Image enhanced colonoscopy: updates and prospects-a review.

Colonoscopy has been proven to be a successful approach in both identifying and preventing colorectal cancer. The incorporation of advanced imaging technologies, such as image-enhanced endoscopy (IEE), plays a vital role in real-time diagnosis. The advancements in endoscopic imaging technology have been continuous, from replacing fiber optics with charge-coupled devices to the introduction of chromoendoscopy in the 1970s. Recent technological advancements include "push-button" technologies like autofluorescence imaging (AFI), narrowed-spectrum endoscopy, and confocal laser endomicroscopy (CLE). Dye-based chromoendoscopy (DCE) is falling out of favor due to the longer time required for application and removal of the dye and the difficulty of identifying lesions in certain situations. Narrow band imaging (NBI) is a technology that filters the light used for illumination leading to improved contrast and better visibility of structures on the mucosal surface and has shown a consistently higher adenoma detection rate (ADR) compared to white light endoscopy. CLE has high sensitivity and specificity for polyp detection and characterization, and several classifications have been developed for accurate identification of normal, regenerative, and dysplastic epithelium. Other IEE technologies, such as blue laser imaging (BLI), linked-color imaging (LCI), i-SCAN, and AFI, have also shown promise in improving ADR and characterizing polyps. New technologies, such as Optivista, red dichromatic imaging (RDI), texture and color enhancement imaging (TXI), and computer-aided detection (CAD) using artificial intelligence (AI), are being developed to improve polyp detection and pathology prediction prior to widespread use in clinical practice.

Tenapanor in the Treatment of Irritable Bowel Syndrome with Constipation: Discovery, Efficacy, and Role in Management.

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction (DGBI). IBS significantly impacts the quality of life of patients. Since its pathogenesis is unclear and can be multifactorial, it highlights the need for new and improved pharmaceutical drugs that not only improve bowel symptoms, but also address global IBS symptoms, such as abdominal pain. Tenapanor, a recently Food & Drug Administration (FDA)-approved medication for IBS with constipation (IBS-C), is a small molecule inhibitor of the sodium/hydrogen exchanger isoform 3 (NHE3) that inhibits the absorption of sodium and phosphate in the gastrointestinal tract, resulting in fluid retention and softer stool. Furthermore, tenapanor reduces intestinal permeability to improve visceral hypersensitivity and abdominal pain. Due to its recent approval, tenapanor was not included in the recent IBS guidelines, however, it may be considered for IBS-C patients failing first-line treatment of soluble fiber. In this review article, we aim to provide in-depth information to the reader regarding the design of tenapanor, its development through Phase I, II and III randomized clinical trials, and its role in the treatment of IBS-C.

Trends in Gastroparesis Management: A United States Population-based Study From 2010 to 2020.

BACKGROUND: There is little consensus on the medical management of gastroparesis, a disorder characterized by delayed gastric emptying with symptoms of early satiety, nausea, vomiting, and upper abdominal pain. GOALS: We utilized population-level data to: (1) describe the prevalence of different pharmacological and nonpharmacological therapies in patients with gastroparesis; and (2) trend the prevalence of these therapies from 2010 to 2020. STUDY: More than 59 million unique medical records across 26 US-based major health care systems were surveyed using the Explorys platform to identify a cohort of adults with gastroparesis who completed both a gastric emptying study and upper endoscopy or upper gastrointestinal tract imaging. Prevalence of antiemetic, prokinetic, neuromodulator prescriptions, and surgical therapies for gastroparesis were searched within this cohort and trended annually from 2010 to 2020. RESULTS: Antiemetics (72% of patients), prokinetics (47%), and neuromodulators (75% of patients, 44% of patients without a concomitant psychiatric or diabetic peripheral neuropathy diagnosis) were all commonly used in the treatment of patients with gastroparesis. From 2010 to 2020, there was an increase in the prevalence of antiemetic and neuromodulator prescriptions (36.4% to 57.6%, P <0.001 and 47.0% to 66.9%, P <0.001, respectively), whereas the prevalence of prokinetics remained relatively constant (31.8% to 31.6%, P =0.52). Procedural and surgical treatments were used in 5% of gastroparesis patients. CONCLUSIONS: Treatments for gastroparesis have changed over the last decade: antiemetic and neuromodulator use has increased whereas prokinetic use has remained constant. This practice pattern may reflect the growing number and availability of antiemetics and neuromodulators and the small number and known side effects of prokinetics.

