Renal Cell Carcinoma Presenting With Combined Cervical Lymphadenopathy and Cardiac Metastasis Without Inferior Vena Cava Involvement.

Renal cell cancer is the third most common urological malignancy following prostate and bladder malignancies. Cardiac metastases to the right side of the heart without inferior vena cava (IVC) involvement are exceedingly rare, with only a handful of cases described in the literature. Metastasis to the head and neck region is also rare, occurring in an estimated 1% of cases. Here we present a case of a patient with recurrent syncopal events secondary to renal cell carcinoma without IVC involvement, with metastases both to the right ventricle and cervical lymph nodes. To our knowledge, this is the first case that presents with both of these rare findings together and that highlights cancer screening in patients with high risk factors and new exam findings in patients with syncopal events having negative initial workup.

A Patient with Eosinophilic Esophagitis and Herpes Simplex Esophagitis: A Case Report and Literature Review.

Acute herpes simplex esophagitis (HSE) is common in immunocompromised patients. Eosinophilic esophagitis (EoE) is characterized by immune-mediated eosinophil-predominant esophageal inflammation. We report a patient with human immunodeficiency virus infection who presented with dysphagia and odynophagia and was found to have HSE and EoE. The combination of these two relatively rare conditions suggests possible predisposition.

Transplantation of liver from hepatitis C-infected donors to hepatitis C RNA-negative recipients: Histological and virologic outcome.

BACKGROUND: The virologic and histologic outcomes of a hepatitis C virus (HCV)-infected liver graft into an HCV-negative recipient are not well understood. We aimed to evaluate the sustained virologic response (SVR) rate and the liver histology at 1 year post-Orthotopic liver transplantation (OLT) with an HCV-infected graft. METHODS: A total of 33 patients received the HCV antibody (Ab)+/nucleic acid amplification test (NAT)+ graft. Of these patients, 23 were HCV-negative recipients and 10 were HCV-positive recipients. The 1-year biopsy data were available for 24 patients: 15 patients in HCV-negative group who received an HCV Ab+/NAT+graft and 9 patients in HCV-positive group who received an HCV Ab+/NAT+ graft. Patients with (+) HCV ribonucleic acid (RNA) were started on direct-acting antiviral (DAA) treatment approximately 107 days after OLT using either a Glecaprevir-Pibrentasvir or Sofosbuvir-Velpatasvir or Sofosbuvir-Ledipasvir. RESULTS: All patients (n = 33) were treated with DAA and achieved SVR. The 1-year post-OLT liver biopsies were available in 24 patients: 9 patients had F1 and F2 fibrosis and 17 patients had minimal to moderate inflammation. There was no statistical difference in fibrosis and inflammation between the HCV-negative vs. HCV-positive recipients. All patients who received the NAT+ graft developed viremia and subsequently achieved SVR with treatment. CONCLUSION: At 1 year protocol liver biopsy, patients had inflammation consistent with viral hepatitis despite the successful eradication of HCV.

Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis.

BACKGROUND: Heller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM. METHODS: We searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM. RESULTS: We included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM. CONCLUSIONS: POEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.

Impact of Moderate versus Deep Sedation and Trainee Participation on Adenoma Detection Rate-Analysis of a Veteran Population.

BACKGROUND/AIMS: The adenoma detection rate (ADR) is used as a quality indicator for screening and surveillance colonoscopy. The study aimed to determine if moderate versus deep sedation affects the outcomes of the ADR and other quality metrics in the veteran population. METHODS: A retrospective review of colonoscopies performed at Memphis Veterans Affairs Medical Center over a one-year period was conducted. A total of 900 colonoscopy reports were reviewed. After exclusion criteria, a total of 229 index, average-risk screening colonoscopies were identified. Data were collected to determine the impact of moderate (benzodiazepine plus opioids) versus deep (propofol) sedation on the ADR, polyp detection rate (PDR), and withdrawal time. RESULTS: Among 229 screening colonoscopies, 103 (44.9%) used moderate sedation while 126 (55%) were done under deep sedation. The ADR and PDR were not significantly different between moderate versus deep sedation at 35.9% vs. 37.3% (p=0.82) and 58.2% vs. 48.4% (p=0.13), respectively. Similarly, there was no significant difference in withdrawal time between moderate and deep sedation (13.4 min vs. 14 min, p=0.56) during screening colonoscopies. CONCLUSION: In veterans undergoing index, average-risk screening colonoscopies, the quality metrics of the ADR, PDR, and withdrawal time are not influenced by deep sedation compared with moderate sedation.

