Dissemination of Gastroenterology and Hepatology Research on Social Media Platforms Is Associated With Increased Citation Count.

INTRODUCTION: The purpose of this study was to find out whether dissemination of gastroenterology and hepatology (GI) research on social media networks correlates with citation count at 5 years. METHODS: We correlated the Altmetric Attention Score with Web of Science citation counts at 5 years for scholarly work published in the 10 highest impact factor GI journals in 2014. RESULTS: In 4,026 analyzed items, the correlation (r) between Altmetric Attention Score and citations at 5 years was 0.62 (P < 0.001), representing strong correlation. Twitter was the platform with the strongest correlation with citations. DISCUSSION: Social media attention garnered by GI scholarly work strongly correlates with the number of citations at 5 years.

Effect of active versus passive void trials on time to patient discharge, urinary tract infection, and urinary retention: a randomized clinical trial.

PURPOSE: We sought to determine the effect of active versus passive voiding trials on time to hospital discharge and rates of urinary tract infection (UTI) and urinary retention (UR). METHODS: We performed a prospective, randomized trial comparing active (AVT) versus passive (PVT) void trials of inpatients requiring urethral catheter removal. Of 329 eligible patients, 274 were randomized to AVT (bladder filled with saline before catheter removal) or PVT (spontaneous bladder filling after catheter removal). Primary outcome was time to hospital discharge. Secondary outcomes were UTI (NSQIP criteria) and UR (requiring repeat catheterization) within 2 weeks of void trial. RESULTS: The median time to void was 18 (5-115) versus 236 (136-360) min in the AVT and PVT groups, respectively (p < 0.0001). However, no difference was seen in comparison of the median time to hospital discharge between AVT [28.4 (13.6-69.3) h] and PVT [30.0 (10.4-75.6) h] cohorts, respectively (p = 0.93). Six (4.8%) and 13 (12.9%) patients developed UTI in the AVT and PVT groups, respectively (p = 0.03). Eleven (8.8%) and 12 (11.9%) patients developed UR in the AVT and PVT groups, respectively (p = 0.36). CONCLUSION: Our study comparing AVT versus PVT demonstrated no difference in time to discharge despite a 3.6 h reduction in time to void associated with AVT. AVT was associated with a 63% reduction in UTI, with no difference seen in UR rates across cohorts. Given the reduction in UTI and technical advantages, our data suggest that AVT should be considered as a recommended technique for void trial protocol. TRIAL REGISTRATION: NCT02886143 (clinicaltrials.gov).

Vape-Associated Pulmonary Injury (VAPI) Presenting With a "Miliary" Pattern on Imaging.

Electronic (E)-cigarette use or vaping is associated with pulmonary injury. Users can present with wide-ranging symptoms, varying degrees of pulmonary injury, and respiratory distress. Lung injury secondary to vaping is associated with a variety of patterns on pulmonary imaging. Typical radiographic findings are consistent with bilateral, basilar ground-glass opacities and or consolidation with septal thickening. We present a case of vape-associated pulmonary injury (VAPI) in a previously healthy adult who was found to have atypical radiographic findings. A 34-year-old male presented with a chief complaint of a two-week history of malaise, nausea, cough, and worsening shortness of breath. A chest CT scan without contrast revealed diffuse nodules in a miliary pattern. The patient reported a six-month history of tetrahydrocannabinol (THC) vape use. Bronchoscopy with cytologic analysis confirmed findings consistent with the VAPI. To our knowledge, this is the first report of a "miliary" pattern of infiltrates and nodules in a patient with VAPI. This pattern on CT imaging led to increased suspicion for other possible etiologies, including tuberculosis. Thus, moving forward, we believe that VAPI needs to be considered in the differential diagnosis if a patient presents with radiographic findings consistent with a miliary or diffuse micronodular pattern.

Sarcoidosis-associated acro-osteolysis.

Sarcoidosis is characterised by the formation of noncaseating granulomas classically affecting lungs, lymph nodes and skin. Osteoarticular involvement affects up to 15% of patients; however, acro-osteolysis, destruction involving distal phalanges of fingers and toes, associated with sarcoidosis, is extremely rare. A 44-year-old woman with a history of biopsy-proven sarcoidosis managed with prednisone and methotrexate presented with swelling and pain in the distal fingers of her right hand without skin manifestations. Radiographic imaging showed erosion of distal phalanges on second, third and fifth fingers and bone resorption in bilateral toes. A biopsy of the finger lesions showed noncaseating granulomas consistent with sarcoidosis. She was diagnosed with sarcoid acro-osteolysis and started on adalimumab with clinical and radiographic improvement. While most cases of osteoarticular sarcoidosis are asymptomatic and respond to standard immunosuppression, we present a case with progressive and refractory clinical course. This is the first reported case of sarcoid acro-osteolysis affecting the toes.