Expanding beyond endoscopy: A review of non-invasive modalities in Barrett's esophagus screening and surveillance.

Barrett's esophagus (BE) is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of esophageal adenocarcinoma. Current guidelines recommend endoscopic evaluation for screening and surveillance based on various risk factors which has limitations such as invasiveness, availability of a trained specialist, patient logistics and cost. Trans-nasal endoscopy is a less invasive modality but still has similar limitations such as limited availability of trained specialist and costs. Non-endoscopic modalities, in comparison, require minimal intervention, can be done in an office visit and has the potential to be a more ideal choice for mass public screening and surveillance, particularly in patents at low risk for BE. These include newer generations of esophageal capsule endoscopy which provides direct visualization of BE, and tethered capsule endomicroscopy which can obtain high-resolution images of the esophagus. Various cell collection devices coupled with biomarkers have been used for BE screening. Cytosponge, in combination with TFF3, as well as EsophaCap and EsoCheck have shown promising results in various studies when used with various biomarkers. Other modalities including circulatory microRNAs and volatile organic compounds that have demonstrated favorable outcomes. Use of these cell collection methods for BE surveillance is a potential area of future research.

A cross-sectional study describing peripheral neuropathy in patients with symptoms of gastroparesis: associations with etiology, gastrointestinal symptoms, and gastric emptying.

BACKGROUND: Peripheral neuropathy (PN) is present in diabetic gastroparesis but is not described in idiopathic gastroparesis. AIMS: (1) Determine prevalence of PN in idiopathic gastroparesis; (2) assess if patients with symptoms of gastroparesis and PN differ in gastric emptying and symptoms, both gastrointestinal and psychosocial, from patients without PN (nPN); (3) compare this relationship to that in other etiological groups. METHODS: 250 patients with symptoms of gastroparesis underwent gastric emptying scintigraphy and answered questionnaires including severity of gastroparesis symptoms using the Gastroparesis Cardinal Symptom Index (GCSI) and presence of peripheral neuropathy using the Neuropathy Total Symptom Score-6 (NTSS-6). RESULTS: PN, defined by NTSS-6 > 6, was present in 70/250 (28%) patients: 22/148 (15%) idiopathic, 33/61 (54%) diabetic, and 11/32 (34%) postsurgical (p < 0.01). Among 148 patients with symptoms of idiopathic gastroparesis, defined as non-diabetic, non-postsurgical, and not caused by a known disorder such as Parkinson's or connective tissue disease, symptoms of gastroparesis were more severe in PN than nPN: bloating (4.05 ± 1.17 vs. 2.99 ± 1.61, p < 0.01), abdominal distension (3.86 ± 1.49 vs. 2.45 ± 1.68, p < 0.01), and upper abdominal pain (3.64 ± 1.22 vs. 2.71 ± 1.78, p = 0.03). Ninety-nine idiopathic patients underwent gastric emptying scintigraphy: 7/43 (16%) patients with delayed gastric emptying and 9/56 (16%) patients with normal gastric emptying had PN. Among patients with idiopathic gastroparesis, abdominal distension (4.43 ± 0.53 vs. 2.89 ± 1.68, p = 0.01) was more severe in PN than nPN. The association of PN and worse gastrointestinal symptoms was not as apparent in patients with symptoms of diabetic or postsurgical gastroparesis. CONCLUSIONS: PN was present in 70/250 (28%) of patients with symptoms of gastroparesis and was present to a lesser extent in idiopathic than diabetic gastroparesis. The presence of PN in IG was associated with more severe gastroparetic symptoms than in nPN. Screening for PN may help identify a gastroparesis cohort with peripheral neuropathy who are more symptomatic.

Hiatal hernias associated with acid reflux: size larger than 2 cm matters.

