The Burden of Overweight and Obesity-Associated Gastrointestinal Cancers in Low and Lower-Middle-Income Countries: A Global Burden of Disease 2019 Analysis.

INTRODUCTION: Obesity is associated with cancer, including gastrointestinal (GI). Data from low (LICs) and lower-middle-income countries (MICs) are limited. METHODS: We utilized data from the Global Burden of Disease Study 2019 to determine the mortality from GI cancer risk of high body mass index (BMI) in these countries. RESULTS: Mortality rates of GI cancers from high BMI increased in LICs and lower MICs, while burdens decreased or remained stable in high and middle-income countries. DISCUSSION: The GI cancer-related burden from high BMI increased in LICs and lower MICs, necessitating a concerted effort to tackle the obesity pandemic.

Body mass index and risk of clostridioides difficile infection: a systematic review and meta-analysis.

OBJECTIVE: To comprehensively investigate the association between obesity/high body mass index (BMI) and risk of Clostridioides difficile infection (CDI) using systematic review and meta-analysis. METHODS: Potentially eligible studies were identified from Medline and EMBASE databases from inception to February 2021 using search strategy consisting of terms for "Body Mass Index" and "Clostridioides Difficile". We only included studies that consist of a group of individuals with CDI and another group without CDI. Then, the studies must report their BMI or history of obesity. Odds ratio (OR) and 95% CIs of the association between BMI status and CDI were retrieved from each study and combined using the generic inverse variance method. Funnel plot was used to assess publication bias. RESULTS: A total of 4609 articles were identified. After two rounds of systematic review, 17 studies met the eligibility criteria and were included into the meta-analysis. Pooled analysis showed that individuals with high BMI had a significantly decreased odds of CDI with the pooled OR of 0.88 (95% CI 0.80-0.97). This meta-analysis had high statistical heterogeneity with I2 of 74%. Funnel plot was symmetric, which was not suggestive of presence of publication bias. CONCLUSION: This meta-analysis revealed a significant negative association between BMI and CDI.

The Association Between Asthma and Risk of Myasthenia Gravis: A Systematic Review and Meta-analysis.

PURPOSE: This study aimed to investigate the association between asthma and risk of myasthenia gravis (MG) using the method of systematic review and meta-analysis. METHODS: Potentially eligible studies were identified from Medline and EMBASE databases from inception to July 2020 using search strategy that comprised terms for "Asthma" and "Myasthenia Gravis". Eligible cohort study must consist of one cohort of individuals with asthma and another cohort of individuals without asthma. Then, the study must report relative risk (RR) with 95% confidence intervals (95% CIs) of incident MG between the groups. Eligible case-control studies must include cases with MG and controls without MG. Then, the study must explore their history of asthma. Odds ratio (OR) with 95% CIs of the association between asthma status and MG must be reported. Point estimates with standard errors were retrieved from each study and were combined together using the generic inverse variance method. RESULTS: A total of 6,835 articles were identified. After two rounds of independent review by five investigators, two cohort studies and three case-control studies met the eligibility criteria and were included into the meta-analysis. Pooled analysis showed that asthma was significantly associated with risk of MG with the pooled risk ratio of 1.38 (95% CI 1.02-1.86). Funnel plot was symmetric, which was not suggestive of publication bias. CONCLUSION: The current study found a significant association between asthma and increased risk of MG.

An atorvastatin-induced positive anti-HMGCR immune-mediated necrotizing myopathy case.

Statins can commonly cause myopathy. Most of the time, stopping the culprit drug should solve the problem. However, if the drug has been discontinued but muscle weakness continues to worsen, immune-mediated myopathy should be taken into consideration.

Endoscopic Ultrasound-Guided Choledochoduodenostomy With Lumen-Apposing Metal Stent Through Duodenal Stent, a Success Case, and a Salvage Case.

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) has become a feasible alternative technique in cases of malignant bile duct obstruction, especially when the endoscopic retrograde cholangiopancreatography is not feasible or has failed. In the case of duodenal obstruction, when a duodenal stent has been initially placed, performing endoscopic retrograde cholangiopancreatography could be quite difficult with a low success rate. Thus, EUS-CD could be a good alternative. In this study, we present 2 particularly challenging endoscopic cases in which EUS-CD was performed with a lumen-apposing metal stent inserted through a previously placed duodenal stent.

Postprandial abdominal pain and weight loss as the initial presentation of abdominal neuroendocrine tumor recurrence.

