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.

Association of CDH1 Germline Variants and Colon Polyp Phenotypes in Patients with Hereditary Diffuse Gastric Cancer.

Background and Aims: Germline CDH1 variants resulting in E-cadherin loss of function result in an increased risk of diffuse type gastric cancer and lobular type breast cancer. However, the risk of developing other epithelial neoplasms, specifically colorectal cancer, is unknown. Methods: Patients enrolled in a prospective natural history study of hereditary gastric cancer who underwent at least one colonoscopy were evaluated. Results: Out of 300 patients with CDH1 pathogenic or likely pathogenic variants, 85 underwent colonoscopy. More than half of patients (56%, 48/85) had at least one colorectal polyp. Most of those patients (83%, 40/48) had at least one precancerous polyp (adenoma or sessile serrated lesion). More than half (56%) of patients younger than age 45 had a colorectal polyp. Of those with polyps, the most frequent CDH1 variant type was canonical splice site (27%, 13/48) followed by nonsense (21%, 10/48). There was no association between CDH1 variant type and increased likelihood of colorectal polyps. Conclusions: In summary, a majority of CDH1 variant carriers who underwent colonoscopy had colorectal polyps detected, and most subjects were less than 45 years old. This study of colorectal cancer risk based on the prevalence of colorectal polyps in the CDH1 population requires further investigation to appropriately counsel patients on colorectal cancer screening. Clinical trial registry website: https://clinicaltrials.gov/. Clinical trial number: NCT03030404.

Social Media and Research Publication Activity During Early Stages of the COVID-19 Pandemic: Longitudinal Trend Analysis.

BACKGROUND: The COVID-19 pandemic has highlighted the importance of rapid dissemination of scientific and medical discoveries. Current platforms available for the distribution of scientific and clinical research data and information include preprint repositories and traditional peer-reviewed journals. In recent times, social media has emerged as a helpful platform to share scientific and medical discoveries. OBJECTIVE: This study aimed to comparatively analyze activity on social media (specifically, Twitter) and that related to publications in the form of preprint and peer-reviewed journal articles in the context of COVID-19 and gastroenterology during the early stages of the COVID-19 pandemic. METHODS: COVID-19-related data from Twitter (tweets and user data) and articles published in preprint servers (bioRxiv and medRxiv) as well as in the PubMed database were collected and analyzed during the first 6 months of the pandemic, from December 2019 through May 2020. Global and regional geographic and gastrointestinal organ-specific social media trends were compared to preprint and publication activity. Any relationship between Twitter activity and preprint articles published and that between Twitter activity and PubMed articles published overall, by organ system, and by geographic location were identified using Spearman's rank-order correlation. RESULTS: Over the 6-month period, 73,079 tweets from 44,609 users, 7164 journal publications, and 4702 preprint publications were retrieved. Twitter activity (ie, number of tweets) peaked in March 2020, whereas preprint and publication activity (ie, number of articles published) peaked in April 2020. Overall, strong correlations were identified between trends in Twitter activity and preprint and publication activity (P<.001 for both). COVID-19 data across the three platforms mainly concentrated on pulmonology or critical care, but when analyzing the field of gastroenterology specifically, most tweets pertained to pancreatology, most publications focused on hepatology, and most preprints covered hepatology and luminal gastroenterology. Furthermore, there were significant positive associations between trends in Twitter and publication activity for all gastroenterology topics (luminal gastroenterology: P=.009; hepatology and inflammatory bowel disease: P=.006; gastrointestinal endoscopy: P=.007), except pancreatology (P=.20), suggesting that Twitter activity did not correlate with publication activity for this topic. Finally, Twitter activity was the highest in the United States (7331 tweets), whereas PubMed activity was the highest in China (1768 publications). CONCLUSIONS: The COVID-19 pandemic has highlighted the potential of social media as a vehicle for disseminating scientific information during a public health crisis. Sharing and spreading information on COVID-19 in a timely manner during the pandemic has been paramount; this was achieved at a much faster pace on social media, particularly on Twitter. Future investigation could demonstrate how social media can be used to augment and promote scholarly activity, especially as the world begins to increasingly rely on digital or virtual platforms. Scientists and clinicians should consider the use of social media in augmenting public awareness regarding their scholarly pursuits.

Evaluation of confocal laser endomicroscopy for detection of occult gastric carcinoma in CDH1 variant carriers.