Hiatal hernia (HH) is associated with gastroesophageal reflux disease (GERD); the effect of HH size on GERD is not well defined. To evaluate the relationship between HH size as measured by high-resolution esophageal manometry (HREM) and reflux parameters on esophageal pH-impedance testing (multichannel intraluminal impedance-pH [MII-pH]) to define HH sizes associated with GERD. HREM and MII-pH studies were reviewed. The relationship of HH size to other parameters was analyzed with multivariable logistic regression. Correlation coefficients were determined using Spearman and Pearson's tests. A total of 897 patients underwent both HREM and MII-pH. There were 529 (58.9%) patients with HH size <1 cm, 203 (22.6%) with HH 1.0-1.9 cm, and 165 (18.4%) with HH ≥2 cm. Larger HH size was associated with lower esophageal sphincter (LES) basal and residual pressures (r = -0.43 and r = -0.48, p < 0.01), higher acid exposure time (AET) (r = 0.17, p < 0.01), number of acidic refluxes (r = 0.16, p < 0.05), and number of reflux episodes detected by impedance (total r = 0.22, p < 0.01). HH ≥ 2 cm compared with smaller size HH was associated with higher proximal AET%, acidic refluxes, and reflux episodes detected by impedance (p < 0.05). Increasing HH size was associated with older age, higher AET, and number of reflux episodes. HH ≥2 cm was associated with multiple worsened GERD parameters. Low LES pressure was weakly associated with an increase in the number of reflux episodes. Larger HHs, particularly >2 cm, are associated with more severe GERD parameters.

Gastric half emptying time (T½ ) for 4-h gastric emptying scintigraphy simplifies reporting but reduces detection of gastroparesis.

BACKGROUND: Gastric emptying scintigraphy (GES) reports percent retention at 1, 2, and 4 h. Time to empty half the meal (T½ ) could simplify GE reporting. AIMS: To compare the performance of GES T½ to 1-, 2-, and 4-h retention. METHODS: GES studies were reviewed; results determined according to retention at 1, 2, and 4 h. T½ was determined using 3 methods: (1) GES curve fitting using 0, 0.5, 1, 2, 3, and 4 h data; (2) linear interpolation using 0, 0.5, 1, 2, 3, and 4 h data; and (3) linear interpolation using only 0, 1, 2, and 4 h data. RESULTS: Of 495 patients, 265 had normal GE, 4 rapid GE (<30% retention at 1 h), and 226 delayed GE: 17 delayed only at 2 h (>60% ret); 94 delayed only at 4 h (>10% ret); and 115 delayed at both 2 h and 4 h. Strong correlations were seen between each T½ method and 1, 2, 3, and 4 h %-empty values: curve-fit T½ (r = -0.851, -0.942, -0.864, -0.744), linear T½ using all imaging times (r = -0.848, -0.972, -0.878, -0.763), and linear T½ using standard imaging times (r = -0.853, -0.974, -0.868, -0.760). The 132 min cutoff for delayed GE captures 99.1% to 100% of delayed GE at both 2 h and 4 h, 76.5% to 94.1% delayed at 2 h only, but only 36.7% to 39.4% delayed at 4 h only; 3.5 to 11.3% of patients with normal GE miscategorized as delayed. CONCLUSIONS: GES T½ correlates more strongly with retention at 2 h than at 4 h. T½ alone may misclassify patients, particularly those with late-phase (4 h only) delays, reducing its utility for diagnosing gastroparesis.

Demographics of Gastroparesis Hospitalizations Through the Age Spectrum Using National Inpatient Databases: Children Compared With Adults.

