"Syphilitic Hepatitis": A Comprehensive Review of Clinical Features, Diagnostic Approaches, and Management Considerations.

Syphilitic hepatitis is a very rare presentation of syphilis infection, characterized by inflammation of the liver due to the invasion of hepatic tissue by the bacterium Treponema pallidum. This review article provides an in-depth analysis of the existing body of information pertaining to syphilitic hepatitis. The article primarily concentrates on key aspects such as the epidemiology, clinical manifestations, diagnostic methods, and therapeutic approaches associated with this condition. Despite its rarity, awareness of syphilitic hepatitis is vital for accurate diagnosis and appropriate intervention. The clinical presentations frequently exhibit similarities with many liver illnesses, hence presenting difficulties in making an accurate diagnosis. Common symptoms include fatigue, stomach pain, and jaundice. Diagnostic procedures encompass the use of serological assays, including rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-ABS), in conjunction with imaging modalities to evaluate hepatic engagement. The primary therapeutic approach is the prompt initiation of antibiotic therapy, with a particular emphasis on penicillin, to eradicate the causative bacterial infection and facilitate the restoration of liver function. Failure to swiftly manage this condition may result in substantial morbidity. In summary, syphilitic hepatitis is a very uncommon but medically relevant manifestation of syphilis infection. The significance of increased clinical suspicion, precise diagnostic techniques, and prompt antibiotic administration is emphasized in this review since these are crucial in reducing the potentially severe outcomes associated with this illness.

Improving Fecal Immunochemical Testing Rates for Colon Cancer Screening in the Outpatient Setting.

OBJECTIVES: The amount of colorectal cancer (CRC) screening using the noninvasive fecal immunochemical test (FIT) at a federally qualified health center, Five Rivers Health Clinic (Dayton, Ohio), has been low historically. Our quality improvement (QI) project aimed to improve CRC screening adherence in eligible patients who opted for FIT. METHODS: Three hundred ninety-two patients with FIT orders for CRC were screened during an 11-month period. The preintervention group (pre-I) was enrolled from December 1, 2018 to May 31, 2019, and the postintervention group (post-I) from June 1, 2019 to October 31, 2019. Three interventions were used: resident physicians trained during clinic meetings regarding FIT education for patients, posters displayed in patient rooms outlining the benefits of CRC screening, and standardized US mail reminder letters sent to FIT patients. Patient demographics and clinical variables were collected along with return rate. RESULTS: The return rate for post-I was twice that of pre-I (74.4%, 95% confidence interval 64.6-82.3 vs 31.1, 95% confidence interval 26.2-36.6; P < 0.001). The pre-I/post-I groups did not differ on demographic and clinical characteristics, and, except for race, none of these variables was associated with returning the FIT screening card. CONCLUSIONS: The compliance rate for FIT completion and return more than doubled among our clinic patients after using a three-component QI intervention. Except for a difference in race, the lack of association between demographic and clinical characteristics with either pre-I/post-I group or return/no return of the FIT card leads us to conclude that our QI program for increasing FIT compliance is effective. Other settings where CRC screening is a prominent component of preventive care may benefit from adopting a similar QI intervention.

Evaluating alcohol use among Russian women at risk for an alcohol-exposed pregnancy: A comparison of three measures of alcohol use.

The Quick Drinking Screen (QDS) and Timeline Followback (TLFB), measures of alcohol use, have yielded similar reports of drinking with English speakers. The present study, a secondary data analysis, compared three measures of alcohol use (i.e., QDS, TLFB, and AUDIT) among Russian-speaking women. This is the first study to compare all three measures. This study replicated the findings of studies with English speakers and demonstrated that brief screening measures (QDS, AUDIT) provide reliable summary measures of alcohol use when compared to a detailed drinking measure (TLFB). The use of brief screening measures is recommended for use with Russian women.

Two Brief Measures of Alcohol Use Produce Different Results: AUDIT-C and Quick Drinking Screen.

