Budd-Chiari Syndrome as an Initial Presentation of Non-Promyelocytic Acute Myelogenous Leukemia

Budd-Chiari syndrome (BCS) is a rare disease characterized by hepatic venous outflow tract obstruction, frequently due to an underlying thrombophilic disorder. Acute myeloid leukemia rarely presents as acute BCS due to hyperfibrinolysis, hyperleukocytosis, nonspecific proteolytic activity, and disseminated intravascular coagulation causing acute hepatic vein thrombosis. In patients presenting with acute BCS with acute liver failure (ALF), a high index of suspicion and exclusion of underlying malignancy is a must, as it is a contraindication for liver transplantation. We report a case of a 19-year-old Caucasian male who presented with acute BCS causing ALF as an initial presentation of acute myelogenous leukemia.

Malignant Peritoneal Mesothelioma Mimicking Recurrent Diverticulitis

Mesothelioma is an uncommon type of cancer arising from the mesothelial cells that form the lining of several cavities in the body. Exposure to asbestos is the leading known cause of mesothelioma. We present a 73-year-old male with a significant asbestos exposure and a recent history of recurrent diverticulitis who reported persistent left lower quadrant (LLQ) pain despite several courses of empiric antibiotic therapy. A recent computed tomography (CT) performed due to nonresolving symptoms showed possible nodularity of the mesentery and subsequent positron emission tomography (PET) scan demonstrated multiple hypermetabolic mesenteric lesions, notably in the left paracolic gutter. A colonoscopy was subsequently performed which demonstrated severe diverticulosis, but no obvious luminal lesions. The patient underwent an exploratory laparoscopy showing extensive peritoneal carcinomatosis involving all mesenteric surfaces and partial involvement of the right diaphragm. Final pathology revealed malignant epithelial mesothelioma with peritoneal seeding. The patient was referred to oncology and was started on hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS). Our case highlights a challenging presentation of malignant peritoneal mesothelioma (MPM), which is often initially misdiagnosed due to vague symptoms. Physicians should consider further diagnostic workup for unrelenting LLQ abdominal pain after diverticulitis has been treated.

Seroconverting nonresponder of high-dose intramuscular HBV vaccine with intradermal HBV vaccine: A case report

INTRODUCTION

Liver disease is a leading cause of death among human immunodeficiency virus (HIV)-infected patients in the United States. Patients with HIV and hepatitis B virus (HBV) coinfection have accelerated liver disease, higher rates of cirrhosis, and liver cancer, and markedly increased liver-related mortality. The CDC and US Advisory Committee on Immunization Practices recommend hepatitis B vaccination for all HIV-infected individuals. Unfortunately, HIV-infected patients have a worse response rate after standard HBV vaccination. Intradermal (ID) vaccination continues to emerge as an important modality in such difficult to vaccinate individuals and should be considered whenever permissible. Herein, we report a case of a 46-year-old male with HIV who failed to mount an immune response to standard intramuscular vaccine, standard booster dose, and repeat high-dose booster vaccine but subsequently mounted an immune response to the ID vaccine which was sustained at 3 months postvaccination.

CONCLUSION

ID vaccination continues to emerge as an important modality in difficult to vaccinate individuals and should be considered in all applicable cases.

Effect of acute aerobic exercise on vaccine efficacy in older adults

The most effective way of avoiding influenza is through influenza vaccination. However, the vaccine is ineffective in about 25% of the older population. Immunosenescence with advancing age results in inadequate protection from disease because of ineffective responses to vaccination. Recently, a number of strategies have been tested to improve the efficacy of a vaccine in older adults. An acute bout of moderate aerobic exercise may increase the efficacy of the vaccine in young individuals, but there are limited efficacy data in older adults who would benefit most.

PURPOSE

This study sought to evaluate whether acute moderate-intensity endurance exercise immediately before influenza vaccination would increase the efficacy of the vaccine.

METHODS

Fifty-nine healthy volunteers between 55 and 75 yr of age were randomly allocated to an exercise or control group. Antibody titers were measured at baseline before exercise and 4 wk after vaccination. C-reactive protein (CRP) and interleukin-6 (IL-6) were measured at 24 and 48 h after vaccination.

RESULTS

Delta CRP and IL-6 at 24 and 48 h were significantly higher after vaccination as compared to the sham injection. There were no differences in the levels of antibody titers against the H3N2 influenza strain between groups. However, women in the exercise group had a significantly higher antibody response against the H1N1 influenza strain as compared to the men, probably because of lower prevaccine titers. There were no significant differences in seroprotection between groups.

CONCLUSIONS

Acute moderate aerobic exercise was not immunostimulatory in healthy older men but may serve as a vaccine adjuvant in older women.