GOAL: The goal of this study was to characterize the etiology and demographics of hospitalized patients with gastroparesis (Gp) across different age groups. BACKGROUND: Gp is a chronic condition associated with increasing hospitalizations and costs. The gender and etiology distributions of Gp throughout the age spectrum are unknown. MATERIALS AND METHODS: Nationwide Inpatient Sample (NIS) and Kid's Inpatient Database (KID) were used to identify patients using International Classification of Diseases (ICD)-10 codes for Gp as a primary diagnosis or as secondary diagnosis with the first diagnosis a GI-related symptom. RESULTS: There were a total of 15,790 admissions (75.6% female, age: 46.2±18.0 y). After age 6, female admissions percentage increased: ages 2 to 5: 45.0%, ages 6 to 12: 62.8%, ages 13 to 20: 76.7% ( P <0.001), with a distinct increase at age 12. Diabetic gastroparesis (DG) was seen in 3995 (25.3%) of all Gp admissions but in only 1.1% of children under the age of 20. Overall, 68% of DG admissions were female, but a higher percentage of DG was seen among male admissions for Gp compared with female admissions for Gp between ages 21 and 64 (38.3% vs. 23%, P <0.001). The most common races were white (63.2%), African American (20.6%), and Hispanic (8.7%). DG was more often present in Native American (61.9%), Hispanic (39.1%), and African American (38.2%) admissions than in white patients (17.8%; P <0.05). CONCLUSIONS: This study using large inpatient databases shows that the gender, race, and etiology of Gp admissions is age-dependent. The female predominance of Gp admissions is more prominent from the second decade of life. DG, although uncommon in children, is seen more often in nonwhite admissions.

Meal Eating Characteristics of Patients with Gastroparesis.

BACKGROUND: Patients with gastroparesis often consume only small meals due to early satiety. AIMS: (1) Describe meal eating characteristics of patients with gastroparesis; (2) Relate meal eating characteristics to symptoms, gastric emptying (GE), and body weight. METHODS: Patients with gastroparesis filled out questionnaires including Patient Assessment of Upper GI Symptoms (PAGI-SYM), and questionnaire about meal habits and body weight. Patients underwent gastric emptying scintigraphy. RESULTS: Of 192 gastroparesis patients, 93% endorsed early satiety (ES) with severity of 3.7 ± 1.5 (scored from 0-5) and 93% endorsed postprandial fullness (PPF) with severity of 3.9 ± 1.3. Time spent consuming meals averaged 13.6 ± 17.7 min. Main reasons patients stopped eating were fullness (61%), nausea (48%), and abdominal pain (31%). Time spent eating correlated inversely with severity of nausea (r = -0.18, p < 0.05), stomach fullness (r = -0.21, p < 0.01), PPF (r = -0.23, p < 0.01), loss of appetite (r = -0.34, p < 0.01). Postprandial fullness lasted for 316 ± 344 min. Duration of PPF correlated with nausea (r = 0.30, p < 0.01), retching (r = 0.29, p < 0.01), vomiting (r = 0.28, p < 0.01), stomach fullness (r = 0.33, p < 0.01), loss of appetite (r = 0.35, p < 0.01), and constipation (r = 0.27, p < 0.01). Underweight patients had increased inability to finish a normal size meal (p < 0.01), loss of appetite (p < 0.01), and lower abdominal pain/discomfort (p < 0.05). Patients had lost 3.06 ± 10.60 kgs from their baseline weight. Weight loss correlated with nausea (r = 0.26, p < 0.01), ES (r = 0.30, p < 0.01), loss of appetite (r = 0.28, p < 0.01). CONCLUSIONS: Early satiety and postprandial fullness were common with high severity. The main reasons for meal cessation were early satiety, nausea, and abdominal pain. Body weight and change in body weight were associated with symptoms of gastroparesis.

Management of the patient with esophagogastric junction outflow obstruction.

PURPOSE OF REVIEW: Esophagogastric junction outflow obstruction (EGJOO), defined as elevated integrated residual pressure (IRP) with preservation of esophageal peristalsis, is a common finding on high-resolution esophageal manometry. RECENT FINDINGS: The recent Chicago classification version 4.0 proposes changes to the criteria for diagnosing EGJOO, making this diagnosis more restrictive to now include elevated IRP in both supine and upright positions (with preservation of esophageal peristalsis), presence of obstructive symptoms, and confirmatory tests for EGJOO, such as timed barium esophagram with barium tablet or functional lumen imaging probe. SUMMARY: Once the diagnosis of EGJOO is established, secondary causes need to be ruled out, especially the use of opioid medications. Upper endoscopy is needed for evaluation of EGJOO patients, though cross-sectional imaging is usually not necessary. Many patients improve without intervention; thus, expectant management is recommended for patients with mild or atypical symptoms. There seems to be a limited role for medical treatment. Botox injection into the lower esophageal sphincter is often used to see if the patient improves before committing to more definitive treatments, such as pneumatic dilation, peroral endoscopic myotomy, or Heller myotomy.