Spontaneous Tumor Lysis Syndrome in Blastoid-Variant Mantle Cell Lymphoma: Considerations for the General Internist.

Spontaneous tumor lysis syndrome (SPTLS) is a rare phenomenon that can manifest in rapidly proliferating hematological malignancies and solid tumors prior to initiating cytotoxic therapy. We encountered a patient who originally presented with diffuse lymphadenopathy, abdominal distention, and dyspnea, who had laboratory abnormalities suggestive of SPTLS. His peripheral flow cytometry and lymph node biopsy revealed blastoid-variant mantle cell lymphoma. Prior to initiating chemotherapy, acute kidney injury (AKI) and uric acid had improved with intravenous fluids and the initiation of allopurinol. However, after beginning chemotherapy, the patient developed a second AKI concerning for tumor lysis syndrome (TLS). He went on to have renal recovery and did not require renal replacement therapy. With the exception of case reports, there is limited evidence to guide general medicine clinicians who encounter cases of SPTLS. Expert-based guidelines are available to guide use of rasburicase, an uricase enzyme, before initiation of chemotherapy for certain malignancies when risk for TLS is considered high. Despite these guidelines, the role of rasburicase in preventing AKI remains controversial after inconclusive results in a meta-analysis. The causative relationship between uric acid and AKI in TLS is based on a mechanism of tubular obstruction. There are also mechanisms by which uric acid may cause AKI without tubular obstruction related to acute hyperuricemic nephropathy. Further characterization of the role of uric acid in causing AKI in patients without tubular obstruction may identify new mechanisms of injury and offer insight into new treatment strategies.

Acalculous cholecystitis with gallbladder necrosis in a patient presenting without abdominal pain.

An 83-year-old man with a history of chronic myelogenous leukaemia in remission maintained with bosutinib presented with new-onset fevers. He denied pain and had no other focal symptoms. Ultrasound imaging revealed mild gallbladder wall thickening. Non-contrasted CT revealed right upper quadrant inflammation of indeterminate source. The diagnosis of acalculous cholecystitis was made on the third day when a CT with oral contrast demonstrated a remarkably inflamed biliary tree. The gallbladder was surgically removed and found to be necrotic. The case highlights an unusual presentation for a well-known condition. Both ultrasound and CT have limited diagnostic sensitivity for acalculous cystitis. This case adds to existing literature to support development of acalculous cholecystitis in non-critically ill patients. Clinicians should maintain awareness of this condition among patients presenting to the hospital or clinic with abdominal pain. Careful discussion with radiology and surgery is indicated to guide diagnostic testing when initial imaging results are indeterminate.

Systemic Capillary Leak Syndrome Secondary to Coronavirus Disease 2019.

Systemic capillary leak syndrome is a rare disorder characterized by dysfunctional inflammatory response, endothelial dysfunction, and extravasation of fluid from the vascular space to the interstitial space leading to shock, hemoconcentration, hypoalbuminemia, and subsequent organ failure. The condition may be idiopathic or secondary to an underlying cause, which can include viral infections. Here we describe a patient with acute coronavirus disease 2019 (COVID-19) infection who presented with hemoconcentration, shock, and hypoalbuminemia. The patient subsequently developed rhabdomyolysis and compartment syndrome of all four extremities, requiring fasciotomies. This is the first reported case of systemic capillary leak syndrome associated with COVID-19 infection. This case adds to the evolving spectrum of inflammatory effects associated with this viral infection.

Anti-MDA-5 Dermatomyositis With Development of Drug-Mediated Necrolytic Skin Lesions.

