Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis.

BACKGROUND: Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration. METHODS: Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record. RESULTS: The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n = 162), hepatology (n = 45), or both (n = 41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p = 0.03) or depression (1.50, p = 0.05) or who were younger (0.97, p = 0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p = 0.05), prior AUD treatment (9.92, p < 0.0001), and a higher PHQ-2 depression score (2.85, p = 0.004). CONCLUSIONS: We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

Prospective evaluation of an assessment tool for technical performance of duodenoscopes.

OBJECTIVE: While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes. METHODS: An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool. RESULTS: The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores. CONCLUSIONS: The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.

Epidermoid Cyst in the Appendix: A Rare Entity.

Epidermoid cysts are benign cystic lesions that are usually found in the skin. They can also be found in the organs of the gastrointestinal system. Here, we report a rare case of epidermoid cyst of the appendix which has been published in only three cases in the literature. They can be either congenital or acquired. Congenital epidermoid cysts are related to the inclusion of ectodermal elements at the time of neural groove closure. Acquired cysts are thought to be due to trauma or iatrogenic implantation of the epidermis in locations favorable to growth during surgery. Diagnosis is mainly by histopathological examination of the tissue sample. Complete excision of the cyst with the walls intact is considered curative.

Kambo Frog Poison as a Cause of Esophageal Rupture.

The authors present a case of a patient who used Kambo frog poison for body cleansing that induced severe vomiting and led to esophageal rupture followed by tension pneumothorax and septic shock. Kambo is the waxy substance secreted by the nocturnal giant tree frog Phyllomedusa bicolor. Kambo, which is poisonous, is commonly believed in South America to have cleansing and healing properties. As alternative medicine becomes more common, and as more tourists frequent our hospitals, knowledge of these types of ritual related exposures is important for the practicing emergency physician to be aware of.

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.

Benign Granular Cell Tumor of the Cecum.

Granular cell tumors (GCT) are usually benign, soft tissue tumors that are mostly found in the oral cavity, skin, and subcutaneous tissue. GCTs in the gastrointestinal (GI) tract are mainly located in the esophagus. A 63-year-old male was referred to the gastroenterology clinic for a major complaint of six months of painless rectal bleeding. Laboratory results showed mild macrocytic anemia. He denied any prior colonoscopies and hence, a lower endoscopic procedure was done. The colonoscopy showed multiple polyps, one of them located at the cecum. The cecal polyp showed polygonal cells with abundant eosinophilic infiltration and S100 stain positive. This confirmed a diagnosis of GCT. GCTs are thought to be derived from the neural tissue (Schwann cells). This entity is usually asymptomatic; however, tumors located at the lower GI tract can present with hematochezia. Only 2% of GCTs follow a malignant course, with associated poor prognosis.  This case is being presented because of its asymptomatic nature. It is important to monitor these lesions in order to recognize early signs/symptoms concerning for malignancy.