Prevalence and Clinical Characteristics of Dyssynergic Defecation and Slow Transit Constipation in Patients with Chronic Constipation.

Patients with chronic constipation who do not respond to initial treatments often need further evaluation for dyssynergic defecation (DD) and slow transit constipation (STC). The aims of this study are to characterize the prevalence of DD and STC in patients referred to a motility center with chronic constipation and correlate diagnoses of DD and STC to patient demographics, medical history, and symptoms. High-resolution ARM (HR-ARM), balloon expulsion testing (BET) and whole gut transit scintigraphy (WGTS) of consecutive patients with chronic constipation were reviewed. Patients completed questionnaires describing their medical history and symptoms at the time of testing. A total of 230 patients completed HR-ARM, BET, and WGTS. Fifty (22%) patients had DD, and 127 (55%) patients had STC. Thirty patients (13%) had both DD and STC. There were no symptoms that were suggestive of STC vs. DD; however, patients with STC and DD reported more severe constipation than patients with normal transit and anorectal function. Patients with chronic constipation often need evaluation for both DD and STC to better understand their pathophysiology of symptoms and help direct treatment.

Haloperidol Use in the Emergency Department for Gastrointestinal Symptoms: Nausea, Vomiting, and Abdominal Pain.

INTRODUCTION: Haloperidol (HL) has successfully been used for nausea and abdominal pain in emergency departments (EDs). This study examines outcomes and predictive factors for clinical improvement of patients presenting to an ED with gastrointestinal (GI) symptoms (nausea, vomiting, and abdominal pain) who received HL. METHODS: Review of patients' records who presented to our ED between August 2016 and March 2019 with GI symptoms and received HL. International Classification of Diseases, Tenth Revision codes were used to identify patients. RESULTS: In all, 281 patients (410 encounters) presented to the ED with GI symptoms and received HL for their symptoms: 66% were women, 32% had diabetes, 68% used marijuana, and 27% used chronic opioids. Patients received HL 1.1 ± 0.3 times with dose 2.5 ± 3.0 mg, mostly intravenously (84.6%). Total ED length of stay was 7.5 ± 3.9 hours (3.2 ± 2.1 hours before HL and 4.4 ± 3.4 hours after). Approximately 4.4% of patients developed side effects to HL, including 2 patients with dystonia which improved with medication before discharge. Most patients (56.6%) were discharged home while 43.2% were admitted to hospital mostly because of refractory nausea or vomiting (70.1%). Receiving HL as the only medication in the ED led to lower hospital admission (odds ratio = 0.25, P < 0.05). Diabetes, cannabinoid use, anxiety, male sex, and longer ED stay were associated with increased hospital admissions. DISCUSSION: Most patients treated in our ED with HL for GI symptoms, particularly nausea, vomiting, and/or abdominal pain, were successfully treated and discharged home. HL use seemed relatively safe and, when used as the only medication, led to less frequent hospital admissions.

Addition of small-bowel transit scintigraphy to gastric emptying for assessment of patients with upper gastrointestinal symptoms.

