Boerhaave Syndrome Mimicking Acute Coronary Syndrome.

Boerhaave syndrome, an esophageal perforation due to increased intraesophageal pressure, may mimic other cardiovascular conditions including acute coronary syndrome. In this report, we present a case of a 63-year-old man who presented with chest pain and ischemic electrocardiogram abnormalities, prompting an initial diagnosis of ST elevation myocardial infarction. After coronary stenting, the patient continued to have chest pain, ST segment elevations, and newly elevated cardiac enzymes. A computed tomography scan showed esophageal perforation, requiring endoscopic stenting. This case underscores the diagnostic and therapeutic challenges of Boerhaave syndrome and the importance of considering this condition in adults with chest pain and ischemic electrocardiogram changes.

Physicians' perception on using a multi-cancer early detection blood test to reduce disparities in cancer screening.

 INTRODUCTION: Cancer causes significant morbidity and mortality in the United States. It is the second most common cause of death in the United States, after heart disease. African Americans are disproportionately affected by malignancy, with overall higher death rates compared to other racial and ethnic groups. Screening tests can identify early stage malignancy allowing for timely intervention. However, African Americans less frequently undergo cancer screening. Advancement in genomic technology has led to the identification of signals for cancer in the blood. This has resulted in the development of multi-cancer early detection (MCED) tests which evaluate for circulating cell-free DNA (cfDNA). This study evaluated physicians' perception of the use of a multi-cancer early detection test (MCED). METHODS: An anonymous, 29 question survey was administered to African American / Black physicians and medical students. Survey participants were identified through the National Medical Association and other professional organizations that included primarily African American physicians. Surveys were excluded from analysis if respondent was non-African American / Black or was not a physician or medical student. The survey collected physician demographics, percentage of African American / Black patients in their practice, patient barriers to screening, potential use of MCED tests and factors influencing decision to recommend testing. Descriptive statistics were generated. Additional analysis was performed using Chi-Square with statistical significance set at p-value <0.05. The survey was pilot tested for reliability and validity. RESULTS: 1196 (681 female, 515 male) physicians and medical students completed the survey. 95.8 % were physicians who were or had been in clinical practice. Fifty-three percent of physicians reported that >40 % of their patients were African American / Black. Barriers to cancer screening included lack of understanding of the importance (33.8 %), lack of or limited insurance coverage (23.5 %), socioeconomic factors unrelated to insurance coverage (16.2 %), fear of cancer (8.8 %), history of racism and bias in the health care system (7.4 %) with 8.8 % reporting 'other' and 1.5 % reporting no perceived barriers. There was a significant difference (p<0.03) in the rate that physicians' perceived racism and bias in the health care system as barrier for cancer screening in African American / Black patients when compared to other patients. Most physicians and medical students indicated that a MCED test would benefit all patients (86.8 %), would encourage further cancer screening tests (83.8 %), and would be beneficial for minority and under-represented patients regardless of socioeconomics or health care access (83.8 %). Seventy-five percent of survey respondents indicated that a MCED test would be beneficial in promoting further cancer screening and early detection in African American / Black patients. Factors that would impact the ordering of an MCED test included scientific evidence and test validity (63.2 %), efficiency, accessibility, ease of ordering and ease of receiving results (11.8 %), insurance coverage (13.2 %) and 'other factors' (11.8 %). DISCUSSION: This is one of the largest surveys to assess physicians' perceptions about MCED testing and is the first study to evaluate the perspectives of African American physicians. It offers insight about physician acceptance and potential incorporation of MCED into clinical practice. It is important that a multifaceted approach is employed to improve cancer outcomes and reduce disparities in survival. MCED tests, a relatively new advancement in genomic technology, have the potential to be an important component in cancer screening strategies.

Distal Ileitis Caused by Diffuse Large B-Cell Lymphoma in an Elderly Patient From Honduras.