Peroral Endoscopic Myotomy Is a Safe and Feasible Option in Management of Esophageal Diverticula: Systematic Review and Meta-Analysis.

Esophageal diverticula can cause significant symptoms and affect the quality of life. There has been recent interest in the use of peroral endoscopic myotomy in the management of esophageal diverticula (D-POEM). In this meta-analysis, we have evaluated the efficacy and safety of D-POEM in the management of esophageal diverticula. Several databases were reviewed from inception to 6/19/2020 to identify the studies evaluating the feasibility, efficacy and safety of D-POEM in the management of esophageal diverticula. Our outcomes of interest were technical success, adverse events and difference in mean pre- and post-procedure symptom score. We performed subgroup analysis including patients with Zenker's diverticulum who underwent POEM (Z-POEM). Pooled rates with 95% confidence intervals (CI) for all outcomes were calculated using random effect model. We calculated standard mean difference (SMD) with 95% CI to compare mean pre- and post-procedure symptom score. We included 7 studies with 233 patients. For D-POEM, pooled rates (95% CI) for technical success and adverse events were 95% (91%, 97%) and 6% (3%, 10%) respectively. For Z-POEM, pooled rates (95% CI) for technical success and adverse events were 95% (90%, 97%) and 6% (3%, 10%) respectively. Mean post-procedure symptom score for all patients who underwent D-POEM was significantly lower compared to mean pre-procedure symptom score, SMD (95% CI) 2.17 (1.51, 2.83).  This meta-analysis demonstrated that D-POEM is a safe and feasible option for patients with symptomatic esophageal diverticula.

African Americans have a distinct clinical and histologic profile with lower prevalence of NASH and advanced fibrosis relative to Caucasians.

BACKGROUND AND AIMS: Racial/ethnic disparities have been reported in the prevalence of nonalcoholic fatty liver disease (NAFLD). Thus, we aimed to understand the inter-ethnic clinical, biochemical, and histological differences in a large cohort of Caucasians and African-Americans (AA). METHODS: Laboratory and liver biopsy data of 942 NAFLD patients were retrospectively analyzed. Nine hundred seven patients were included in the analysis: 677 (74.6%) Caucasians and 230 (25.3%) AA. RESULTS: AA had higher mean BMI compared to Caucasians (42.6 ± 9.5 vs. 39 ± 8.6 kg/m2). The prevalence of nonalcoholic steatohepatitis (NASH), defined by NAFLD activity score (NAS . 5), was higher in the Caucasians (n = 67) compared to AA (n = 7) (9.8% vs. 3%, P = 0.0007). One hundred fifteen patients (12.8%) had advanced fibrosis: 109 (16.2%) Caucasians and six (2.6%) AA. No AA patients had stage 4 fibrosis or cirrhosis. Multivariate logistic regression analysis revealed advanced fibrosis was significantly associated with age at liver biopsy (OR 1.03, 95% CI 1.0.1.1, P = 0.017, lower platelet count (OR 0.99, 95% CI 0.98.0.99, P = <0.0001), AST/ALT ratio (OR 5.19, 95% CI 2.9.9.2, P <0.0001) and Caucasian race (OR 7.49, 95% CI 2.53.22.2, P = 0.0003). Advanced fibrosis in AA was predicted by lower platelet count and AST/ALT ratio. Whereas Advanced fibrosis in Caucasians was predicted by age at biopsy, lower platelet count and AST/ALT ratio. CONCLUSION: The AA have a distinct clinical and histologic phenotype. Caucasians have a significantly greater proportion of NASH and are eight times more likely to develop advanced fibrosis than AA.

Impact of left ventricular diastolic dysfunction on liver transplantation outcomes based on the latest American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations.