Key Clinical Message: Neuroendocrine tumors, rare and slow-growing, primarily affect the gastrointestinal tract, causing symptoms due to hormone secretion or mass effect. This case image described postprandial abdominal pain as an atypical initial presentation of abdominal neuroendocrine tumor recurrence in a middle-aged male. Abstract: Neuroendocrine tumors are a group of rare, slow-growing neoplasms, most commonly affecting the gastrointestinal tract. Clinical presentations include symptoms related to the mass or hypersecretion of hormones, such as flushing, diarrhea, or bronchoconstriction. Postprandial abdominal pain is most commonly related to chronic mesenteric ischemia from atherosclerotic changes but is rarely linked to external mass compression, including gastrointestinal tumors. Hereby, the authors highlight an uncommon presentation of NET, which is very challenging to diagnose and demands a high index of suspicion.

Neutrophilic eccrine hidradenitis from granulocyte-stimulating factor in a patient with ANCA vasculitis.

Neutrophilic eccrine hidradenitis (NEH) is one of the cutaneous manifestations of chemotherapy side effects. However, it can arise from other non-chemotherapy medications. The granulocyte-colony-stimulating factor is a medication reported to trigger NEH.

Outcomes of peritoneal dialysis in cirrhosis: A systematic review and meta-analysis.

BACKGROUND: Cirrhosis and end-stage kidney disease (ESKD) are significant global health concerns, contributing to high mortality and morbidity. Haemodialysis (HD) is frequently used to treat ESKD in patients with cirrhosis. However, it often presents challenges such as haemodynamic instability during dialysis sessions, leading to less than optimal outcomes. Peritoneal dialysis (PD), while less commonly used in cirrhotic patients, raises concerns about the risks of peritonitis and mortality. Our systematic review and meta-analysis aimed to assess outcomes in PD patients with cirrhosis. METHODS: We executed a comprehensive search in Ovid MEDLINE, EMBASE and Cochrane databases up to 25 September 2023. The search focused on identifying studies examining mortality and other clinical outcomes in ESKD patients with cirrhosis receiving PD or HD. In addition, we sought studies comparing PD outcomes in cirrhosis patients to those without cirrhosis. Data from each study were aggregated using a random-effects model and the inverse-variance method. RESULTS: Our meta-analysis included a total of 13 studies with 15,089 patients. Seven studies compared ESKD patients on PD with liver cirrhosis (2753 patients) against non-cirrhosis patients (9579 patients). The other six studies provided data on PD (824 patients) versus HD (1943 patients) in patients with cirrhosis and ESKD. The analysis revealed no significant difference in mortality between PD and HD in ESKD patients with cirrhosis (pooled odds ratio (OR) of 0.77; 95% confidence interval (CI), 0.53-1.14). In PD patients with cirrhosis, the pooled OR for peritonitis compared to non-cirrhosis patients was 1.10 (95% CI: 1.03-1.18). The pooled ORs for hernia and chronic hypotension in cirrhosis patients compared to non-cirrhosis controls were 2.48 (95% CI: 0.08-73.04) and 17.50 (95% CI: 1.90-161.11), respectively. The pooled OR for transitioning from PD to HD among cirrhotic patients was 1.71 (95% CI: 0.76-3.85). Mortality in cirrhosis patients on PD was comparable to non-cirrhosis controls, with a pooled OR of 1.05 (95% CI: 0.53-2.10). CONCLUSIONS: Our meta-analysis demonstrates that PD provides comparable mortality outcomes to HD in ESKD patients with cirrhosis. In addition, the presence of cirrhosis does not significantly elevate the risk of mortality among patients undergoing PD. While there is a higher incidence of chronic hypotension and a slightly increased risk of peritonitis in cirrhosis patients on PD compared to those without cirrhosis, the risks of hernia and the need to transition from PD to HD are comparable between both groups. These findings suggest PD as a viable and effective treatment option for ESKD patients with cirrhosis.

Massive hemoptysis with end stage renal disease (ESRD): An initial symptom of rare disease.

Microscopic polyangiitis is a rare autoimmune vasculitis, that could present with renal-pulmonary symptoms, posing diagnostic challenges in patients with preexisting kidney disease. Timely diagnosis is crucial to improve patient outcomes.

SpyGlass DS system-assisted retrieval of proximally migrated pancreatic duct stent in a patient with chronic pancreatitis.

Pancreatic duct (PD) stent migration is among the recognized complications of endoscopic retrograde cholangiopancreatography (ERCP) with PD stent placement. Proximal stent migration poses a challenge for removal due to risks of PD damage, smaller caliber, and possible stricture. Here, we present a case of SpyGlass DS system-assisted PD stent repositioning after failure with traditional tools.

Menopause is associated with increased prevalence of nonalcoholic fatty liver disease: a systematic review and meta-analysis.