Primary gastrointestinal non-Hodgkin lymphoma, while rare, most often presents as diffuse large B-cell lymphoma located in the stomach or ileocecal region. Presenting symptoms include abdominal pain, gastrointestinal bleeding, weight loss, or obstructive symptoms. Imaging can reveal ileitis or obstruction. We report a case of a man from Honduras with latent tuberculosis and chronic hepatitis B who presented with features of Crohn's disease through clinical, radiologic, and endoscopic findings but was ultimately diagnosed with diffuse large B-cell lymphoma by histology. We emphasize the importance of maintaining a broad differential for ileitis and the importance of histologic sampling when evaluating ileitis.

Delay in prior authorization of biologic therapy: Another possible cause of healthcare disparity in IBD patients.

BACKGROUND: Biologics, a mainstay in inflammatory bowel disease (IBD) treatment, typically require prior authorization from insurance companies. Multiple studies show that African Americans are less likely to be prescribed biologics. The prior authorization process may perpetuate disparities in healthcare. This study evaluated the approval time for biologics in IBD. METHODS: A chart review of IBD patients seen in a university gastroenterology clinic over 5 years was performed. Patient gender, race, IBD subtype, biologic use, and insurance type were recorded. Insurance type was classified as private or public (Medicaid or Medicare). Biologic agents evaluated included infliximab, adalimumab, vedolizumab and ustekinumab. Length of time to approval (TTA) and length of time to first infusion or administration (TFI) were recorded. Analysis was performed using t-testing, Fisher's exact testing, and ANOVA with significance set at p<0.05. The study was IRB approved. RESULTS: 458 charts were analyzed. 66 patients were being treated with a biologic. 42 had private insurance, 16 Medicaid and 8 Medicare. 37 patients had ulcerative colitis, 27 Crohn's disease, and 2 indeterminate colitis. There were 38 men and 28 women. 32 patients were white, 26 African American, 1 Asian, 5 other, and 2 declined identification. Average TTA was 30.5 days (range 1-145) and average TFI was 45.3 days (range 2-166). African Americans were more often on public insurance compared to whites (p=0.0001). Crohn's disease compared to ulcerative colitis patients were more often on public insurance (p=0.017). Significantly more private compared to public insurance patients were on infliximab (p=0.001). Medicaid and Medicare patients had significantly longer mean TTAs than private insurance patients (49.1 and 52.7 vs 19.4 days, p=0.007). African Americans had significantly longer mean TTA compared to whites (45.9 vs 24.8 days, p=0.044). Crohn's disease compared to ulcerative colitis patients had significantly longer mean TTA (39.7 vs 21.8 days, p=0.050). DISCUSSION: This study shows that prior authorization for biologic therapy was longer for African Americans. Patients on public insurance also tend to have a longer TTA, and more African Americans were on public insurance compared to White patients in this study which may explain the difference in biologic access for African Americans.

Engaging the community on colorectal cancer screening: Additional factors identified by African Americans as potential barriers during focus groups.

OBJECTIVE: African-Americans have the highest rate of colorectal cancer deaths. Adherence to colorectal cancer screening guidelines can improve outcomes. The objective of this study was to evaluate physician trust and barriers to screening utilizing a unique bi-directional learning focus group involving African-American adults and health care learners. METHODS: A focus group of African-American adults from a community church and university health care learners was conducted to identify colon cancer screening barriers. Health care learners were medical students, resident physicians and gastroenterology fellows. Pre-focus group surveys, including the Wake Forest Physician Trust Scale (WFPTS) and a colon cancer screening knowledge survey, were administered. Audio recording of the focus group was transcribed with subsequent thematic analysis. A post-focus group survey evaluated the colorectal cancer screening barriers identified during the focus group. Analysis of pre- and post- focus group surveys was performed using Fisher Exact test with significance set at p<0.05. RESULTS: The focus group consisted of 18 members (7 African-American community members, 11 non-African American health care learners). WFPTS revealed that 83% (86% community members, 82% health care learners; p = 1.0) strongly agree / agree that their physician would advocate for their health. 77% (86% community members, 73% health care learners; p = 1.0) strongly agree / agree that they trusted their physician. 100% recognized that colon cancer screening is recommended. The focus group identified lack of awareness (81%), colonoscopy preparation (81%), trust in physician (60%), lack of insurance coverage (56%), transportation (56%), colonoscopy wait time (50%), insufficient physician discussion (50%) and fear of procedure or cancer (35%) as screening barriers. Post-focus group surveys revealed that community members more frequently identified racial disparity in health care (p = 0.0474), physician respect toward patients (p = 0.0128) and insufficient physician discussion (p = 0.0006) as screening barriers. CONCLUSIONS: Focus group discussion identified multiple barriers for colorectal cancer screening. Notably, differences in the perceptions of African-American community members and non-African-American health care learners about racial disparity in health care, physician respect toward patients and insufficient physician discussion were revealed. The integration of bi-directional focus group learning can be considered as a potential strategy to assist in the development of focused screening interventions.