BACKGROUND: Several psychometrically sound measures of alcohol use have been developed to assess drinking. The Alcohol Use Disorders Identification Test (AUDIT) and its shorter counterpart the AUDIT-C, which contains the first 3 AUDIT questions, were developed by the World Health Organization and have become the preferred brief measures for screening and evaluating problem severity. This study compared the first 3 questions on the AUDIT with another psychometrically sound brief measure of alcohol use, the Quick Drinking Screen (QDS). METHODS: Data were obtained from a randomized controlled trial of a mail-based intervention promoting self-change with 472 alcohol abusers (n = 280, no prior alcohol treatment; n = 192, prior alcohol treatment). Participants' retrospective self-reports of alcohol consumption were collected using the QDS and the 3 AUDIT-C questions and compared. Although both measures contain similar questions (2 quantity-frequency and 1 binge drinking), they differ in 2 important ways: (i) temporal interval over which data are collected, and (ii) formatting of response options (i.e., a continuous number vs. categorical). RESULTS: Intraclass correlations for drinking variables were moderate to moderately high. A repeated-measures MANOVA using treatment condition and gender as variables revealed significant differences in absolute values between the 2 drinking measures with the QDS showing greater consumption on almost all variables. Participants' numerical answers on the QDS were compared to their categorical answers to the similar alcohol use questions on the AUDIT-C. The comparison revealed that participants' answers on the AUDIT-C were associated with extreme variability compared to their QDS answers. This variability suggests the AUDIT-C would be unreliable as a quantitative measure of alcohol consumption. CONCLUSIONS: The differences between the 3 alcohol use questions on the AUDIT-C and the same questions on the QDS may reflect the imprecision of the AUDIT-C's drinking response categories. Results suggest that the QDS can be used to identify risky drinking and to provide a more informative characterization of a drinker's alcohol consumption than that provided by the AUDIT-C.

Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial of a Self-Administered Version of Project CHOICES with College Students and Nonstudents.

BACKGROUND: Alcohol-exposed pregnancies (AEPs) are a preventable cause of birth defects and developmental disabilities for which many women are at risk. The initial 5-session Project CHOICES intervention was found to prevent AEPs. In the ensuing decade, there have been several additional CHOICES-like studies. This study, Project Healthy CHOICES, had 2 objectives: (i) to compare outcomes for students versus nonstudents; and (ii) to test a self-administered mail-based version of the Project CHOICES intervention. METHODS: A randomized controlled trial (RCT) compared 2 interventions for women of childbearing age (18 to 44) who were at risk of an AEP: (i) motivational feedback based on Project CHOICES and (ii) information only. Advertisements recruited 354 women (145 college students; 209 nonstudents) at risk of an AEP. Intervention and study materials were available in English and Spanish. Of the 354 women, 44% were minorities (25% identified as Hispanics). RESULTS: At the 6-month follow-up, the interventions did not differ and there was no Intervention by Student Study interaction. However, over the entire 6-month follow-up, significantly more students (68%) than nonstudents (46%) were not at risk of an AEP (2.1 odds ratio; confidence interval = 1.47 to 2.95). For all groups, risk reduction occurred primarily through effective contraception. CONCLUSIONS: There was no significant difference between the 2 interventions. However, over the entire 6-month follow-up interval, college students were significantly more likely than nonstudents to not be at risk of an AEP and to use effective contraception. While the student groups had significantly higher reduced risk of AEP outcomes, there was also substantial risk reduction for women in the information only condition. These results suggest that the most effective AEP prevention efforts would be to inform women at risk that they could become pregnant. Because about half of all pregnancies are unplanned, identifying women at risk and preventing the risk of AEPs should be a public health priority.

Risk Factors for 30-Day Readmissions of Individuals with Decompensated Cirrhosis.

