Underutilization of Peptic Ulcer Disease Prophylaxis Among Elderly Users of Antiplatelets and Anticoagulants.

INTRODUCTION: Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting. METHODS: We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. RESULTS: A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. CONCLUSION: PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

ULK2 is essential for degradation of ubiquitinated protein aggregates and homeostasis in skeletal muscle.

Basal protein turnover, which largely relies on the degradation of ubiquitinated substrates, is instrumental for maintenance of muscle mass and function. However, the regulation of ubiquitinated protein degradation in healthy, nonatrophying skeletal muscle is still evolving, and potential tissue-specific modulators remain unknown. Using an unbiased expression analysis of 34 putative autophagy genes across mouse tissues, we identified unc-51 like autophagy activating kinase (Ulk)2, a homolog of the yeast autophagy related protein 1, as particularly enriched in skeletal muscle. Subsequent experiments revealed accumulations of insoluble ubiquitinated protein aggregates associated with the adaptors sequestosome 1 (SQSTM1, also known as p62) and next to breast cancer type 1 susceptibility protein gene 1 protein (NBR1) in adult muscles with ULK2 deficiency. ULK2 deficiency also led to impaired muscle force and caused myofiber atrophy and degeneration. These features were not observed in muscles with deficiency of the ULK2 paralog, ULK1. Furthermore, short-term ULK2 deficiency did not impair autophagy initiation, autophagosome to lysosome fusion, or protease activities of the lysosome and proteasome. Altogether, our results indicate that skeletal muscle ULK2 has a unique role in basal selective protein degradation by stimulating the recognition and proteolytic sequestration of insoluble ubiquitinated protein aggregates associated with p62 and NBR1. These findings have potential implications for conditions of poor protein homeostasis in muscles as observed in several myopathies and aging.-Fuqua, J. D., Mere, C. P., Kronemberger, A., Blomme, J., Bae, D., Turner, K. D., Harris, M. P., Scudese, E., Edwards, M., Ebert, S. M., de Sousa, L. G. O., Bodine, S. C., Yang, L., Adams, C. M., Lira, V. A. ULK2 is essential for degradation of ubiquitinated protein aggregates and homeostasis in skeletal muscle.

Positive Depression Screening at the First Prenatal Visit in a Low-Income Primarily Black Population.

This study documents prevalence of positive depression screens at the first prenatal visit in an urban, low-income, and primarily Black population as part of initiatives to strengthen mental health services in a region with high rates of race disparities in infant and maternal mortality. We conducted a cross-sectional chart review of 500 patients, collecting demographics, medical histories, and scores of the Edinburgh Postnatal Depression Scale (EPDS), the instrument recommended for use during pregnancy by national United States organizations. Of those with a completed EPDS (n=414), 32% screened positive (n=131). These women were more likely to have smoked (p=.02), used illicit drugs (p=.01), or had depression (p<.0001), anxiety (p=.0004), bipolar disorder (p=.02), or postpartum depression for the subgroup with prior pregnancies (p<.0001). A high percentage of patients had positive EPDS screens, highlighting the need for better integration of mental health services into prenatal care for vulnerable populations.

Cervical Cancer Screening in Inflammatory Bowel Disease: Who Should Be Screening?

BACKGROUND: Immunosuppressed women with inflammatory bowel disease (IBD) are at elevated risk of cervical cancer yet have lower screening rates. The objective of this study was to assess the familiarity with cervical cancer screening recommendations, and the perceived responsibility for implementing screening among three physician groups involved in the clinical care of women with IBD: primary care physicians (PCP), gastroenterologists (GI) and gynecologists (GYN). METHODS: We anonymously surveyed a sample of 117 PCP, 52 GYN and 35 GI physicians affiliated with Saint Louis University, Saint Louis, MO, USA, from April 2018 to January 2019. The physicians completed a questionnaire adressing essential aspects of cervical cancer screening such as screening age, screening frequency, human papillomavirus (HPV) vaccination, comfort level in performing Papanicolaou (Pap) smears, perception of physician responsibility in terms of which physicians should perform Pap smears. RESULTS: A total of 2.6% of PCPs, 37% of GIs and 29% of GYNs reported familiarity with cervical cancer screening recommendations. In addition, PCP and GI had no definite opinions regarding which physicians should be in charge of cervical cancer screening and performing Pap smears. However, 94% of GYNs felt that they should be in charge of cervical cancer screening and performing Pap smears. CONCLUSIONS: An apparent lack of familiarity exists among all three physician groups regarding cervical cancer screening recommendations in immunosuppressed patients with IBD. Similarly, there is no consensus regarding which specialty should be responsible for cervical cancer screening in this patient population.

Sporadic Porphyria Cutanea Tarda as the Initial Manifestation of Hereditary Hemochromatosis.

Porphyria cutanea tarda (PCT) is a skin disorder characterized by abnormal heme synthesis. We present a 45-year-old man with intermittent skin lesions recurring annually for years. Skin biopsy and measurement of serum heme precursors confirmed a diagnosis of PCT. He had persistently elevated alanine and aspartate transferase. He was referred to hematology and had genetic testing with iron studies which also revealed hereditary hemochromatosis (HH). Therapeutic phlebotomy was initiated, which led to resolution of iron overload and skin lesions. We highlight the associated conditions of PCT and HH, their common therapy of phlebotomy, and initial manifestations of HH.