BACKGROUND: Hereditary diffuse gastric cancer syndrome, attributed to inactivating germline CDH1 variants, is associated with an elevated lifetime risk of gastric cancer. We sought to evaluate cancer detection using probe-based confocal laser endomicroscopy (pCLE) during endoscopic surveillance. METHODS: A prospective, single-institution study was conducted in asymptomatic adults with pathogenic or likely pathogenic (P/LP) CDH1 variants. Subjects received endoscopic gastric surveillance using pCLE in conjunction with the Cambridge method (CM). Abnormalities visualized by pCLE were biopsied, followed by non-targeted mucosal biopsies according to the CM. Primary endpoint was to determine pCLE sensitivity for detection of occult SRC carcinoma compared to CM. RESULTS: Thirty-six patients with P/LP CDH1 variants underwent endoscopy using pCLE and CM. Majority were female (75%) with median age 47 years. Targeted biopsies of focal abnormalities on WLE were negative for carcinoma. Overall, 19.4% (7/36) patients had SRC detected on ≥1 biopsy. Non-targeted CM biopsies revealed SRC in 11.1% (4/36), whereas pCLE revealed SRC in 16.7% (6/36). Fifteen patients underwent total gastrectomy; all 15 explants contained occult carcinoma. In those 15 patients, the false-negative SRC detection rates for pCLE and CM were 67% and 87%, respectively. CONCLUSIONS: Confocal endomicroscopy alone has low sensitivity for occult cancer detection in CDH1 variant carriers, although it appeared no worse than the current recommended method and required fewer biopsies per patient. A more reliable endoscopic surveillance is needed as a viable alternative to surgery in this high-risk population (ClinicalTrials.gov, Number: NCT03648879).

COVID-19: An analysis of social media and research publication activity during the early stages of the pandemic.

Objectives: The COVID-19 pandemic has highlighted the importance of rapid dissemination of scientific and medical discovery. Social media (SoMe) has become an invaluable platform in science and medicine. This study analyzed activity of SoMe (Twitter), preprints, and publications related to COVID-19 and gastroenterology (GI) during the COVID-19 pandemic. Methods: Data from Twitter, preprint servers and PubMed was collected and analyzed from December 2019 through May 2020. Global and regional geographic and gastrointestinal organ specific social media trends were compared to preprint and publication activity; any associations were identified. Results: Over the 6-month period, there were 73,079 tweets from 44,609 users, 7,164 publications, and 4,702 preprints. Twitter activity peaked during March while preprints and publications peaked in April 2020. Strong correlations were identified between Twitter and both preprints and publications activity (p<0.001 for both). While COVID-19 data across the 3 platforms concentrated on pulmonology/critical care, the majority of GI tweets pertained to pancreatology, most publications focused on hepatology, and most preprints covered hepatology and luminal GI (LGI). There were significant associations between Twitter activity and research for all GI subfields (p=0.009 for LGI, p=0.006 for hepatology and IBD, p=0.007 for endoscopy), except pancreatology (p=0.2). Twitter activity was highest in the US (7,331 tweets) whereas PubMed activity was highest in China (1,768 publications). Conclusions: The COVID-19 pandemic has highlighted the utility of SoMe as a vehicle for disseminating scientific information during a public health crisis. Scientists and clinicians should consider the use of SoMe in augmenting public awareness of their scholarly pursuits.

Twitter As a Noninvasive Bio-Marker for Trends in Liver Disease.

With the success of hepatitis C virus (HCV) direct-acting antiviral therapies, there has been a shift in research focus to the other major chronic liver diseases (CLDs). The use of social media, specifically Twitter, has become a popular platform for understanding public health trends and for performing health care research. To evaluate this, we studied the areas of public interest and social media trends of the following three major CLDs: hepatitis B virus (HBV), HCV, and nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH). Twitter activity data from January 1, 2013, through January 1, 2019, for HBV, HCV, and NAFLD/NASH were collected using the social media analytic tool Symplur Signals (Symplur LLC) software. Content and regression analyses were performed to understand and predict Twitter activity for each of the CLDs. Over the study period, there were 810,980 tweets generating 4,452,939,516 impressions. HCV tweet activity peaked in 2015 at 243,261 tweets, followed by a decline of 52.4% from 2015 to 2016 with a subsequent plateau through 2018. Meanwhile, NAFLD/NASH and HBV tweet activity has continued to increase, with projections that these two CLDs will surpass HCV by the second half of 2023 and 2024, respectively. Treatment and Management was the most popular content category for HCV and NAFLD/NASH, while Prevention was the most popular content category for HBV. Conclusion: Twitter is a useful social media tool to gauge public interest in liver disease over time. The information provided by Twitter can be used to identify gaps in public knowledge or highlight areas of interest that may need further research. Future studies on the use of Twitter in liver disease are warranted.

The association among diet, dietary fiber, and bowel preparation at colonoscopy.

