Hemoglobin A1c Has Suboptimal Performance to Diagnose and Monitor Diabetes Mellitus in Patients with Cirrhosis.

BACKGROUND: Glycated hemoglobin A1c (HbA1c) is routinely used to diagnose and monitor type 2 diabetes mellitus (T2DM) in cirrhotic patients. Remarkably, HbA1c may be falsely low in such patients. AIMS: We assessed the diagnostic and monitoring yield of HbA1c in cirrhotic patients with T2DM (DM-Cirr) and without T2DM (NoDM-Cirr). METHODS: We conducted a composite study allocating 21 NoDM-Cirr into a cross-sectional module and 16 DM-Cirr plus 13 controls with T2DM only (DM-NoCirr) into a prospective cohort. Oral glucose tolerance test (OGTT) was performed in NoDM-Cirr. DM-Cirr and DM-NoCirr were matched by sex, age, BMI, and T2DM treatment and studied with continuous glucose monitoring (CGM). Percent deviations from target, low/high blood glucose indexes (LBGI/HBGI) were calculated from CGM, as well as the average daily risk range (ADRR) as a marker of glucose variability. RESULTS: Overall, HbA1c and OGTT diagnostic yield agreed in 12 patients (57%, ρ = 0.45, p < 0.03). CGM captured 3463 glucose determinations in DM-Cirr and 4273 in DM-NoCirr (p = 0.42). Regression analysis showed an inferior association between HbA1c and CGM in DM-Cirr (R2 = 0.52), when compared to DM-NoCirr (R2 = 0.94), and fructosamine did not improve association for DM-Cirr (R2 = 0.31). Interestingly, cirrhosis and Child-Turcotte-Pugh class accounted for HbA1c variance (p < 0.05). Patients in DM-Cirr were less frequently within target glucose (70-180 mg/dL), but at higher risk for hyperglycemia (HBGI > 9) when compared to DM-NoCirr, and they also showed higher glucose variability (ADRR 13.9 ± 2.5 vs. 8.9 ± 1.8, respectively, p = 0.03). CONCLUSION: HbA1c inaccurately represents chronic glycemia in patients with cirrhosis, likely in relation to increased glucose variability.

Recreational Drug and Psychosocial Profile in Chronic Hepatitis C Patients Seeking Antiviral Therapy.

BACKGROUND AND AIMS: Practitioners treating hepatitis C (HCV) provide healthcare to a special population with high rates of substance abuse and psychiatric disorders. We investigated the psychosocial profile in HCV patients and tested what variables affect commencement of antiviral therapy. MATERIAL AND METHODS: Recreational drug use (RDU), marijuana (THC), alcohol use, and psychiatric history were initially investigated with a questionnaire prior to history and physical. Following an educational intervention, we reinterrogated patients for RDU and THC use, and revision of initial statement was documented. Variables affecting commencement of antiviral therapy were analysed with logistic regression. RESULTS: Out of 153 patients, 140 (92%) answered the questionnaire. Intervention increased total yield by 6%, however, 39% (11/28) of those initially denying use revised their statement. Drug screening identified 9 more patients with RDU/THC use. Half of patients consuming alcohol were heavy drinkers, and psychiatric disease was identified in 54%. Only 73 (48%) of 139 patients eligible for antivirals received treatment. Multivariable analysis revealed that younger patients (OR = 1.04, 95% CI 1.01-1.08), and those testing positive on drug screen (OR = 0.41, 95% CI 0.19-0.92) were less likely to be treated. Denial by insurance and loss to follow-up were the most common reasons for not starting antiviral treatment. CONCLUSION: Substance abuse is highly prevalent among HCV patients, and it is difficult to tell prior from current users. Integral care of HCV patients should include a diligent screen for substance abuse and rehabilitation referral, aiming to increase the pool of patients eligible for antiviral therapy. This can only be achieved through a multidisciplinary approach.

Interplay of gender, age and drug properties on reporting frequency of drug-induced liver injury.