OBJECTIVES: Patients with cirrhosis have a high rate of 30-day hospital readmission that affects their quality of life and contributes to increased healthcare-related costs. The aim of our study was to identify frequency, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis. METHODS: We retrospectively reviewed electronic medical records of all patients with a confirmed diagnosis of decompensated cirrhosis admitted to Dayton VA Medical Center between 2009 and 2013. Demographics, clinical factors, laboratory values, and outcomes were recorded. Univariate analysis was performed using independent samples t tests and Wilcoxon rank sums tests for continuous variables and χ(2) or Fisher exact tests for categorical variables. A multiple logistic regression analysis was performed for variables found to be significant by univariate analysis to predict the risk factors for 30-day readmission. A detailed chart review was conducted for all patients readmitted within 30 days by a single gastroenterologist to identify the reason for readmission and to decide whether any of these readmissions were preventable. RESULTS: The 30-day readmission rate for decompensated cirrhotic patients was 27.03%. The risk factors for 30-day readmission were higher body mass index (BMI), lower body temperature, higher blood urea nitrogen, higher creatinine, more cirrhosis-related complications, and more readmissions per year per univariate analysis. Multivariable analysis revealed only BMI as a significant predictor of 30-day readmission (P = 0.023). A total of 36.7% of 30-day readmissions were possibly preventable. CONCLUSIONS: The independent variable that predicted 30-day readmission in patients with decompensated cirrhosis was higher BMI. Approximately one-third of 30-day readmissions were possibly preventable. These findings support the need to develop specific interventions for disease management to improve patient care and save on extraneous healthcare costs.

Missed esophageal and gastric cancers after esophagogastroduodenoscopy in a midwestern military veteran population.

OBJECTIVES: Esophagogastroduodenoscopy (EGD) with biopsy has become the standard procedure for diagnosing esophageal and gastric cancers (EGC) and is considered to have high sensitivity and specificity. To date, few studies have attempted to examine the rates of missed EGC after EGD and no study addresses the rate of missed EGC in a military veteran patient population. This led to us examine missed EGCs at our VA Medical Center across a 10-year period. METHODS: An electronic database was used to identify patients who were diagnosed between 2000 and 2010 as having EGC. Missed cancers were defined as cancers diagnosed within 1 year of EGD, possible missed cancers as those diagnosed 1 to 3 years after EGD, and latent cancers as those diagnosed between 3 and 5 years after EGD. RESULTS: A total of 94 patients fulfilled the study criteria: 69 had esophageal cancer and 25 had gastric cancer diagnosed at our institution during the study period. Of the included cases, one patient had a missed cancer (1.06%) and four patients had possible missed cancers (4.26%); no patients had latent cancer. CONCLUSIONS: The true incidence of missed EGC in military veteran patients is not known. It is difficult to compare our findings to those of other studies because of the heterogeneity of studies. Our study echoes the findings of the others: EGD remains an important and effective tool in diagnosing EGC. At the same time, it also points out an important limitation, that EGC can be missed on EGD. Our findings also emphasize the importance of obtaining biopsies of any abnormality and timely clinical follow-up and by repeat EGD as needed.

Anatomical distribution of colorectal cancer in a Veterans Affairs Medical Center.

OBJECTIVES: The incidence of sporadic colorectal cancer (CRC) among individuals younger than 50 years of age and the incidence of proximal cancers has varied based on demographic factors in previous studies, and multisociety screening guidelines advise various modalities for average-risk individuals beginning at age 50. We studied the incidence and anatomic distribution of CRC in a population of military veterans to determine whether screening at a younger age is warranted. METHODS: In a retrospective review of the electronic medical records of patients diagnosed as having CRC at the Dayton Veterans Affairs Medical Center between 2000 and 2010, a descriptive analysis of age at diagnosis, race, indication for colonoscopy, and anatomical distribution of the tumor was performed. RESULTS: A total of 280 patients with CRC were identified, 272 of whom were histologically confirmed as having adenocarcinoma. The majority (98.6%) were men, with 25.6% of them African American. The mean age at diagnosis was 68.9 years (range 41-89 years), with 35% diagnosed in the eighth decade of life. Only 8 patients (2.9%) were younger than age 50. Most tumors (55%) were located distal to the splenic flexure, with synchronous lesions identified in seven patients. Screening colonoscopy identified only 18 (3.6%) cases. CONCLUSIONS: Sporadic colorectal adenocarcinoma in patients younger than age 50 was identified in only 2.9% of all cases, whereas 42.5% of all cases were located proximal to the splenic flexure. This reinforces the American College of Gastroenterology guideline recommendation to initiate CRC screening in average-risk individuals at age 50. This study supports optical colonoscopy as the preferred screening modality.