BACKGROUND: Dyspeptic symptoms are not well correlated with gastric emptying (GE) results. AIMS: To determine (a) prevalence of delayed SB transit (SBT) in patients undergoing GE scintigraphy for symptoms of gastroparesis; (b) symptoms associated with delayed SBT. METHODS: Patients with symptoms of gastroparesis underwent combined GE and SBT scintigraphy (GES/SBTS). Patients ingested a mixed solid (S)-liquid (L) meal with egg whites labeled with 500 µCi Tc-99 m sulfur colloid and water with 125 µCi In-111 DTPA. Retained S and L gastric activity and percent of L In-111 activity in terminal ileum (TI) and/or cecum/colon at 6 h were determined. Patient Assessment of Gastrointestinal Symptoms (PAGI-SYM) assessed symptoms from 0 (none) to 5 (very severe). KEY RESULTS: Of 363 patients, 174 (47.9%) had delayed S GE, 141 (38.8%) delayed L GE, and 70 (19.3%) delayed SBT. Delayed SBT was seen in 24 (6.6%) with normal S GE and 46 (12.7%) with delayed S GE. Patients with isolated delayed SBT had highest symptom scores for postprandial fullness (3.5), stomach fullness (3.4), nausea (3.2), bloating (3.2), compared to isolated delayed S GE who had highest symptom scores for postprandial fullness (3.7), nausea (3.6), stomach fullness (3.4), and early satiety (3.3). CONCLUSIONS & INFERENCES: Delayed SBT occurred in 19.3% of dyspeptic patients using GES/SBTS. While postprandial and stomach fullness were common to both delayed S GE and delayed SBT, early satiety was associated with delayed S GE whereas bloating was associated with delayed SBT. Thus, SBTS can augment GES to help explain some symptoms associated with dyspepsia and suspected gastroparesis.

Factors Associated With Hospital Admissions and Readmissions in Patients With Gastroparesis Using the Nationwide Readmission Database.

BACKGROUND: Gastroparesis can be associated with severe symptoms. Health care utilization for gastroparesis has increased in part due to an increase in hospital admissions. GOALS: To characterize patients admitted for gastroparesis-related symptoms and determine risk factors associated with 30-day readmissions. STUDY: The Nationwide Readmission Database (NRD) for the year 2014 was used to identify patients admitted to hospitals using the International Classification of Diseases (ICD)-9 code for gastroparesis as primary diagnosis or as the secondary diagnosis with first diagnosis code of a gastroparesisrelated symptom. Logistic regression was used to determine risk factors associated with 30-day readmission. RESULTS: There were 5268 gastroparesis patients admitted with the average length of stay (LOS) of 5.4±6.6 days. Age averaged 48.9±18.1 years, 73.8% were female individuals, and 31% had diabetes. Inpatient mortality was 0.4%. The overall 30-day readmission rate was 6.2%. Longer LOS [odds ratio (OR)=1.4; 95% confidence interval (CI), 1.0-1.9], younger age, drug abuse (OR=1.6; 95% CI, 1.2-2.2), and marijuana use (OR=1.7; 95% CI, 1.0-2.7) were associated with increased risk of 30-day readmission. Female gender (P=0.083), opioid use (P=0.057), and admission to larger hospital (P=0.070) showed a trend toward higher readmission rates. Older patients, and patients with hypertension and diabetes showed lower rates of readmission. CONCLUSIONS: Use of the Nationwide Readmission Database (NRD) allows better understanding of gastroparesis admissions and readmissions. Average hospital stay was 5.4 days with 0.4% mortality rate. Overall 30-day readmission rate was 6.2%. Higher LOS, drug abuse, and marijuana use increased the 30-day readmission rate. Diabetes, hypertension, and older age were associated with lower readmissions.

Symptom variability throughout the day in patients with gastroparesis.

