence supporting the development of quality measures.

Ever-increasing diversity of drug-induced pancreatitis

With over 100000 hospital admissions per annum, acute pancreatitis remains the leading gastrointestinal cause of hospitalization in the United States and has far-reaching impact well beyond. It has become increasingly recognized that drug-induced pancreatitis (DIP), despite accounting for less than 3% of all cases, represents an important and growing though often inconspicuous cause of acute pancreatitis. Nevertheless, knowledge of DIP is often curtailed by the limited availability of evidence needed to implicate given agents, especially for non-prescription medications. Indeed, the majority of available data is derived from case reports, case series, or case control studies. Furthermore, the mechanism of injury and causality for many of these drugs remain elusive as a definitive correlation is generally not established (< 10% of cases). Several classification systems have been proposed, but no single system has been widely adopted, and periodic updates are required in light of ongoing pharmacologic expansion. Moreover, infrequently prescribed medications or those available over-the-counter (including herbal and other alternative remedies) are often overlooked as a potential culprit of acute pancreatitis. Herein, we review the ever-increasing diversity of DIP and the potential mechanisms of injury with the goal of raising awareness regarding the nature and magnitude of this entity. We believe this manuscript will aid in increasing both primary and secondary prevention of DIP, thus ultimately facilitating more expedient diagnosis and a decrease in DIP-related morbidity.

Impact of propofol sedation versus opioid/benzodiazepine sedation on colonoscopy outcomes: a systematic review with meta-analysis

Background and study aims  Choice of sedation (propofol vs opioid/benzodiazepine) has been studied in the literature and has shown variable outcomes. The majority of recent studies have evaluated propofol sedation (PS) versus opioids, benzodiazepines, or a combination of both. We performed a systematic review and meta-analysis of studies comparing PS to other sedation methods to assess the impact on colonoscopy outcomes. Methods  Multiple databases were searched and studies of interest were extracted. Primary outcome of the study was adenoma detection rate (ADR) and secondary outcomes included polyp detection rate (PDR), advanced adenoma detection rate (AADR), and cecal intubation rate (CIR). Results  A total of 11 studies met the inclusion criteria with a total of 177,016 patients (148,753 and 28,263 in the opioids/benzodiazepine group and PS group, respectively). Overall, ADR (RR: 1.07, 95 % CI 0.99-1.15), PDR (RR: 1.01, 95 % CI 0.93-1.10), and AADR (RR: 1.17, 95 % CI 0.92-1.48) did not improve with the use of PS. The CIR was slightly higher for propofol sedation group (RR 1.02, 95 % CI 1.00-1.03). Conclusion  Based on our analysis, PS and opioid/benzodiazepine sedation seem to have comparable ADR. Our results do not favor use of a particular sedation method and the choice of sedation should be individualized based on patient preference, risk factors and resource availability.

Geoepidemiologic variation in outcomes of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic, progressive, hepatobiliary disease characterized by inflammation and fibrosis of the intra- and extra-hepatic bile ducts. Its natural history is one that generally progresses towards cirrhosis, liver failure, cholangiocarcinoma, and ultimately disease-related death, with a median liver transplantation-free survival time of approximately 15-20 years. However, despite its lethal nature, PSC remains a heterogenous disease with significant variability in outcomes amongst different regions of the world. There are also many regions where the outcomes of PSC have not been studied, limiting the overall understanding of this disease worldwide. In this review, we present the geoepidemiologic variations in outcomes of PSC, with a focus on survival pre- and post-liver transplantation as well as the concurrence of inflammatory bowel disease and hepatobiliary neoplasia.

Efficacy of Hemospray in non-variceal upper gastrointestinal bleeding: a systematic review with meta-analysis

Background

Recently, amongst other hemostatic modalities, Hemospray (TC-325) has emerged as an effective method for managing patients with non-variceal upper gastrointestinal bleeding (GIB). We conducted this systematic review and meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB.

Methods

Our primary outcomes were clinical and technical success; secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality, and treatment failure. A meta-analysis of proportions was conducted for all reported primary and secondary outcomes. A relative risk meta-analysis was conducted for studies reporting direct comparisons between Hemospray and other hemostatic measures.