Metformin use and the risk of esophageal cancer in Barrett esophagus.

OBJECTIVES: Diabetes mellitus is a significant risk factor for total cancer incidence and mortality. Metformin, a commonly used antidiabetic drug, has been shown to be protective against different types of cancers; however, its role in esophageal cancer is unknown. The goal of this study was to determine whether the use of metformin modifies the risk of development of esophageal adenocarcinoma in patients with Barrett esophagus. METHODS: Patients with diagnoses of Barrett esophagus and esophageal cancer were identified during a 20-year period. Demographic and clinical data were collected. The outcome variable was esophageal adenocarcinoma. Univariate analysis was performed using two-sample t tests for continuous variables or the Fisher exact test for categorical variables. Multiple logistic regression analysis was then performed using the significant variables. RESULTS: A total of 583 patients were identified with the diagnosis of Barrett esophagus or esophageal adenocarcinoma from 1992 to 2012. Of these, 115 had esophageal adenocarcinoma and 468 had Barrett esophagus. Age, smoking, and diabetes mellitus were found to be significant risk factors for the development of esophageal cancer with the following results: age (P < 0.001), smoking (P = 0.003), diabetes mellitus (P = 0.007). Statin use was protective against the development of cancer with P = 0.001. Metformin use was neither associated with an increased nor a decreased risk of esophageal cancer. CONCLUSIONS: The three independent variables that predicted progression of Barrett esophagus to esophageal adenocarcinoma in our study were older age, smoking, and diabetes mellitus. Statin use showed protective effect against development of esophageal adenocarcinoma. Metformin use did not demonstrate any statistically significant protective effect.

Does the use of an assistive device by nurses impact peripheral intravenous catheter insertion success in children?

Peripheral intravenous (PIV) access is a common and essential component for the medical management of the hospitalized child. Delayed or failed PIV insertion can increase the risk for complications from delayed intravenous treatment. Repetitive PIV insertion attempts can cause psychological trauma to the child and decrease family satisfaction. This study examined the success of two vein visualization assistive devices in aiding PIV insertions performed by pediatric medical-surgical nurses. During the 11-month investigation period, PIV insertion success was significantly higher when no assistive device was used compared to assisted methods. Implications for practice and further research are discussed.

Macro-Aspartate Aminotransferase: A Benign Cause of Abnormal Laboratory Findings.

Isolated, persistent elevations of aspartate aminotransferase (AST) without plausible explanation may lead to diagnostic confusion. Macro-enzyme aspartate aminotransferase (macro-AST) is an uncommon and benign cause of persistently elevated AST levels in the absence of other diseases. We present a case of macro-AST in an otherwise healthy adult male which was confirmed by polyethylene glycol (PEG) precipitation.

A Rare Case of Gastrointestinal Amyloidosis Presenting as Dysphagia.

A 74-year-old male with an unintentional 20-pound weight loss over the past year presented with new-onset dysphagia to solid foods. Esophagogastroduodenoscopy showed a subtle stricture with ill-defined scar tissue-like findings in the distal esophagus and erosions in the antrum of the stomach without masses. Pathologic findings showed the presence of amyloidosis involving the proximal and distal esophagus, as well as gastric mucosa with chronic inflammation and reactive epithelial changes. We present a rare case of dysphagia as the initial presentation of gastrointestinal amyloidosis.

An Unusual Presentation of Crohn's Disease and Primary Sclerosing Cholangitis.