IMPORTANCE: Data are inconsistent on whether menopause is a risk for nonalcoholic fatty liver disease (NAFLD). OBJECTIVE: Using systematic review and meta-analysis, we aimed to collect all available data to determine the association between menopause and NAFLD. EVIDENCE REVIEW: Potentially eligible studies were identified from EMBASE, MEDLINE, and Web of Science databases from inception to December 2021 using a search strategy that was composed of the terms for "NAFLD" and "menopause." Eligible study must contain two groups of participants: one group of postmenopausal women and another group of premenopausal women. Then, the study must report the association between menopause and prevalent NAFLD. We extracted such data from each study and calculated pooled odds ratio (OR) by combining effect estimates of each study using a random-effects model. Funnel plot was used to assess for the presence of publication bias. FINDINGS: A total of 587 articles were identified. After two rounds of independent review by two investigators, 12 cross-sectional studies fulfilled the eligibility criteria. The meta-analysis of 12 studies revealed the significant association between menopause and NAFLD with a pooled OR of 2.37 (95% CI, 1.99-2.82; I2 = 73%). The association remained significant in a sensitivity meta-analysis of six studies that reported the association with adjustment for age and metabolic factors with a pooled OR of 2.19 (95% CI, 1.73-2.78; I2 = 74%). The funnel plot was fairly symmetric and was not suggestive of publication bias. CONCLUSIONS AND RELEVANCE: The meta-analysis reveals that menopausal status was associated with approximately 2.4 times higher odds of NAFLD.

Increased Prevalence of Gastroesophageal Reflux Disease Among Patients With Rheumatoid Arthritis: A Systematic Review and Meta-analysis.

OBJECTIVE: This study was conducted to determine the association between gastroesophageal reflux disease (GERD) and rheumatoid arthritis (RA) by pooling the evidence from all available studies. METHODS: Potentially eligible studies were identified from MEDLINE and EMBASE database from inception to April 2021 employing a search strategy that consisted of terms for "Rheumatoid Arthritis" and "Gastroesophageal Reflux Disease". Eligible studies for the meta-analysis were recruited with conditions of being cohort studies that included rheumatoid arthritis and without rheumatoid arthritis individuals. Together with this, prevalence of GERD in both groups and the odds ratio (OR) comparing the prevalence of GERD between the two cohorts have been reported. The retrieved point estimates with standard errors from each study were pooled into the final result by the random-effect model and generic inverse variance method as described by DerSimonian and Laird. RESULTS: A total of 3,646 articles were identified. After two rounds of independent review by two investigators, five cohort studies were included in the meta-analysis as they met the eligibility criteria. The pooled analysis demonstrated a significant association between RA and GERD with the pooled odds ratio of 1.98 (95% CI, 1.49 - 2.65). High statistical heterogeneity with I2 of 83% was observed. The funnel plot was symmetric and publication bias was not observed. CONCLUSION: This systematic review and meta-analysis found a significant association between GERD and RA.

Pemphigus vulgaris presenting with epigastric pain.

Pemphigus vulgaris is an autoimmune mucocutaneous disease with an involvement in gastrointestinal tract especially in oral cavity and esophagus. Ulcers can be the initial presentation even before visible mucosal or cutaneous lesions. The presenting symptoms will be in accordance with the affected organ such as throat pain, hoarseness, dysphagia, odynophagia, or even bleeding. Here, we report a case of undiagnosed pemphigus vulgaris presenting with epigastric pain whose endoscopy showed oropharyngeal involvement and isolate esophageal ulcer, which failed proton pump inhibitor treatment.

Gallbladder containing incisional hernia in an elderly woman.

Gallbladder herniation is a rare phenomenon with risk factors of being female, older age, and previous history of hernias. Imaging modalities can confirm the diagnosis. Cholecystectomy and hernia repair to prevent strangulation may be warranted.

Eosinophilia with Lung Involvement in an Elderly Patient with a History of Chronic Obstructive Pulmonary Disease.

Eosinophilia with pulmonary involvement is characterized by the presence of peripheral blood eosinophilia, typically >500 cells/mm3, nonspecific pulmonary symptoms, and radiographic evidence of pulmonary disease. Clinical, laboratory, and radiologic features can be overlapping in these diseases, thus, it is wise to approach eosinophilia with pulmonary involvement systematically to determine the diagnosis and provide definitive treatment for a better outcome. The authors present a case of idiopathic chronic eosinophilic pneumonia in a patient with a long history of chronic obstructive pulmonary disease (COPD) which was resolved by corticosteroid.

Pre-bariatric surgery acute kidney injury: Can this be prevented?