BACKGROUND AND AIMS: Pre-colonoscopy dietary restrictions vary widely and lack evidence-based guidance. We investigated whether fiber and various other foods/macronutrients consumed during the 3 days before colonoscopy are associated with bowel preparation quality. METHODS: This was a prospective observational study among patients scheduled for outpatient colonoscopy. Patients received instructions including split-dose polyethylene glycol, avoidance of vegetables/beans 2 days before colonoscopy, and a clear liquid diet the day before colonoscopy. Two 24-hour dietary recall interviews and 1 patient-recorded food log measured dietary intake on the 3 days before colonoscopy. The Nutrition Data System for Research was used to estimate dietary exposures. Our primary outcome was the quality of bowel preparation measured by the Boston Bowel Preparation Scale (BBPS). RESULTS: We enrolled 201 patients from November 2015 to September 2016 with complete data for 168. The mean age was 59 years (standard deviation, 7 years), and 90% of colonoscopies were conducted for screening/surveillance. Only 17% and 77% of patients complied with diet restrictions 2 and 1 day(s) before colonoscopy, respectively. We found no association between foods consumed 2 and 3 days before colonoscopy and BBPS scores. However, BPPS was positively associated with intake of gelatin, and inversely associated with intake of red meat, poultry, and vegetables on the day before colonoscopy. CONCLUSIONS: Our findings support recent guidelines encouraging unrestricted diets >1 day before colonoscopy if using a split-dose bowel regimen. Furthermore, we found no evidence to restrict dietary fiber 1 day before colonoscopy. We also found evidence to promote consumption of gelatin and avoidance of red meat, poultry, and vegetables 1 day before colonoscopy.

Effective teaching of endoscopy: a qualitative study of the perceptions of gastroenterology fellows and attending gastroenterologists.

BACKGROUND: There is little information describing the perceptions of gastroenterology fellows and attending gastroenterologists of what constitutes effective teaching of endoscopy. We sought to identify common themes regarding endoscopy training methods and their impact among fellows and attendings. METHODS: Focus group exercises and surveys were conducted among fellows, about educational resources, teaching techniques and ways of improving the teaching of endoscopy. The fellows identified the 'best' teachers of endoscopy, who were interviewed regarding their training in endoscopy, their teaching methods, key points of information, and opinions on endoscopy curriculum. RESULTS: Nineteen fellows (68%) had attended the American Society for Gastrointestinal Endoscopy First Year Fellows' Endoscopy course and found it very helpful. Thirteen fellows(46%) had exposure to an endoscopy simulator, but their median duration of use was only 1 hour. Only two out of five fellowship programs used a formal endoscopic skill assessment tool and none of the programs had an endoscopy curriculum of which the fellows were aware. Fellows reported that they learned endoscopy best by performing procedures. They also volunteered that attending gastroenterologists used variable teaching methods, and might benefit from instruction on how to teach endoscopy. Ten attending gastroenterologists (77%) had received training in advanced procedures; none received formal training on teaching endoscopy: they all felt that such training would be beneficial. CONCLUSIONS: A standardized endoscopy curriculum may be beneficial to fellows, who prefer to learn endoscopy by performing procedures-but they want explicit and specific instruction. Both those attending and the fellows thought that formal instruction for attending gastroenterologists on how to teach endoscopy would be beneficial, indicating a role for a 'teach-the-teacher' curriculum.

Elucidation of a pH-folding switch in the Pseudomonas syringae effector protein AvrPto.

Pathogenic bacteria have developed extraordinary strategies for invading host cells. The highly conserved type III secretion system (T3SS) provides a regulated conduit between the bacterial and host cytoplasm for delivery of a specific set of bacterial effector proteins that serve to disrupt host signaling and metabolism for the benefit of the bacterium. Remarkably, the inner diameter of the T3SS apparatus requires that effector proteins pass through in at least a partially unfolded form. AvrPto, an effector protein of the plant pathogen Pseudomonas syringae, adopts a helical bundle fold of low stability (DeltaG(F-->U) = 2 kcal/mol at pH 7, 26.6 degrees C) and offers a model system for chaperone-independent secretion. P. syringae effector proteins encounter a pH gradient as they translocate from the bacterial cytoplasm (mildly acidic) into the host cell (neutral). Here, we demonstrate that AvrPto possesses a pH-sensitive folding switch controlled by conserved residue H87 that operates precisely in the pH range expected between the bacterial and host cytoplasm environments. These results provide a mechanism for how a bacterial effector protein employs an intrinsic pH sensor to unfold for translocation via the T3SS and refold once in the host cytoplasm and provide fundamental insights for developing strategies for delivery of engineered therapeutic proteins to target tissues.