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory gastrointestinal bowel disorders that may affect any part of the alimentary tract. Classically, these two diseases have hallmark associations, such as UC with primary sclerosing cholangitis (PSC). We present a case of a healthy 21-year-old white female with concomitant CD and PSC, complicated by a biliary stricture requiring stent placement. We discuss shared risk factors, disease pathogenesis, and hallmark pathological associations. To the best of our knowledge, there are a limited number of reported cases that demonstrate the dual phenotype of CD and PSC.

Butterfly in the Esophagus: A Case Report on a Rare Esophageal Manometry Catheter Malposition.

We report the case of a 75-year-old man who underwent high-resolution manometry (HRM) testing for solid food dysphagia after an unrevealing upper endoscopy and biopsies. A barium esophagogram confirmed nonspecific motility disorder. A subsequent HRM study was performed, but when all swallow studies were noted to fail, and the manometric images revealed a butterfly wings appearance, it was found that the manometry catheter was actually coiled and folded back cephalad. As there are only a few other case reports with similar presentations, we believe this case would serve as a good reminder for clinicians to practice caution when cannulating the manometry catheter.

Changes in diurnal salivary cortisol levels in response to an acute stressor in healthy young adults.

BACKGROUND: Knowledge of the diurnal cortisol response to acute stress in healthy individuals can help us better understand the physiological and health effects of chronic stress. OBJECTIVE: To compare the diurnal patterns of cortisol secretion of 15 medical students 2 weeks before a major written examination (control phase) and 2 weeks later at the time of the examination (acute stress phase). DESIGN: Interrupted time series within-subjects. RESULTS: During the acute stress phase, less cortisol was secreted over the course of the day, as demonstrated by a more prolonged and steeper decline in cortisol levels. In addition, higher cortisol levels were present in the evening. Despite these changes in the usual diurnal pattern, overall exposure to cortisol remained the same for both phases. CONCLUSIONS: The results of this study suggest that specific adaptations to the diurnal pattern of cortisol are made in the face of acute stress, important information for understanding cortisol regulation in health and illness.

Kayexalate-induced colitis and rectal stricture.

A 57-year-old man underwent emergency laparoscopic loop colostomy for acute recto-sigmoid obstruction. He was hospitalised 2 months previously, at another facility for diabetic ketoacidosis (DKA) and hyperkalaemia. He had no gastrointestinal symptoms prior to the hospitalisation. Both surgical exploration and intraoperative sigmoidoscopy showed ulcerations of sigmoid colon and proximal rectum with a pinhole stricture in mid-rectum. After ruling out all aetiologies, and due to persistence of the colonic ulcerations on a follow-up colonoscopy, a diagnosis of Crohn's colitis was made, and the patient was started on infliximab and 6-mercaptopurine (6-MP). Six months later, on rereview of all the biopsies, it was noted that a key element of presence of crystals suggestive of Kayexalate on the initial colorectal biopsies was missed. It was later found out that the patient had received rectal Kayexalate for treatment of DKA at the other facility. Hence, infliximab and 6-MP were both discontinued. All the colonoscopies, following the discontinuation of the medications, showed complete resolution of colitis but persistence of the mid-rectum stricture. This was treated with a fully covered metal stent for 12 weeks with only partial improvement of the stricture. He was hence referred for ultra-low anterior resection of rectum and take down of colostomy.

The Relationship Between Number of Comorbidities and Age of Colorectal Cancer Diagnosis in US Male Veteran Population: A Single-Center Experience.