Aim of the study: Cirrhotic cardiomyopathy encompasses systolic dysfunction, left ventricular diastolic dysfunction (LVDD), and conduction abnormalities. This study aims to investigate the impact of LVDD on mortality in patients undergoing liver transplantation (LT). Material and methods: A retrospective review of 400 consecutive patients who underwent LT at our institution was performed. Patient demographics, clinical data, and transthoracic echocardiogram (TTE) were reviewed to identify LVDD. The total cohort consisted of 266 patients after excluding patients with insufficient TTE data (n = 56), patients with indeterminate LVDD (n = 71), and patients with ejection fraction (EF) < 55% (n = 7). Statistical analysis was performed using descriptive statistics. Cox regressions with hazard ratios (HRs) and 95% confidence intervals (CI) were applied to predict 5-year all-cause mortality. Kaplan-Meier survival analysis was conducted to understand the impact of LVDD on 5-year all-cause mortality. Results: Patients with LVDD have higher incidence of hyperlipidemia (36% vs. 17%, p = 0.003), hypertension (50% vs. 27%, p = 0.001) and diabetes (52% vs. 30%, p = 0.003). In addition, patients with non-alcoholic steatohepatitis (NASH) were more likely to have LVDD (48% vs. 24%, p = 0.001). A multivariate logistic regression analysis was performed with age, body mass index (BMI), NASH, alcoholic cirrhosis, hepatitis C, history of diabetes, history of hyperlipidemia, and history of hypertension. In this multivariate logistic regression analysis, NASH (odds ratio [OR] = 4.43 [1.10-17.8], p = 0.04), and history of hypertension (OR = 2.33 [1.16-4.66], p = 0.01) were independent predictors of LVDD. The Kaplan-Meier survival analysis and multivariate Cox regression demonstrated that the presence of LVDD had no impact on 5-year all-cause mortality (log-rank test nonsignificant). Conclusions: This study indicates that LVDD in end-stage liver disease (ESLD) patients does not affect immediate post-transplant outcomes or 5-year all-cause mortality.

Efficacy and safety of tranexamic acid in acute upper gastrointestinal bleeding: meta-analysis of randomised controlled trials.

BACKGROUND: Studies evaluating the role of tranexamic acid in acute upper GI bleeding (UGIB) have reported conflicting results. In this systematic review, we have evaluated the efficacy and safety of tranexamic acid in UGIB. METHODS: We searched several databases from inception to June 6, 2020 to identify randomised controlled trials (RCTs) that compared tranexamic acid and placebo in UGIB. Our outcomes of interest were mortality, rebleeding, all thromboembolic events, venous thromboembolic events, need for transfusion, endoscopic intervention and surgery. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using fixed effect model. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the certainty of evidence. RESULTS: We included 12 RCTs comprising 14,100 patients. We found no significant difference in mortality, pooled RR (95% CI) 0.87 (0.74-1.01), rebleeding, pooled RR (95% CI) 0.90 (0.79-1.02), need for surgery, pooled RR (95% CI) 0.86 (0.73-1.02), need for transfusion, pooled RR (95% CI) 1.00 (0.99-1.01) or thromboembolic events, RR (95% CI) 1.16 (0.87-1.56) between treatments. We found an increased risk of venous thromboembolic events with tranexamic acid, pooled RR (95% CI) 1.94 (1.23-3.05). Certainty of evidence based on the GRADE framework for the different outcomes ranged from low to very low. CONCLUSIONS: Tranexamic acid does not improve outcomes in UGIB and may increase the risk of venous thromboembolic events.

Prophylactic hemoclips in prevention of delayed post-polypectomy bleeding for ≥ 1 cm colorectal polyps: meta-analysis of randomized controlled trials.