A 59-year-old male presented with 1 month of progressive dyspnea, 30-lb weight loss, and skin changes on the digits of the hands. In the 4 weeks prior to admission, he was admitted and treated twice for pneumonia at another hospital and received intravenous (IV) vancomycin, ceftriaxone, and azithromycin for a total of 10 days. After admission, he underwent computed tomography imaging of chest, which revealed findings suggestive of interstitial lung disease but given the fact that infection was not ruled out, empiric antibiotics were initiated. The skin lesions on the fingers were felt to be consistent with Gottron's papules, and his overall constellation of findings were felt to be consistent with dermatomyositis (DM). Over the following 3 days, he developed diffuse, violaceous skin lesions, elevation of liver transaminases, and severe thrombocytopenia. The skin lesions progressed to epidermal necrosis. He developed erosions of the oral mucosa and scrotum. Before skin biopsy results were finalized, IV immunoglobulin and IV dexamethasone were started empirically for suspected DM and immune-mediated thrombocytopenia. His laboratory abnormalities normalized within a week. Biopsy results of the skin were consistent with Stevens-Johnson syndrome (SJS). Autoantibody test for anti-MDA5 were positive, confirming a diagnosis of anti-MDA5 associated DM. Subsequent development of SJS was likely due to antibiotic exposure in the preceding month. Simultaneous development of anti-MDA5 DM and SJS raises the question of a link between the 2 conditions. To our knowledge, this is the first reported association of these 2 conditions reported in the literature.

Unplanned 30-Day Readmission after Coronary Artery Bypass in Patients with Acute Myocardial Infarction.

BACKGROUND/PURPOSE: The Centers for Medicare and Medicaid services penalizes hospitals with higher than expected readmissions for coronary artery bypass graft surgery (CABG). Little information exists regarding outcomes in patients who sustain an acute myocardial infarction (MI) and undergo CABG as the primary revascularization strategy. Our goal was to determine the unplanned 30-day readmission rate in this high-risk population and predictors of readmission. MATERIALS/METHODS: An institutional database was queried to identify patients from 2011 to 2017 who were admitted with an acute MI and underwent CABG within 30 days. Chart review was performed to collect demographics, medical comorbidities and clinical information related to hospital course and readmission status. RESULTS: A total of 150 patients were included. The 30-day unplanned readmission rate was 23%, and the majority (80%) were non-cardiac related. Predictors of unplanned readmission included female sex (OR 2.61, 95% CI 1.042-6.549, p = 0.041), CABG performed <7 days following MI (OR 2.82, 95% CI 1.21-6.59, p = 0.017), and post-operative atrial fibrillation (OR 3.25, 95% CI 1.07-9.87, p = 0.038). Complications were identified in 32% of clinic visits in patients who did not require readmission. CONCLUSIONS: Patients who undergo CABG following MI are a high-risk population with nearly one-quarter readmitted within 30 days. Female sex, <7 days between the index MI and CABG, and post-operative atrial fibrillation are strong predictors for readmission. Early outpatient follow-up may be an effective intervention to reduce hospital readmissions by reassuring patients that non-cardiac symptoms are in line with anticipated post-operative pain and healing.

Combined zinc and vitamin B6 deficiency in a patient with diffuse red rash and angular cheilitis 6 years after Roux-en-Y gastric bypass.

A 39-year-old woman with a history of Roux-en-Y gastric bypass (RYGB) surgery and alcohol use presented with a confluent erythematous rash involving the perineum spreading outward to the abdomen, thighs and lower back. She had angular cheilitis and glossitis. The rash was painful and blistering in scattered areas. She was hypotensive and appeared to be in septic or hypovolemic shock at presentation. Serum levels of zinc and vitamin B6 were critically low and biopsy of her rash returned suggestive of a nutritional deficiency as its source. The rash slowly improved over the following 2 weeks with oral zinc and vitamin B6 replacement. The body rash resembled that of infants born with inherited defects in zinc transporters, referred to as acrodermatitis enteropathica (AE). This case may represent an acquired case of AE in the setting of prior RYGB.

Solitary ascending colon ulcer diagnosed as gastrointestinal CMV disease.

A 42-year-old woman with a history of cholangiocarcinoma on adjuvant chemotherapy with capecitabine presented with painless haematochezia. She was found to have an isolated twenty-five mm ulcer in the ascending colon. Biopsies of the ulceration demonstrated typical cytomegalovirus (CMV) inclusions and her peripheral blood CMV PCR was significantly elevated. This is an unusual case of a solitary proximal colon ulcer. Non-steroidal anti-inflammatory drugs, inflammatory bowel disease and malignancy, are the most frequent causes of isolated ulcers in the proximal colon. Gastrointestinal (GI) CMV disease most commonly causes CMV colitis and is considered rare outside of the transplant population and other severely immunosuppressed patient groups. Patients who have received chemotherapy may also be at risk for GI CMV disease. The diagnosis should be suspected in patients who present with haematochezia or watery diarrhoea within a broad window of time after receiving chemotherapy.

Effective uric acid reduction with probenecid and febuxostat in a patient with chronic kidney disease.