Population-based assessment of heartburn in urban Black Americans

Prevalence data for heartburn in the urban Black American community is lacking. In order to estimate prevalence for this community, we analyzed data from an ongoing cohort study in progress at our hospital. Comprehensive interviews allowed for exploration of factors associated with heartburn. Complex, stratified sampling design was the method used. Survey invitations are hand-delivered to random blocks in a single zip code tabulation area. One member per eligible household is invited to complete a computer-based survey. Heartburn was defined as ≥ 3 days/week of symptoms as defined by the Montreal Definition and Classification of gastroesophageal reflux disease. Scaling and weighting factors were utilized to estimate population level prevalence. Multivariate logistic regression was used to identify independent predictor variables for heartburn. Enrolled 379 participants corresponding to a weighted sample size of 22,409 (20,888-23,930) citizens. Demographic characteristics of the sample closely matched those of the entire targeted population. Overall, the weighted prevalence of heartburn ≥ 3 times per week was 17.6% (16.4-18.8%). Variables independently associated with heartburn were body mass index, daily caloric and fat intake, diabetes mellitus (odds ratio = 2.95; 2.59-3.36), cigarette smoking, and alcohol consumption (odds ratio = 2.55; 2.25-2.89). Factors inversely associated included illicit drug use and increased physical activity. Waist : hip ratio showed no relationship. The prevalence of heartburn ≥ 3 times per week is high in the Black American community. Adverse lifestyle behaviors showed particularly important associations. Our study needs to be replicated in other communities with similar demographics.

Predictive value of body mass index at age 18 on adulthood obesity: results of a prospective survey of an urban population

INTRODUCTION

Overweight children often become obese adults. The main purpose of this study was to define the risk of teenage obesity as a predictor of adulthood obesity in an under-studied and urban population. A secondary aim was to determine whether gender had an effect on the predictive value of teenage obesity. The final goal was to examine the influence of dietary habits on obesity.

METHODS

This cross-sectional survey was conducted using convenience sampling of an urban, primarily African American, community. Demographic questions were supplemented by a dietary history and measurement of body anthropometrics.

RESULTS

Five hundred three subjects were interviewed; 86% were African American, and the mean age was 43 years. Body mass index (BMI) at age 18 was the strongest factor associated with current obesity status in univariate and multivariate analyses. Sixty-nine (13.7%) subjects were overweight at age 18, and 28 (5.6%) were obese. Of the 28 obese teenagers, 22 (78.6%) went on to become obese as adults. Only 2.1% of nonobese adults were obese as teenagers. For women, BMI at age 18 was more predictive of adult BMI than for men. Gain of ≥ 5 BMI units after age 18 was linked to a higher prevalence of diabetes and hypertension. No dietary differences were found between obese and nonobese adults.

CONCLUSIONS

The results of this study provide evidence that high BMI at age 18 is strongly correlated with adulthood obesity, much more so with women than men. Eating habits did not have an impact, suggesting that obesity may be the result of a combination of factors yet to be clearly defined.

Prevalence and risk factors for gastroesophageal reflux disease in an impoverished minority population

BACKGROUND AND AIMS: An epidemiological link between an increased body mass index and complaints of typical heartburn symptoms has been identified. It appears that increasing waist circumference, rather than overall weight is most important. Studies to date have not included minority, impoverished communities. Our aim was to determine the impact of obesity on the prevalence of reflux disease in an impoverished community while controlling for known confounders. METHODS: DESIGN Cross-sectional survey delivered by in-home interviews, convenience sampling, and targeted mailing. Data queried include demographics, medical history, lifestyle habits, and symptoms of reflux disease. Height, weight, hip and waist circumference measured in participating subjects. PARTICIPANTS: 503 subjects living in the zip code immediately surrounding Temple University Hospital. Included only adults living in the hospital's zip code for at least 3 years. RESULTS: The highest quartile of waist circumference (≥42 in.) demonstrated a strong association with GERD (AOR = 2.15; 95% CI 1.18-3.90). Smoking increased the odds by 1.72 (95% CI 1.13-2.62). There was no relationship between body mass index, waist-hip ratio, or diet and reflux classification. CONCLUSIONS: Increasing waist circumference, but not overall body mass index or waist-hip ratio, and smoking are risk factors for prevalent GERD. No association between reflux disease and lifestyle choices such as coffee drinking and fast food dining were found. LIMITATIONS: Potential for recall bias and disease misclassification. Possible methodological errors in self-measurement of waist and hip circumference.

Trends in gastroesophageal reflux disease as measured by the National Ambulatory Medical Care Survey

BACKGROUND

The prevalence of reflux disease is increasing. Health-care utilization including physician visits for this disorder is lacking. Our purpose was to analyze the trend in physician visits for GERD from the period 1995-2006 using the National Ambulatory Medical Care Survey. We also sought to determine health-care utilization for GERD indirectly by assessing prescription trends for proton-pump inhibitors and H2 receptor blockers during the period.

METHODS

The National Ambulatory Medical Care Survey is a survey of approximately 3,000 office-based physicians that uses a three-stage probability sampling procedure to allow extrapolation to the US population. All visits between 1995 and 2006 for symptoms and/or diagnoses compatible with GERD were combined into a single categorical variable. Weighted data was utilized for descriptive and inferential statistical analysis.

RESULTS

After weighting, there were N = 321,513 adult ambulatory care encounters for all diagnoses. Visits for reflux increased throughout the examined period. Using logistic regression, visits for reflux were associated with female gender, age over 40, and calcium channel blocker use. Proton-pump inhibitor use increased substantially during the study period while H2 blocker use declined. Family practitioners and internists saw the majority of reflux patients.

CONCLUSIONS

The frequency of ambulatory visits in the United States for gastroesophageal reflux disease increased significantly between 1995 and 2006. The use of PPI therapy is increasing even more substantially. Older age, female gender, and use of calcium channel blockers were associated with a higher frequency of GERD visits. Health-care utilization for this disorder is increasing perhaps due to our ever-increasing epidemic of obesity.