Results

A total of 20 studies with 1280 patients were included in the final analysis. Technical success of Hemospray was seen in 97% of cases (95% confidence interval [CI] 94-98%, I²=52.89%) and a significant trend towards increasing technical success was seen during publication years 2011-2019. Clinical success of Hemospray was seen in 91% of cases (95%CI 88-94%, I²=47.72%), compared to 87% (95%CI 75-94%, I²=0.00%) for other hemostatic measures. The secondary outcomes of aggregate rebleeding, early rebleeding, delayed rebleeding, refractory rebleeding, mortality and treatment failure following the use of Hemospray were seen in 27%, 20%, 9%, 8%, 8%, and 31% of cases, respectively.

Conclusion

Hemospray is safe, effective and non-inferior to traditional hemostatic measures for the management of non-variceal upper GIB, and can thus be used as an alternative option.

Prolonged Peripheral Hypoperfusion Promotes Neuroprotection in Ischemic Stroke

Objectives

Sublethal, transient occlusion of peripheral vessels, called remote ischemic preconditioning (RIPC), induces a neuroprotective state against brain infarction. Recent studies suggest chronic hypoperfusion in patients with peripheral vascular disease (PVD) has analogous effects. We hypothesized a positive correlation between the severity of chronic hypoperfusion and the extent of neuroprotection. To determine if this correlation exists, we compared stroke volumes and clinical measures of modified ranking scale (mRS) and National Institute of Health Stroke Scale (NIHSS) between cases with and without PVD, subgrouping PVD cases by ankle-brachial-index (ABI) values.

Patients and methods

Cases of ischemic stroke with and without PVD were sampled retrospectively from a local institutional data base. Charts were manually reviewed for demographics (age, sex, ethnicity), comorbidities (diabetes, hypertension, hyperlipidemia, coronary artery disease, smoking, and stroke history), clinical measures (admission NIHSS, prior mRS, three-month mRS, and survival) and stroke volumes in each case. Those diagnosed with PVD and ABI indicating active disease were grouped as PVD cases; those not diagnosed with PVD or having ABI indicating absence of disease were used as controls. PVD cases were subgrouped by disease severity per ABI values: mild (ABI 0.8-0.9), moderate (ABI 0.5-0.9) and severe (ABI < 0.5). Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted cox proportional hazards models were used to estimate associations between survival and PVD.

Results

A total of 105 patients, 50 PVD cases and 55 controls, were collected. Mean age was 72.54 years, 51.4% were males and 48.6% females, and 94% were Caucasian. There were 17 mild, 22 moderate, and 11 severe cases of PVD. A higher incidence of comorbidities was present in PVD cases. The mean admission NIHSS was 4.44 and did not differ significantly between groups. Stroke volumes were significantly lower (p = .021) in PVD cases (4.39 ± 8.97 ml) compared to controls (19.33 ± 44.31 ml). There was also a significant difference (p = .04) between volumes of mild (3.86 ± 5.47 ml) and severe (0.63 ± 0.76 ml) PVD cases. There were significant differences (p = .012) in the incidence of good outcomes in moderate to severe PVD cases (100%) compared to controls (83.3%). There was no difference in survival between groups (p = .538).

Conclusion

Increasing degrees of hypoperfusion related to PVD have a potential neuroprotective effect in acute ischemic stroke quantified by lower stroke volumes and better clinical outcomes at three months as seen in other preclinical models of RIPC.

Student Initiative Improves HIV Screening Rate in Student-Run Free Clinic

Background The Center for Disease Control provides recommendations for preventative services and screenings including recommendations for a one-time HIV screening of all adult patients between the ages of 13-64. But not all clinics are fully compliant with these recommendations. We identified a need for increased screening at two clinics in a rural setting. As a healthcare quality improvement initiative, we developed educational informatics to increase screening compliance. Methods This project assessed HIV screening rates before and after educational interventions at two clinics, the Coyote Clinic and the Avera Downtown Clinic. Three changes were implemented to increase the HIV screening rate and ultimately provide more effective high-quality health care. The three initiatives focused on patients, physicians, and student volunteers in order to provide a strong foundation of knowledge to all parties involved in a patient's care. Results Prior to any interventions, the baseline screening rate (screenings/100 persons) at the Avera Downtown Clinic was 0.84 while the screening rate at the Coyote Clinic was 0.00. After the proposed interventions, the screening rate of the Downtown Clinic improved to 3.97 and the screening rate at the Coyote Clinic improved to 29.4. Using a Fisher's Exact test, we found a statistically significant post-intervention increase in HIV screening at the Coyote Clinic after the intervention (p = 0.0002) but not at the Downtown Clinic (p = 0.0940.) Conclusion HIV screening rates improved after the implementation of interventional education initiatives tailored for patients, medical students, and physicians. Implementation of low-cost quality improvement measures such as the ones detailed herein may significantly improve long-term patient management, particularly in the context of screening tests.