A Common Infection in a Highly Atypical Patient: Hematochezia From a Cytomegalovirus Colonic Ulcer in a Young and Healthy Immunocompetent Patient.

Gastrointestinal (GI) cytomegalovirus (CMV) infections are far more common in immunocompromised as opposed to immunocompetent patients. Immunocompetent patients who develop GI tract CMV infections are typically older with medical comorbidities. As such, descriptions of GI CMV infections in younger immunocompetent patients are lacking. Here, we present a case of a GI CMV infection in a young and healthy immunocompetent patient. A 41-year-old male with hyperlipidemia and hypothyroidism presented with painless, intermittent hematochezia. He denied changes in bowel habits or appetite, abdominal pain, fevers, chills, fatigue, or weight loss. His history was pertinent for insertive and receptive intercourse with one male partner. Medications were emtricitabine/tenofovir for pre-exposure prophylaxis, levothyroxine, and atorvastatin. A colonoscopy revealed a cecal ulcer surrounded by nodular-appearing mucosa that felt firm and friable when biopsied. The remaining colon and terminal ileum were normal. There was no diverticulosis or hemorrhoids. Pathology was positive for CMV. A subsequent serological evaluation revealed a normal complete blood count and comprehensive metabolic panel. Tests for human immunodeficiency virus, syphilis, viral hepatitis, chlamydia, and gonorrhea were negative. He was treated with valganciclovir 900 mg twice daily for 21 days. A subsequent test for CMV deoxyribonucleic acid polymerase chain was negative. Hematochezia resolved. A repeat colonoscopy revealed normal mucosa in the cecum. GI CMV infections in immunocompetent patients are rare and typically occur in older patients with medical comorbidities. Further, such case reports are needed to inform clinicians about risk factors and the presentation of GI CMV infections in young healthy immunocompetent patients.

Icteric Leptospirosis Leading to Multiorgan Failure and Concomitant Pancreatitis.

Leptospirosis is a zoonotic disease caused by the spirochete Leptospira interrogans with a majority of cases occurring in the tropics. Diagnosing leptospirosis is challenging due to the variable and non-specific clinical presentation. While severe leptospirosis may present with renal failure, liver failure, and pulmonary hemorrhage, there are few described cases of renal failure and liver failure accompanied by pancreatitis and dysrhythmias, particularly in temperate climates. We present a case of severe leptospirosis presenting with bilateral calf pain, acute oliguric renal failure, acute liver failure, dysrhythmias, and pancreatitis. Clinicians must consider this diagnosis in temperate climates and consider testing and empirically treating for leptospirosis in patients with similar symptom constellations, vague symptoms, and lab abnormalities of unknown etiology.

Collagenous Gastritis: An Atypical Presentation of a Rare Disease.