BACKGROUND: Symptoms of gastroparesis (Gp) can fluctuate at different times of the day. Our aims are (1) To characterize Gp symptom variability throughout the day and in relation to meals and (2) to compare the daily symptom variability in subtypes of Gp-diabetic gastroparesis (DGp) and idiopathic gastroparesis (IGp). METHODS: Patients with Gp filled Patient Assessment of Gastrointestinal Symptoms (PAGI-SYM) and completed a modified GCSI-DD seven times a day (GCSI-Throughout the Day [GCSI-TTD]; before and after meals, and before going to bed) over a 2-week period. KEY RESULTS: A total of 44 patients participated (86% females), including 29 (66%) with IGp, 13 (30%) with DGp, and 2 (4%) with postsurgical Gp. Using the GCSI-TTD, patients with Gp reported significant postprandial worsening of overall symptom severity, as well as severities of nausea, early satiety, stomach fullness, and abdominal pain. Patients also had progressive worsening of the overall symptom severity, early satiety, stomach fullness, and abdominal pain during the day; however, nausea severity did not differ during the day. Number of vomiting and retching episodes did not show significant variations postprandially or during the day. Patients with IGp had greater symptom severity throughout the day and greater postprandial increase in symptoms compared to patients with DGp. CONCLUSIONS AND INFERENCES: Patients with Gp experience postprandial worsening of overall symptom severity, as well as severities of nausea, early satiety, stomach fullness, and abdominal pain. These symptoms also progressively worsen during the day, except for the severity of nausea which persists throughout the day. Understanding the symptom variability in patients with Gp throughout the day and postprandially may be useful in treatment of patients with Gp.

A Complicated Case of Serratia marcescens Infective Endocarditis in the Era of the Current Opioid Epidemic.

While bacteremia due to Serratia marcescens is not uncommon, it rarely causes infective endocarditis. We report an isolated case of a 53-year-old male with history of intravenous drug abuse who presented with multiple acute pain symptoms and was found to have S. marcescens bacteremia with septic emboli in his spleen, brain, and testes, secondary to a large aortic vegetation, as well as aortic infective endocarditis with severe aortic regurgitation requiring aortic valve replacement. His course of disease was further complicated by epidural and psoas abscesses and a necrotic testicle requiring orchiectomy due to his ongoing intravenous drug abuse. This case is an atypical presentation of S. marcescens infection, as he had no overt signs of infection such as fever or significant leukocytosis that are typical of bacteremia, and it also highlights the severity and complicated nature of S. marcescens-infective endocarditis.

De novo coronary artery disease in graves' disease. coincidence?

Hyperthyroidism is associated with increased risk of cardiovascular conditions. We report a case of a 50-year-old woman with no prior cardiac history who presented to the emergency department with shortness of breath, chest pain, lower extremity swelling, and generalized fatigue. She was found to have Graves' Disease (GD) and extensive coronary artery disease (CAD), suggesting the possibility of increased risk of de novo CAD in patients with GD in the absence of other risk factors.

Zinc-deficiency acrodermatitis in a patient with chronic alcoholism and gastric bypass: a case report.

Acquired adult-onset zinc deficiency is occasionally reported in patients with malnutrition states, such as alcoholism, or malabsorptive states, such as post-bariatric surgery. The defining symptoms of hypozincemia include a classic triad of necrolytic dermatitis, diffuse alopecia, and diarrhea. We report a case of zinc deficiency in a 39-year-old man with history of gastric bypass surgery and alcoholism. For this patient, severe hypozincemia confirmed acrodermatitis, and zinc supplementation was met with gradual improvement.

Comparison of hypertension and diabetes mellitus prevalence in areas with and without water arsenic contamination.

BACKGROUND: Arsenic (As), one of the most significant hazards in the environment affecting millions of people around the world is associated with several diseases including cancers, Diabetes Mellitus (DM) and Hypertension (Htn). Drinking water contaminated with inorganic arsenic (iAs) is the primary route of exposure. This study was conducted to determine the difference in the prevalence of DM and Htn in areas with different levels of water contamination of As. MATERIALS AND METHODS: In this analytic ecologic study, after measurement of As level in drinking water in all urban regions of Qazvin Province (Islamic Republic of Iran), two cities with As level of 20-30 µg/L and two with the As level <5 µg/L were selected as exposed and unexposed groups, respectively. Measuring the prevalence of above-mentioned diseases in the 30-60 year-old population of the said regions as total sampling, the results were statistically analyzed and compared. RESULTS: The mean prevalence of Htn in exposed and unexposed areas were 7.09% and 3.73%, respectively and for DM were 4.53% and 1.99% in the said groups, respectively. There was a positive correlation between As level and Htn (P < 0.001) and between As level and DM (P < 0.001). CONCLUSION: High level of As in drinking water, even in the range of 20-30 µg/L has a relationship with increased prevalence of DM and Htn.