Antidepressant Use for Improving Functional Ischemic Stroke Outcomes

Objective

To assess the effect of antidepressants on functional post-stroke recovery, we conducted a retrospective analysis among acute ischemic stroke patients with a subgroup analysis of severe stroke cases, assessing outcomes through 18 months.

Methods

A retrospectively gathered ischemic stroke population was obtained from an institutional database. Grouping was via intention-to-treat with antidepressant use post-stroke or lack thereof. Patients with severe stroke (NIHSS ≥ 21) were further analyzed independently. The primary and secondary outcomes were modified Rankin scale (mRS) and survival over 18 months, respectively. Patient demographics and NIHSS were obtained. Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted Cox proportional hazards models were used to estimate associations between survival and antidepressants.

Results

Eight-hundred six patients (52 severe strokes) received antidepressants post-stroke while 948 (56 severe) did not. The antidepressant group was more female (56% to 43.5%) and had significantly better survival rates (88% vs. 79%, HR 0.62, p < 0.01) but not mRS scores (2.13 vs 2.24, p = 0.262) by the end of the study period. Among severe stroke cases, those receiving antidepressants showed better survival rates (79% vs. 60%, HR 0.36, p=0.026) and most recent mRS score (3.9 vs 5, p < 0.01). The analysis controlling for demographics variables retained significance.

Conclusion

Antidepressant use post-stroke may improve functional outcomes in patients suffering from severe stroke and may decrease all-cause mortality for strokes of any severity.

Opinions, Views, and Expectations Concerning the Radiology Report: A Rural Medicine Report

This study seeks to examine a potential agreement and/or discordance of specific aspects of the radiology report between referring clinicians and radiologists within a medical group in a predominately rural setting. This study also aims to compare results with similar studies conducted in other geographic regions. This was done using a previously validated survey tool that examines five different aspects of the radiology report: importance, clinical correlation, clinicians’ satisfaction, content, structure, and style. Dichotomized results were statistically analyzed using χ² or Fischer’s exact test and showed significant differences in the areas of importance and content. Non-dichotomized results unique to clinicians and radiologists were assessed qualitatively. Most clinicians found the radiology report to be useful in their clinical decision making and that they received radiology reports in a timely enough fashion to affect their decision making. These results were largely found to be in accordance with similar studies, but significant differences unique to the sampled population were present. Based on these findings, we have included specific recommendations that may enhance the clinical efficiency of radiology reports as used by clinicians and potentially reduce medical errors secondary to clinical information not always fully captured in radiology reports.

Revascularization for Posterior Cerebral Artery Infarction in Decompensated Moyamoya Disease

Moyamoya disease is a rare pathological disorder characterized by progressive intracranial artery stenosis and collateral vessel formation. Posterior cerebral artery involvement is rare with a predilection towards infarction. Herein we present a case of a young female with moyamoya disease treated with bilateral encephalomyosynangiosis which subsequently progressed to posterior cerebral artery involvement, requiring encephalomyosynangiosis to prevent further infarction.

"Homomorphic" Tumor Metastases as an Endodiagnostic Clue: A Case Series of Renal-Cell Carcinoma Metastatic to the Stomach

Distinguishing between a primary malignancy and a metastasis can be challenging in some cases. Herein, we describe 2 cases of gastric lesions that were endoscopically sampled and ultimately found to be metastatic from a renal-cell carcinoma. In both cases, the gastric metastases were endoscopically homomorphic to the primary organ (the kidney); i.e., grossly resembling and thus providing an endoscopic clue as to the primary tumor source. We report on the evaluation of obscure metastatic gastric involvement of malignancy and present the concept of homomorphism as a potential diagnostic clue in determining the source of unknown and often unsuspected primary malignancy.