We examined the effect of gender, age, and drug properties on liver events reporting frequency (RF) to assess patient- and drug-related risks for drug-induced liver injury (DILI). We performed a data-mining analysis of the WHO VigiBase™ to 1) identify drugs with gender- and age-biased RF and 2) characterize drug properties using the Liver Toxicity Knowledge Base. Age-, gender-specific Empirical Bayes Geometric Mean of relative reporting ratio of liver events with 90% confidence interval (CI) was calculated for 375 drugs with DILI potential. Forty-one drugs showed an increased RF in women, which had a higher prevalence of reactive metabolite formation and mitochondrial dysfunction and transporter inhibition. Fifty-nine drugs showed an increased RF in younger women (<50 yrs), many of which had a signature pattern of hepatocellular injury. In contrast, half of 17 drugs that showed an increased RF in men had a cholestatic pattern. In the older group (≥50 yrs), 17 drugs showed an increased RF and had higher transporter inhibition, Cmax, and plasma protein binding, yet shorter plasma elimination. Specific drug properties were associated with gender- and age-biased liver events RF, suggesting possible interactions of drug properties, gender, and age in DILI development.

An immunosuppressed man with an aortic rupture secondary to Salmonella aortitis successfully treated with endovascular aortic repair.

A 75-year-old immunosuppressed man presented with fever and central abdominal pain 3 weeks after having positive blood cultures for Salmonella enteritidis. A computed tomography scan demonstrated a contained perforation of a nonaneurysmal abdominal aorta. Salmonella aortitis was suspected, and given his recent history of coronary artery stent insertion, endovascular aortic repair was performed, with lifelong antibiotic therapy. At 6 months, there were no remaining clinical or radiological concerns for aortitis or aneurysmal development. This case highlights the high index of suspicion required for aortitis in immunosuppressed patients and verifies endovascular aortic repair, an appropriate alternative in patients with severe comorbidities.

Cholangiocarcinoma Presenting as Linitis Plastica with Unusual Metastases to the Psoas Muscle and Urinary Bladder.

Cholangiocarcinoma offers poor prognosis. Infrequent sites of metastasis are poorly described and often diagnostically delayed or missed. Bile duct brush cytologies provide poor diagnostic sensitivity/specificity. We present an unusual case of cholangiocarcinoma in a 34-year-old woman with rare distant metastasis to the psoas muscle and urinary bladder. It is the first case of metastatic cholangiocarcinoma presenting as linitis plastica, and our patient is the youngest to be described with metastatic cholangiocarcinoma to the psoas muscle leading to diagnosis. We conclude that seemingly idiopathic biliary strictures that fail to respond to testing should prompt alarm and referral for cholangioscopy, where available.

Colorectal cancer screening use among insured adults: Is out-of-pocket cost a barrier to routine screening?

AIM: To describe the characteristics of adults who needed to see a doctor in the past year but could not due to the extra cost and assess the impact of limited financial resources on the receipt of routine fecal occult blood test, sigmoidoscopy, or colonoscopy for colon cancer screening among insured patients. METHODS: Data obtained from the 2012 Behavioral Risk Factor Surveillance System included 215436 insured adults age 50-75 years. We computed frequencies, adjusted odds ratios (aORs), and 95%CIs using SAS v9.3 software. RESULTS: Nine percent of the study population needed to see a doctor in the past year but could not because of cost. The numbers were significantly higher among those aged 50-64 (P < 0.0001), Non-Hispanic Whites (P < 0.0001), and those with a primary care physician (P < 0.0001) among other factors. Adjusting for possible confounders, aORs for not seeing the doctor in the past year because of cost were: stool occult blood test within last year aOR = 0.88; 95%CI: 0.76-1.02, sigmoidoscopy within last year aOR = 0.72; 95%CI: 0.48-1.07, colonoscopy within the last year aOR = 0.91; 95%CI: 0.81-1.02. CONCLUSION: We found that the limited financial resources within the past 12 mo were significantly associated with colorectal cancer (CRC) non-screening. Patients with risk factors identified in this study should adhere to CRC guidelines and should receive financial help if needed.

Endosonographer-driven dynamic telecytopathology of pancreatic lesions-a pilot study.

