Role of demographics in non-invasive testing for colorectal cancer screening: do targeted cut-off values improve detection?

BACKGROUND: Fecal immunochemical test (FIT) is a yearly alternative colorectal screening modality for average risk individuals unwilling or unable to undergo invasive colorectal cancer (CRC) screening due to cost and accessibility. This study aims to determine whether FIT should be interpreted within the context of patient demographics and medical history. METHODS: Patients >50 years old who had a FIT followed by colonoscopy within 1 year were analyzed based on age, race, BMI, social and medical comorbidities. False positive (FP) and false negative (FN) FIT results within each patient demographic and medical history variable were determined by comparing with the gold standard of colonoscopy using Chi-square analysis. RESULTS: 1025 patients were reviewed. 21.8% of FIT results were positive. Factors which differed in positive FIT rates were age (p=0.003), smoking (p<0.001), alcohol (p=0.001), and hypertension (p<0.001). The difference in rates of FP and FN FIT outcomes among each variable underwent further sub-analysis. The FP was 66.8% and the FN rate was 12.8%. Higher FN outcomes were noted in those above 70, males and smokers, though the result was only statistically significant for males (p=0.009). Females were observed to have higher FP rates (p=0.019). CONCLUSIONS: Females had higher FP FIT rates compared to males, indicating that sex may influence FIT outcomes and should be accounted for when interpreting FIT results. This information can be utilized to identify populations at higher risk of FP or FN FIT results to target CRC screening. Additionally, recalculating the FP and FN rates for each variable may help determine new FIT targets.

Simultaneous Massive Esophageal Mucosal Candidiasis and Profound Cytomegaloviral Esophageal Ulcers with Recurrence of Both Infections 12 Years Later in a Patient with Long-Standing AIDS: Endoscopic, Radiologic, and Pathologic Findings.

Immunocompromised patients with acquired immunodeficiency syndrome (AIDS) can develop opportunistic esophageal candidial and cytomegaloviral infections. A case is reported which extends the clinico-endoscopic severity of these infections. A 32-year-old bisexual man with AIDS since 1997, and intermittently compliant with antiretroviral therapy, presented (2007) with dysphagia and 32 kg-weight loss. EGD revealed a massive, cheesy, esophageal mucosal exudate from Candida albicans. Cytomegalovirus was isolated by viral culture. The patient improved after fluconazole/ganciclovir therapy. The patient re-presented (2019) with hematemesis and dysphagia. EGD revealed cheesy esophageal exudate and profound "punched out" esophageal ulcers mimicking pseudo-diverticula. Histopathology confirmed candidiasis. Viral cultures revealed cytomegalovirus. Barium esophagram revealed deep esophageal ulcers/pseudo-diverticula. Repeat EGD 8 weeks later after ganciclovir/micafungin therapy revealed mostly healed lesions. This demonstrates that AIDS patients may have massive mucosal esophageal candidiasis; that both infections can recur years after apparent eradication; and that cytomegaloviral esophageal ulcers may be profound and mimic pseudo-diverticula. A comprehensive literature review revealed only one abstract of esophageal pseudo-diverticula associated with cytomegalovirus. Simultaneous esophageal candidial and CMV infections have also been rarely reported in immunocompromised patients without AIDS.

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy.

GOALS AND BACKGROUND: The utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with HE. STUDY: Retrospective review of cirrhotic patient encounters with HE between 2016 and 2018 at Beaumont Health, in Michigan was performed. A low-risk (LR) indication for HCT was defined as altered mental status (AMS), which included dizziness and generalised weakness. A high-risk (HR) indication was defined as trauma/fall, syncope, focal neurological deficits (FNDs) or headache. Descriptive statistics and univariate/multivariate analyses by logistic regression were performed using SPSS to identify HCT abnormality correlates. RESULTS: Five hundred twenty unique encounters were reviewed. Mean age was 63.4 (12.1) years, 162 (37.5%) had alcoholic cirrhosis and median Model for End-Stage Liver Disease (MELD)-score was 17 (13-23). LR indication was reported in 408 (78.5%) patients and FNDs reported in 24 (4.6%) patients. Only 13 (2.5%) patients were found to have an acute intracranial pathology (seven haemorrhagic stroke, two ischaemic stroke, four subdural haematoma). Aspirin use prior to presentation (aOR 4.6, 95% CI 1.1 to 19.2), and HR indication (aOR 7.3, 95% CI 2.3 to 23.8) were independent correlates of acute intracranial pathology on HCT. Age, sex, MELD-score, haemoglobin, platelet count, race and cirrhosis aetiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 in HR indications versus 82 for LR indications. CONCLUSION: Routine HCTs in cirrhotic patients presenting with HE with AMS in the absence of history of trauma, headache, syncope, FNDs or aspirin use is of low diagnostic yield.

Epidemiology, Clinical Characteristics, and Outcomes of a Large Cohort of COVID-19 Outpatients in Michigan.