A novel player: cyclosporine therapy in the management of inflammatory bowel disease

Amongst other indications, cyclosporine therapy has emerged as a novel agent for the management of severe refractory ulcerative colitis (UC). In the historic population of patients receiving cyclosporine therapy-namely solid organ transplant patients-renal toxicity has proven to be a significant mitigating side effect limiting the therapeutic window. However, dose-limiting sequelae amongst patients receiving cyclosporine for inflammatory bowel disease (IBD) have not been as significant. As a result, the fear of renal toxicity as an adverse effect is less of a concern in IBD patients. The goal of this manuscript is to emphasize the need for future research to explore optimal drug dosing and extended use of cyclosporine therapy in the treatment of IBD-given its pathophysiology, efficacy, and safety profile in patients with IBD.

Effects on Stroke Metrics and Outcomes of a Nurse-led Stroke Triage Team in Acute Stroke Management

Background Timely administration of healthcare in acute stroke, congruent with national stroke metrics, relates to better patient outcomes. A nurse-led stroke triage team instituted at our facility was hypothesized to improve metrics and outcomes. To evaluate the effect of the nurse-led stroke triage team we compared specific stroke metrics and patient outcomes before and after the program initiation.  Methods In retrospective review, we analyzed stroke metrics one year prior to the start of the triage program (controls) and one year after the start of the program (cases), including the following metrics: patient arrival, emergency department assessment, neurology contact, head computed tomography (CT) scan, and delivery of tissue plasminogen activator (tPA) or puncture for mechanical thrombectomy. Primary outcome measures were improved metric times.  Results Ninety-five acute stroke events were analyzed: 26 controls and 69 cases. Cohort demographics included means of age 72.82 years, National Institutes of Health Stroke Scale (NIHSS) 15.96, discharge and 90-day mRS 3.71 and 3.55 respectively, and length of stay 5.98 days. There were significantly different improvements in metrics between arrival time to CT start, emergency room physician evaluation to CT start, neurology contact to CT start, and neurology contact to tPA initiation for cases post-triage team institution. No significant differences during this period were seen for other metrics. Multivariate analysis controlling for age, sex and NIHSS found no significant difference for discharge or 90-day mRS scores.  Conclusions An interdisciplinary approach to acute stroke management can impact stroke metrics. These data support the integration of specially trained stroke nurses in acute stroke triage for quality improvement efforts.

Recurrent, Idiopathic Spontaneous Hemoperitoneum Requiring Multiple Laparoscopic Evacuations: A Rare Case of Bleeding Adnexal Arteriovenous Malformation

Arteriovenous malformations (AVMs) are abnormal vascular connections that can form in many anatomic locations. The adnexa are particularly rare sites of AVM formation and the symptomatology is heterogeneous. Herein we present a case of life-threatening adnexal AVM. A 21-year-old female presented with abdominal pain and syncope, her third such presentation within 10 days. Her history was significant for ectopic pregnancy six months prior. Diagnostic laparoscopy revealed intraperitoneal blood without active bleeding. Transabdominal pelvic ultrasound revealed a large amount of complicated pelvic fluid and increased right-adnexal vascularity. Interventional radiology performed an urgent uterine arteriogram revealing a right-adnexal AVM with supply from both the right uterine and right ovarian arteries. The AVM was subsequently embolized, resolving her symptoms. AVMs are exceedingly rare, often unconsidered causes of occult pelvic bleeding. Pelvic, and in particular, adnexal AVMs should be considered in females with idiopathic spontaneous hemoperitoneum.

Amiodarone-induced Hemoptysis: A Rare Presentation of Amiodarone-induced Pulmonary Toxicity Occurs at a Low Dose

Amiodarone-induced pulmonary toxicity (APT) is one of the most feared and underappreciated adverse effects of this commonly prescribed antiarrhythmic. APT has a variable presentation, among the rarest of these is amiodarone-induced diffuse alveolar hemorrhage with hemoptysis. Though previous cases confirmed with biopsy averaged a dose of 570 mg PO daily, APT can occur at any dose. Previous literature has suggested the importance of cumulative exposure to amiodarone rather than the patient's actual dose. The presented case describes amiodarone-induced hemoptysis occurring at a dose of 200 mg PO daily for five years. Additionally described is the treatment regimen which managed a patient with metabolic syndrome and elevated A1c while addressing the recommended treatment of extended high-dose steroids for APT with complicated respiratory status. To the best of the authors' knowledge, only two biopsied cases have been described at a dose this low. Furthermore, this case describes a more typical timeline for APT than those two cases.