Key Clinical Message: Pre-bariatric surgery dietary recommendations should take into account daily protein intake and other risk factors for kidney injury. This is important because a high protein intake can potentially lead to kidney injury. Abstract: Bariatric surgery has been shown to be a highly effective intervention for achieving weight loss and reducing obesity related-comorbidities. Acute kidney injury (AKI) is considered one of the common complications in perioperative and post-bariatric surgery. However, pre-bariatric surgery AKI has never been reported. Several studies demonstrated that pre-bariatric surgery weight loss improved surgical outcomes and decrease postoperative complications. Some diet regimens have been introduced including low-caloric diet (LCD), very-low caloric diet (VLCD), and very-low caloric ketogenic diet (VLCKD). We present a patient who develops AKI after 10 days of having a high-protein diet from a pre-bariatric weight loss strategy.

Thrombocytopenia and hyperthyroidism: A case report and literature review.

Key Clinical Message: Immune thrombocytopenic purpura (ITP) is very challenging to diagnose with concurrent comorbidities affecting platelet count including PAH and autoimmune thyroid disease. ITP resolution can be achieved with tailored treatment of the underlying conditions to avoid adverse events. Abstract: Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a platelet count of <100 × 109/L in the absence of other causes of thrombocytopenia. It is classified as primary or idiopathic and secondary due to various coexisting conditions, including autoimmune thyroid diseases. It is especially challenging when the patient has comorbidities that affect platelet count easily, leading to anchoring bias. The first-line treatment of ITP is corticosteroids, and it is also recommended to treat the primary causes of secondary ITP. Here, the authors report a case of secondary ITP in a patient with a recent diagnosis of Grave's disease and a history of idiopathic pulmonary hypertension with baseline chronic thrombocytopenia, possible mechanisms, and treatment strategies with a multidisciplinary approach.

COVID-19 Infections and Inflammatory Markers in Patients Hospitalized During the First Year of the Pandemic.

BACKGROUND: The clinical presentations in patients with SARS-CoV-2 (COVID-19) infections range from asymptomatic upper respiratory infections to acute respiratory failure with bilateral pulmonary infiltrates requiring mechanical ventilation. Clinicians often measured inflammatory markers in hospitalized patients to characterize the severity of the infection. Multiple studies published in 2020 reported information on the frequency of elevated inflammatory markers in hospitalized patients in various categories of disease severity. METHODS: The PubMed database was searched using the terms "Inflammatory markers in COVID-19 patients" and "Clinical features of patients infected with COVID-19." Thirty-three publications were analyzed in detail to determine which inflammatory markers were increased and the frequency of these increases in various clinical classifications, including patients requiring hospitalization, patients with pneumonia, patients with severe infection, patients requiring intensive care unit admission, and patients who died. RESULTS: C-reactive protein (CRP) was the most frequently elevated inflammatory marker in all categories. Ferritin, D-dimer, and erythrocyte sedimentation rate levels were also frequently elevated. In general, frequencies were higher in patients with more severe infections. For example, 24 out of 24 patients who died had an elevated CRP level. CONCLUSION: This review provides concrete information about the frequency of various inflammatory markers in patients with COVID-19 infection who required hospitalization. It also provides us some insight into the approach clinicians took in the early phase of this pandemic in their efforts to characterize these patients and perhaps understand the disease process better. However, these results might suggest that clinicians and laboratory directors should develop protocols to optimize laboratory testing.

Chronic diarrhea as a presentation of Behçet's disease.

Key Clinical Messages: Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder with findings of oral aphthous ulcers, genital ulcers, and uveitis. Gastrointestinal (GI) involvement can be the initial presentation as presented in this case. Abstract: Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder of unknown etiology with classical findings of oral aphthous ulcers, genital ulcers, and ocular involvements including chronic anterior, intermediate, posterior, and even panuveitis. Gastrointestinal involvement in BD usually presents with chronic diarrhea, hematochezia as the disease affects ileocecal area which might be similar to presentation of inflammatory bowel diseases. Here, we report a case of undiagnosed BD who presented with chronic diarrhea for 4 months, leading to the diagnosis of BD and responded well to corticosteroid therapy.

Pulmonary artery aneurysm in a young female with Takayasu arteritis.

Key Clinical Message: In suspected cases of systemic vasculitis, imaging studies should include the pulmonary artery. This is a rare case of Takayasu arteritis with a large pulmonary aneurysm. Medical management is the first line and vascular intervention if fails prior. Abstract: Takayasu arteritis (TA) should be suspected in young women presented with hypertension, carotidynia, and claudications. Pulmonary artery involvement is frequent, occurring in 20%-50% of patients with TA. However, this case highlights the rare presentation of TA with a large pulmonary aneurysm and minimal aortic involvement. Medical management including immunosuppressive agents and biological therapies remains an important role, with vascular intervention remains as an option if medical therapy failed.