BACKGROUND: Comorbidities of tobacco and alcohol abuse and obesity are major risk factors for colon carcinogenesis. These risk factors are considered the most prevalent modifiable risk factors linked to malignancies including colorectal cancer (CRC) in both high- and low-income countries. The aim of this study was to investigate the relationship between number of comorbidities and age of CRC diagnosis in US male veteran population. METHODS: A retrospective single-center study using chart review and the International Classification of Diseases, Ninth Revision (ICD-9) codes to identify patients with a diagnosis of CRC and comorbidities of tobacco abuse, alcohol abuse, hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD). The primary aim was to study effect of these comorbidities on age of CRC diagnosis. Univariable and then multivariable logistic regression models were fit to age at diagnosis for each patient variable. RESULTS: A total of 362 patients were included in the study. The mean age of CRC diagnosis was 66.8. Eighty percent were Caucasians, and 20% were African Americans. African Americans were diagnosed with CRC 3.8 years younger compared to Caucasians (P = 0.01). Controlling for other variables in the multivariable model, age at CRC diagnosis was significantly lower for African Americans and for patients with higher total counts for tobacco and alcohol abuse and obesity. HTN, DM and CKD were not associated with a lower age of CRC diagnosis. CONCLUSIONS: Tobacco and alcohol abuse and obesity have negative cumulative effect on age of CRC diagnosis in US male veteran population. Patients with increasing number of these comorbidities are associated with significantly lower age of CRC diagnosis. It is important to identify veterans with these comorbidities and encourage CRC screening.

Differential MicroRNA Signatures in the Pathogenesis of Barrett's Esophagus.

OBJECTIVES: Barrett's esophagus (BE) is the precursor lesion and a major risk factor for esophageal adenocarcinoma (EAC). Although patients with BE undergo routine endoscopic surveillance, current screening methodologies have proven ineffective at identifying individuals at risk of EAC. Since microRNAs (miRNAs) have potential diagnostic and prognostic value as disease biomarkers, we sought to identify an miRNA signature of BE and EAC. METHODS: High-throughput sequencing of miRNAs was performed on serum and tissue biopsies from 31 patients identified either as normal, gastroesophageal reflux disease (GERD), BE, BE with low-grade dysplasia (LGD), or EAC. Logistic regression modeling of miRNA profiles with Lasso regularization was used to identify discriminating miRNA. Quantitative reverse transcription polymerase chain reaction was used to validate changes in miRNA expression using 46 formalin-fixed, paraffin-embedded specimens obtained from normal, GERD, BE, BE with LGD or HGD, and EAC subjects. RESULTS: A 3-class predictive model was able to classify tissue samples into normal, GERD/BE, or LGD/EAC classes with an accuracy of 80%. Sixteen miRNAs were identified that predicted 1 of the 3 classes. Our analysis confirmed previous reports indicating that miR-29c-3p and miR-193b-5p expressions are altered in BE and EAC and identified miR-4485-5p as a novel biomarker of esophageal dysplasia. Quantitative reverse transcription polymerase chain reaction validated 11 of 16 discriminating miRNAs. DISCUSSION: Our data provide an miRNA signature of normal, precancerous, and cancerous tissue that may stratify patients at risk of progressing to EAC. We found that serum miRNAs have a limited ability to distinguish between disease states, thus limiting their potential utility in early disease detection.

Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue.

BACKGROUND: To determine whether sleep quality and fatigue associated with breast cancer adjuvant chemotherapy treatments can be improved with behavioral therapy (BT) [Individualized Sleep Promotion Plan (ISPP)] including modified stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene. METHODS: Randomized-controlled trial based on Piper Integrated Fatigue Model, 219 stages I-IIIA breast cancer patients. Prior to the initial chemotherapy treatment, BT participants developed an ISPP plan that was regularly reinforced and revised. Controls received healthy eating information and attention. Pittsburgh Sleep Quality Index (PSQI), daily diary, actigraph, and Piper Fatigue Scale (PFS) data were collected 2 days prior, during the 7 days after each treatment, and 30 days after the last treatment. Repeated measures analysis of variance was used. RESULTS: Prior to chemotherapy, participants reported mild fatigue and fairly poor sleep quality. All variables changed over time. A group by time interaction was found for sleep quality (PSQI) improving in the BT group. Diary revealed group differences on number of awakenings, minutes awake after sleep onset, and sleep efficiency. Fatigue (PFS) was similar between groups. CONCLUSIONS: The BT group showed improved sleep quality over time and better sleep (diary). Perceptions of improved sleep quality over time are not consistently associated with diary or actigraph, or result in lower fatigue.