A 33-year-old male with poorly controlled chronic tophaceous gout and chronic kidney disease (CKD) with estimated glomerular filtration rate (GFR) of 37 cc/min. His uric acid was 11 mg/dL despite maximal dosing of febuxostat. He had previously failed pegloticase infusions as well. This patient had a reduction in his uric acid level to less than 6 mg/dL following addition of probenecid to his febuxostat regimen. Most guidelines recommend against utilisation of probenecid therapy in patients with GFR <50, but there is no obvious contraindication to its use, provided renal calculi do not develop. Our case illustrates the synergistic effect probenecid can add to maximal xanthine oxidase inhibitor therapy for patients with refractory hyperuricaemia in a patient with CKD stage IIIb. With the approval of a new uricosuric medication, lesinurad, probenecid may remain a suitable alternative for patients with financial limitations to achieve target uric acid levels.

Double origin of the posterior inferior cerebellar artery: association with intracranial aneurysm on catheter angiography.

OBJECTIVE: Double origin of the posterior inferior cerebellar artery (PICA) is a congenital anomaly in which the PICA forms from two separate vessels arising from the vertebral artery. The prevalence of double origin of the PICA on catheter angiography is unknown because only four case reports have been published. Because some congenital intracranial vascular oddities are associated with an elevated incidence of aneurysm formation, we sought to determine the association between intracranial aneurysm and double origin of the PICA and to measure the prevalence of double origin of the PICA on catheter angiography. MATERIALS AND METHODS: A retrospective review was done over a 27-month period to identify patients with double origin of the PICA. Patients were excluded if both PICAs were not adequately visualized on catheter angiography. The cohort was then divided into two groups consisting of patients with and those without intracranial aneurysm. RESULTS: A total of 207 patients (101 males, 106 females) met the inclusion criteria. One or more cerebral aneurysms were found in 35.3% and double origin of the PICA in 1.45% of the patients. Double origin of the PICA was present in 4.1% of the patients with an aneurysm, and none of the patients without an aneurysm had double origin of the PICA (p = 0.043). A majority of the seven known cases of double origin of the PICA described by angiography in the peer-reviewed literature have associated intracranial aneurysm disease. CONCLUSION: Our data show that double origin of the PICA is seen in 4.1% of patients with intracranial aneurysm and on 1.45% of catheter angiograms. Double origin of the PICA has an increased association with intracranial aneurysmal disease and may represent a risk factor for subsequent development of intracranial aneurysm.

Relations among renal function, risk of sudden cardiac death, and benefit of the implanted cardiac defibrillator in patients with ischemic left ventricular dysfunction.

Implanted cardioverter defibrillator therapy has been shown to be associated with a significant reduction in the risk of sudden cardiac death (SCD) in patients with ischemic left ventricular dysfunction. However, data on the relation between renal function and SCD in this population are limited, and the effect of renal dysfunction on the implanted cardioverter defibrillator benefit has not been determined. We performed a retrospective analysis of the outcome associated with renal dysfunction, as determined by the estimated glomerular filtration rate (eGFR), in patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial-II. Multivariate analysis in conventionally treated patients showed that for each 10-U reduction in eGFR, the risk of all-cause mortality and SCD increased by 16% (p = 0.005) and 17% (p = 0.03), respectively. Defibrillator therapy was associated with a survival benefit in each eGFR category of > or = 35 ml/min/1.73 m2 (overall risk reduction for all-cause mortality 32%, p = 0.01 and for SCD 66%, p < 0.001). However, no implanted cardioverter defibrillator benefit was shown among patients with an eGFR < 35 ml/min/1.73 m2 (all-cause mortality hazard ratio 1.09, p = 0.84; SCD hazard ratio 0.95, p = 0.95). In conclusion, in patients with high-risk cardiac disease enrolled in the Multicenter Automatic Defibrillator Implantation Trial-II, a significant increase was found in the risk of SCD with declining renal function. Defibrillator therapy was associated with a significant survival benefit among the study patients with mild to moderate or no renal disease, but no benefit was shown among patients with more advanced renal dysfunction.

Advances in clinical 3-tesla neuroimaging.

Three-tesla magnetic resonance (MR) imaging represents one of the major forefronts of diagnostic neuroradiology today. Heat deposition, changes in T1 relaxation rates, susceptibility differences, and greater inherent sensitivity to motion artifacts represent challenges to clinical implementation. However, the situation appears remarkably similar to that encountered almost 15 years ago as the field of MR transitioned from 0.3-0.6 T to 1.5 T units. Current-generation 3 T MR units already provide markedly improved imaging of the brain as compared with 1.5 T units. This is illustrated in the article that follows, together with many of the advanced techniques now available and in the pipeline to deal with the difficulties inherent at 3 T.