BACKGROUND: Most outpatients with coronavirus disease 2019 (COVID-19) do not initially demonstrate severe features requiring hospitalization. Understanding this population's epidemiological and clinical characteristics to allow outcome anticipation is crucial in healthcare resource allocation. METHODS: Retrospective, multicenter (8 hospitals) study reporting on 821 patients diagnosed with COVID-19 by real-time reverse transcriptase-polymerase chain reaction assay of nasopharyngeal swabs and discharged home to self-isolate after evaluation in emergency departments (EDs) within Beaumont Health System in March, 2020. Outcomes were collected through April 14, 2020, with a minimum of 12 day follow-up and included subsequent ED visit, admission status, and mortality. RESULTS: Of the 821 patients, mean age was 49.3 years (SD 15.7), 46.8% were male and 55.1% were African-American. Cough was the most frequent symptom in 78.2% of patients with a median duration of 3 days (IQR 2-7), and other symptoms included fever 62.1%, rhinorrhea or nasal congestion 35.1% and dyspnea 31.2%. ACEI/ARBs usage was reported in 28.7% patients and 34.0% had diabetes mellitus. Return to the ED for re-evaluation was reported in 19.2% of patients from whom 54.4% were admitted. The patients eventually admitted to the hospital were older (mean age 54.4 vs 48.7 years, p=0.002), had higher BMI (35.4 kg/m2 vs 31.9 kg/m2, p=0.004), were more likely male (58.1% vs 45.4%, p=0.026), and more likely to have hypertension (52.3% vs 29.4%, p<0.001), diabetes mellitus (74.4% vs 29.3%, p<0.001) or prediabetes (25.6% vs 8.4%, p<0.001), COPD (39.5% vs 5.4%, p<0.001), and OSA (36% vs 19%, p<0.001). The overall mortality rate was 1.3%. CONCLUSION: We found that 80.8% of patients did not return to the ED for re-evaluation. Sending patients with COVID-19 home if they experience mild symptoms is a safe approach for most patients and might mitigate some of the financial and staffing pressures on healthcare systems.

Epstein-Barr virus induced haemophagocytic lymphohistiocytosis.

Haemophagocytic lymphohistiocytosis (HLH) is a rare condition of uncontrolled immune activation as a result of an inherited genetic defect or in response to malignancy, autoimmune disease, rheumatological disease, AIDS infection or post-transplant immunosuppression. Described here is the case of a 19-year-old Caucasian man who presented with complaints of worsening fever, new-onset jaundice and lethargy after failing treatment for suspected infectious mononucleosis. Physical examination was significant for fever and splenomegaly while laboratory results revealed transaminitis, cytopaenia, indirect hyperbilirubinaemia and elevated ferritin, raising the likelihood of both autoimmune haemolytic anaemia and HLH. He tested positive for Epstein-Barr virus (EBV), and bone marrow biopsy revealed hypercellular marrow with haemophagocytosis and no evidence of malignancy. High dose steroids were initiated with significant improvement in haemoglobin, resulting in a final diagnosis of HLH secondary to acute EBV infection. The patient was discharged on continued high-dose prednisone with planned taper and consideration of outpatient rituximab therapy for 4 weeks. High clinical suspicion and prompt evaluation were critical to early treatment and decreased morbidity.

Pancreatic Ganglioneuroma Presenting in an Octogenarian.

Pancreatic ganglioneuromas occur mostly in children and rarely in young adults, with no cases reported in adults older than 60 years. An 86-year-old-woman, with active advanced multiple myeloma, presented with epigastric pain for 2 days. Abdominal and pelvic computed tomography demonstrated a distended gallbladder, mildly dilated biliary tree, and a 13 × 8-mm hypodense mass in pancreatic body, without extrapancreatic invasion at endoscopic ultrasound. Fine-needle endoscopic ultrasound-guided core biopsy revealed characteristic histopathology of ganglioneuroma, as confirmed by immunohistochemical positivity for S100, SOX-10, and synaptophysin. This demonstrates novel finding of pancreatic ganglioneuroma occurring in the elderly. Lesion inclusion in the differential diagnosis may mandate tissue for pathologic diagnosis and complete lesion resection.

Novel Case Report: A Previously Reported, but Pathophysiologically Unexplained, Association Between Collagenous Colitis and Protein-Losing Enteropathy May Be Explained by an Undetected Link with Collagenous Duodenitis.

Collagenous colitis (CC) is associated with non-bloody, watery diarrhea, which is pathophysiologically reasonable because normal colonic absorption (or excretion) of water and electrolytes can be blocked by the abnormally thick collagen layer in CC. However, CC has also been associated with six previous cases of protein-losing enteropathy (PLE), with no pathophysiologic explanation. The colon does not normally absorb (or excrete) amino acids/proteins, which is primarily the function of the small bowel. Collagenous duodenitis (CD) has not been associated with PLE. This work reports a novel case of CD (and CC) associated with PLE; a pathophysiologically reasonable mechanism for CD causing PLE (by the thick collagen layer of CD blocking normal intestinal amino acid absorption); and a novel association of PLE with severe COVID-19 infection (attributed to relative immunosuppression from hypoproteinemia, hypoalbuminemia, hypogammaglobulinemia, and malnutrition from PLE).

Proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report.

BACKGROUND: Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis. AIM: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported. METHODS: Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper. RESULTS-SYSTEMATIC-LITERATURE-REVIEW: Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space. RESULTS-ILLUSTRATIVE-CASE-REPORT: Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days. STUDY LIMITATIONS: Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population. CONCLUSIONS: Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.