INTRODUCTION: Telecytopathology for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been shown to be an alternative to rapid on-site evaluation (ROSE). Gastroenterologists (endosonographers) performing EUS-FNA can be trained to evaluate a specimen for adequacy. This study examined the ability of an endosonographer with focused cytopathologic training to assess the adequacy of pancreatic FNA specimens and transmit diagnostic images to a remotely located cytopathologist as compared to an experienced cytotechnologist. MATERIALS AND METHODS: This was a retrospective study of consecutive pancreatic lesions sampled by EUS-FNA reviewed by an endosonographer and a cytotechnologist. The participants were assessed based on their ability to (1) determine adequacy, (2) locate and transmit representative cell groups, (3) provide a preliminary diagnosis, and (4) provide concordance with actual diagnosis. RESULTS: 105 consecutive cases of EUS-FNA of the pancreas were analyzed, including: adenocarcinoma (n = 39), cyst (n = 17), neuroendocrine neoplasia (n = 7), pancreatitis (n = 14), benign pancreas (n = 9), other neoplasms (n = 6), suspicious/atypical (n = 3), and nondiagnostic (n = 10). The cytotechnologist demonstrated superiority in accuracy 92.7% versus 70% (P = 0.003) and subcategorization 95.0% versus 76% (P = 0.007). There was no difference in "broad" categorization (benign/malignant) between the endosonographer and cytotechnologist, 98% and 98.2% (P = 0.946), respectively. Also, there was no difference with regard to adequacy assessment (P = 0.29). A steady learning curve for the endosonographer was demonstrated in their cytologic assessment (P = 0.041). The endosonographer was shown to be able to remotely transmit diagnostic images to a pathologist. CONCLUSION: An endosonographer with limited training can examine for specimen adequacy, transmit images, and demonstrate representative cell groups. Larger studies are required though preliminary results are encouraging.

Endoscopic Dissolution of Gastric Lipoma with Argon Plasma Coagulation.

A 47-year-old patient presented from outside the hospital for evaluation of iron deficiency anemia (IDA). The endoscopic workup suggested a gastric antral subepithelial lesion with an overlying arteriovenous malformation (AVM). Endoscopic ultrasound (EUS) revealed the lesion to be a lipoma. Given the patient's anemia and blood transfusion requirements, the AVM was treated with argon plasma coagulation (APC). During this treatment, desiccation of fat was noted with a significant decrease in the size of the subepithelial lesion (the gastric lipoma). While the APC therapy was intended for management of the overlying AVM, it resulted in the partial dissolution of the gastric lipoma, proving to be a potential diagnostic and therapeutic tool.

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease.

The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Ventricular Standstill Following Intravenous Erythromycin and Borderline Hypokalemia.

Ventricular standstill (VS) is a potentially fatal arrhythmia that is usually associated with syncope, if prolonged and is rarely asymptomatic[1]. Its mechanism involves either a lack of supraventricular impulse or an interruption in the transmission of these signals from the atria to the ventricles, resulting in a sudden loss of cardiac output[2]. Although rare, ventricular arrhythmias have been associated with intravenous (IV) erythromycin. However, to our knowledge, VS has not been reported following the administration of IV erythromycin. The Authors describe a rare case of asymptomatic VS and subsequent third-degree atrioventricular block, following the administration of IV erythromycin in a 49-year-old woman with borderline hypokalemia. Through this case, the Authors highlight the importance of cardiac monitoring and electrolyte replacement when administering IV erythromycin, as well as discuss several other mechanisms that contribute to ventricular arrhythmias. LEARNING POINTS: Intravenous erythromycin is associated with prolongation of the QTc interval and ventricular arrhythmias.Ventricular standstill is a rare but potentially fatal arrhythmia, and may have an association with the administration of intravenous erythromycin.Cardiac monitoring in patients with baseline QTc prolongation and correction of electrolyte disturbances are important when administering intravenous erythromycin.

What is the current role of endoscopy in primary sclerosing cholangitis?

Endoscopy has important roles in the management of primary sclerosing cholangitis (PSC), ranging from narrowing down the differential diagnoses, screening for complications, determining prognosis and therapy. While the need for a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be obviated by a positive magnetic resonance cholangiopancreatography (MRCP), a negative MRCP does not exclude PSC and may therefore necessitate an ERCP, which is traditionally regarded as the gold standard. In this editorial we have not covered the endoscopic management of inflammatory bowel disease in the context of PSC nor of endoscopic surveillance and treatment of portal hypertension complicating PSC.