Collagenous gastritis is a rare inflammatory condition of unknown etiology defined histologically by subepithelial deposition of collagen bands ≥ 10 µm in the lamina propria. Adults typically present with diarrhea, often attributed to concurrent collagenous sprue or collagenous colitis. Children more commonly present with abdominal pain and anemia, with inflammation typically limited to the stomach. Herein, we present a case of collagenous gastritis in a 38-year-old female with a history of iron deficiency and hypothalamic amenorrhea who presented with a one-year history of microcytic anemia. Celiac disease panel, Helicobacter pylori testing, and anti-parietal cell and intrinsic factor antibodies were negative. Esophagogastroduodenoscopy revealed diffusely erythematous and nodular gastric mucosa in the antrum and pylorus. Biopsy from the gastric body showed complete loss of oxyntic glands and deposition of a thick band of collagen under the surface epithelium infiltrated by a few eosinophils, consistent with collagenous gastritis with severe atrophy. She was treated with omeprazole 40 mg daily for six weeks and iron supplementation. Our patient's symptoms and endoscopic findings are consistent with previously described pediatric, but not adult, cases of collagenous gastritis, yielding insight into the variable clinical presentation of this rare disease.

Disparities in utilization of robotic surgery for colon cancer: an evaluation of the U.S. National Cancer Database.

Despite the benefits of minimally invasive surgery for colorectal procedures, significant disparities in access to these techniques remain. While these gaps have been well-documented for laparoscopy, few studies have evaluated inequalities in access to robotic surgery. We analyze whether disparities exist in the use of robotic surgery in the management of colon cancer. The U.S. National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma who underwent resection with the robotic platform (2010-2016). Demographic, clinicopathologic, and treatment facility-related variables were analyzed with respect to preferential utilization of robotic surgery with multivariable logistic regression. Patients with metastatic disease, missing or incomplete surgical information, and those who underwent local tumor excision were excluded. 74,984 patients were identified, 3001 (4%) of whom underwent robotic surgery. In multivariable analysis, patients who were older, Black, or were living in an urban area had decreased odds of receiving robotic surgery compared with open or laparoscopic surgery. Patients who were privately insured or living in areas with higher education had increased odds of receiving robotic surgery. Robotic surgery was also preferentially associated with lower clinical stage, more recent year of diagnosis, and hospitals with higher procedural volume. As advantages of the robotic platform are becoming better understood, use of this approach is increasing in popularity for treatment of non-metastatic colon cancer. Despite this, significant disparities exist with respect to patient demographics and socioeconomic factors, and access may only be limited to certain types of hospitals. Further studies are needed to define why these inequalities exist.

Better clinical outcomes in hospitalized COVID-19 minority patients with accompanying gastrointestinal symptoms.

BACKGROUND AND AIMS: The novel coronavirus (SARS-CoV-2) is highly contagious pathogen that primarily causes respiratory illnesses. Howerver, multiple gastrointestinal (GI) symptoms have been reported in Coronavirus Disease of 2019 (COVID-19). We conducted a retrospective cohort study of inpatients with COVID-19 at the George Washington University Hospital (GWUH) to assess the prevalence of GI symptoms and their association with clinical outcomes. METHODS: We reviewed the charts of 401 adults admitted to GWUH with positive SARS-CoV-2 tests from February 24 to May 21, 2020, ultimately including 382 inpatients. RESULTS: 87% of our cohort was African American or Latinx. 59% of patients reported at least one GI symptom, with diarrhea being the most common (29%). Patients with GI symptoms were slightly younger (58 +/- 15.8 vs. 65 +/- 16.9, p = 0.0005), have higher body mass index (31.5 +/- Standard Deviation of 8.7 vs. 28 +/- 8.2, p = 0.0001), and more likely to be Latinx (34 vs. 27, p = 0.01). Patients who presented with abdominal pain, nausea, vomiting, or diarrhea had significantly lower rates of death during hospitalization compared to those who did not present those symptoms (Odds Ratio 0.48, 95% Confidence Interval 0.28-0.8, p = 0.004). CONCLUSIONS: Our study suggests that GI symptoms portend a less-severe clinical course of COVID-19 which may reflect a different disease phenotype and lower overall immune response. Additional research should focus on more robust symptom reporting and longer follow-up.