Long-term clinical course of patients after termination of ventricular tachyarrhythmia by an implanted defibrillator.

BACKGROUND: The implanted cardioverter defibrillator (ICD) improves survival in high-risk cardiac patients. This analysis from the MADIT-II trial database examines the long-term clinical course and subsequent mortality risk of patients after termination of life-threatening ventricular tachyarrhythmias by an ICD. METHODS AND RESULTS: Life-table survival analysis was performed, and proportional hazards regression analysis was used to evaluate the contribution of baseline clinical factors and time-dependent defibrillator therapy to mortality during long-term follow-up. Of 720 patients with an ICD (average follow-up 21 months), 169 patients received 701 antiarrhythmic device therapies for ventricular tachyarrhythmias. Few baseline characteristics distinguished patients who received appropriate ICD therapy for their first ventricular tachyarrhythmic episode. The probability of survival for at least 1 year after first therapy for ventricular tachycardia (VT) or ventricular fibrillation (VF) was 80%. The hazard ratios for the risk of death due to any cause in those who survived appropriate therapy for termination of VT and VF were 3.4 (P<0.001) and 3.3 (P=0.01), respectively, compared with those who survived without receiving ICD therapy, with a high frequency of heart failure and late nonsudden cardiac death after first successful ICD therapy for VF. CONCLUSIONS: Successful appropriate therapy by an ICD for VT or VF is associated with 80% survival at 1 year after arrhythmia termination. These patients are at increased risk for heart failure and nonsudden cardiac death after device termination of VT or VF and should receive special attention for the prevention and management of progressive left ventricular dysfunction during long-term follow-up.

Analysis of mortality events in the Multicenter Automatic Defibrillator Implantation Trial (MADIT-II).

OBJECTIVES: The purpose of this study was to determine the efficacy of implantable cardiac defibrillator (ICD) therapy in preventing sudden cardiac death (SCD) in post-infarction patients with advanced left ventricular (LV) dysfunction. BACKGROUND: The Multicenter Automatic Defibrillator Implantation Trial (MADIT-II) randomized 1,232 post-infarction patients with an ejection fraction of < or =30% to ICD or conventional therapy. In the ICD group, there was a 31% decrease in the risk of total mortality. However, a better understanding of the mode of death is desirable in order to refine therapeutic interventions in high-risk populations. METHODS: We evaluated the 202 deaths, using a variation of the Hinkle-Thaler classification system as well as a clinical classification system to determine the incidence of SCD and the incidence of cardiac death due to progressive LV failure. RESULTS: The SCD rates were 10.0% in the conventional group and 3.8% in the ICD group (p < 0.01). The hazard ratio for the risk of SCD in the ICD group compared with the conventional therapy group was 0.33 (95% confidence interval 0.20 to 0.53, p < 0.0001). The ICD had no meaningful effect on non-sudden death (p = 0.32). The effect of defibrillator therapy in reducing SCD was similar in subgroup analyses stratified according to relevant baseline characteristics. CONCLUSIONS: The decrease in mortality with ICD therapy in MADIT-II is entirely due to a reduction in SCD, with similar reductions in SCD in a spectrum of subgroups stratified according to relevant baseline characteristics.

Atherosclerotic risk genotypes and recurrent coronary events after myocardial infarction.

The association of a group of prespecified atherosclerotic risk genotypes with recurrent coronary events (coronary-related death, nonfatal myocardial infarction, or unstable angina) was investigated in a cohort of 1,008 patients after infarction during an average follow-up of 28 months. We used a carrier-ship approach with time-dependent survivorship analysis to evaluate the average risk of each carried genotype. Contrary to expectation, the hazard ratio for recurrent coronary events per carried versus noncarried genotype was 0.89 (95% confidence interval 0.80 to 0.99, p = 0.03) after adjustment for relevant genetic, clinical, and environmental covariates. This hazard ratio, derived from the 7 prespecified genotypes, indicated an average 11% reduction in the risk of recurrent coronary events per carried versus noncarried genotype. At 1 year after hospital discharge, the cumulative probability of recurrent coronary events was 26% in those who carried < or =1, 20% for those with 2 to 4, and 13% for those with > or =5 of these genotypes (p = 0.02). This unexpected risk reversal is a likely consequence of changes in the mix of risk factors in pre- and postinfarction populations. In conclusion, this under appreciated, population-based, risk-reversal phenomenon may explain the inconsistent associations of genetic risk factors with outcome events in previous reports involving coronary populations with different risk attributes.