In Silico Docking of Alkylphosphocholine Analogs to Human Serum Albumin Predicts Partitioning and Pharmacokinetics

Alkylphosphocholine (APC) analogs are a novel class of broad-spectrum tumor-targeting agents that can be used for both diagnosis and treatment of cancer. The potential for clinical translation for APC analogs will strongly depend on their pharmacokinetic (PK) profiles. The aim of this work was to understand how the chemical structures of various APC analogs impact binding and PK. To achieve this aim, we performed in silico docking analysis, in vitro and in vivo partitioning experiments, and in vivo PK studies. Our results have identified 7 potential high-affinity binding sites of these compounds on human serum albumin (HSA) and suggest that the size of the functional group directly influences the albumin binding, partitioning, and PK. Namely, the bulkier the functional groups, the weaker the agent binds to albumin, the more the agent partitions onto lipoproteins, and the less time the agent spends in circulation. The results of these experiments provide novel molecular insights into the binding, partitioning, and PK of this class of compounds and similar molecules as well as suggest pharmacological strategies to alter their PK profiles. Importantly, our methodology may provide a way to design better drugs by better characterizing the PK profile for lead compound optimization.

Massive Cecal Variceal Hemorrhage Treated with Transjugular Intrahepatic Portosystemic Shunt with Right Colic Vein and Ileocolic Vein Embolization

A 40-year-old male suffering from hallucinations and bizarre behavior was brought to our emergency room (ER) by the police. His drug and alcohol screens were positive for amphetamines and a blood alcohol content of 0.029 mg/dL. His past medical history was significant for alcohol use disorder, end-stage liver disease, ascites, esophageal varices, portal hypertension, and hepatic encephalopathy. He was admitted in an encephalopathic state and developed worsening hematochezia and hemodynamic instability over the course of days. Multiple investigations including contrast enhanced computed tomography (CT), upper and lower endoscopy, and mesenteric angiography did not identify a clear cause of the bleeding. Eventually, his source of bleeding was found to be from cecal varices. A transjugular intrahepatic portosystemic shunt procedure and coil embolization of the right colic and ileocolic veins stabilized the patient and he was discharged home a few days later.

Diagnosis of Primary Colorectal Carcinoma with Primary Breast Cancer: Associations or Connections?

Introduction

Although once very uncommon, multiple primary malignant neoplasms (MPMN) are becoming an increasingly popular subject in medical literature. With 182,000 new diagnoses per annum, breast cancer is the most frequently diagnosed cancer amongst women in the United States. Colorectal cancer remains the second most commonly diagnosed cancer in females, and the third in males worldwide.

Methods

In order to gather literature on synchronous and metachronous occurring breast and colon cancer, we searched PubMed using keywords such as 'colorectal cancer', 'breast cancer', and 'MPMN'. We searched through case reports, case series, clinical trials, letters to the editor, and retrospective series. We included any manuscript in English published between January 1990 and January 2019. The articles featured patients who had primary colorectal cancer with primary breast cancer. Articles featuring patients with more than two malignancies or malignancies other than colorectal and breast cancer were excluded. Furthermore, any metastatic cancers were excluded as well. This narrowed our search down from over 100 manuscripts to just four. 

Results

Fortunately, the prognosis was found to be no different for these patients with MPMN assuming diagnosis and treatment are performed in a timely fashion. Additionally, it appears that although a patient with one primary cancer is at a greater risk for the development of a second cancer, it is still an odd phenomenon and thus an unlikely occurrence.

Conclusion

Detection of one cancer increases the odds of detecting another cancer. Hence, it is important to consider the possibility of a synchronous tumor in a patient with a newly diagnosed colon tumor, as well as to not only consider disease recurrence when following up post-resection.

Clinton Woolsey: functional brain mapping pioneer

Dr. Clinton Woolsey was a leading 20th-century neuroscientist for almost 4 decades. His most significant achievements were the novel use and refinement of evoked potential techniques to functionally map mammalian brains, the discovery of secondary cortical areas, and a wide repertoire of comparative neurofunctional studies across many species. The authors discuss his life and work through a historical context with contemporaries, highlight the primitive state of brain mapping before Woolsey, and review his involvement in advancing its rapid development through work at both Johns Hopkins University and University of Wisconsin in Madison. Dr. Woolsey's lasting impact on basic and clinical neuroscience, neurosurgery, and neurology and his important roles as a scientific mentor and leader are also described.