Background and aim Studies evaluating the role of prophylactic hemoclips (HC) in prevention of delayed post-polypectomy bleeding (DPPB) have reported conflicting results. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the role of prophylactic HC placement in prevention of DPPB for polyps ≥ 1 cm in size. Methods We reviewed several databases to identify RCTs evaluating the role of HC in prevention of DPPB. The outcomes assessed included prevention of DPPB with polyps 1 to 1.9 cm, ≥ 2 cm, any polyp ≥ 1 cm, proximal colon polyps, distal colon polyps, and perforation. We analyzed data using a fixed effect model and reported summary pooled risk ratios (RR) with 95 % confidence intervals (CI). We assessed heterogeneity with the I 2 statistic. Results We included nine RCTs with 4550 patients. For polyps ≥ 2 cm, there was a statistically significantly lower risk of DPPB with use of HC; RR 0.55, 95 % CI 0.36, 0.86. There was also a statistically significantly lower risk for proximal colon polyps ≥ 2 cm; RR 0.41 (0.24, 0.70) but no significant difference for distal polyps; RR 1.23 (0.45, 3.32). There was also no significant difference in risk for polyps 1 to 1.9 cm; RR 1.07 (0.59, 1.97). There was no significant reduction in risk of perforation with HC use for any polyp size. Conclusions Prophylactic HC placement is effective in prevention of DPPB from proximal colon polyps ≥ 2 cm, but of no significant benefit for polyps 1 to 1.9 cm in size or for distal colon polyps ≥ 2 cm.

A Case Report of Disseminated Blastomycosis With Thyroid Involvement in a Pregnant Patient.

Blastomyces dermatitidis is the causal agent of blastomycosis, an invasive and often serious fungal infection. Blastomycosis typically presents as a pulmonary infection, but common extrapulmonary manifestations of blastomycosis include the skin, bones, and reticuloendothelial systems. Disseminated blastomycosis occurs more prominently in immunocompromised individuals, such as organ transplant recipients, HIV patients, and pregnant women. We report here a rare case of disseminated blastomycosis to the thyroid in a pregnant patient. This case emphasizes the unique challenges of diagnosing and treating disseminated fungal infections in pregnancy.

Left ventricular diastolic dysfunction in liver transplantation: a stronger association with non-alcoholic steatohepatitis.

AIM OF THE STUDY: Cardiovascular death is an important cause of mortality in end stage liver disease (ESLD) patients undergoing orthotopic liver transplant (OLT). Left ventricular diastolic dysfunction (LVDD) is often the early manifestation and only measurable manifestation of cirrhotic cardiomyopathy. Therefore, it is important to understand the risk factors for LVDD in ESLD patients undergoing OLT and its immediate impact post-operatively. MATERIAL AND METHODS: Electronic medical records (EMR) of 100 consecutive patients who underwent OLT were reviewed at the University of Tennessee/Methodist University Hospital in Memphis, Tennessee, USA. Transthoracic echocardiogram (TTE) reports were accessed to evaluate for LVDD based on the latest 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines. The clinical and demographic variables were obtained and variable quality measures, incidence of cardiac arrhythmias, and 30-day all-cause mortality were compared. RESULTS: Patients with LVDD were older (62.7 ±6.3 years vs. 55.9 ±12.3 years, p = 0.017) and were more often female (57% vs. 31%, p = 0.026). In addition, patients with non-alcoholic steatohepatitis (NASH) were more likely to have LVDD (48% vs. 12%, p = 0.001). In contrast, patients with alcoholic liver disease were less likely to have LVDD (10% vs. 33%, p = 0.032). In a multivariate logistic regression analysis, NASH (OR = 4.4 [95% CI: 1.33-14.5], p = 0.015) and female gender (OR = 3.31 [95% CI: 1.09-9.99], p = 0.033) were independent predictors of LVDD. CONCLUSIONS: In our cohort of patients, the presence of NASH was associated with a higher risk of LVDD. However, presence of LVDD did not influence immediate post-transplant outcome or 30-day all-cause mortality.

Colonic diaphragm disease secondary to nonsteroidal anti-inflammatory drug use.

Diaphragm disease is a rare condition associated with the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) and can lead to severe complications. Most strictures occur in the small bowel, and occurrence in the colon is rare. We report a case of an asymptomatic patient with colonic diaphragm disease secondary to NSAID use.

Natural History of Non-Alcoholic Fatty Liver Disease: A Study With Paired Liver Biopsies.

BACKGROUND: Although there is unequivocal evidence for progression of nonalcoholic steatohepatitis (NASH) to cirrhosis, there is uncertainty with regard to the progression to nonalcoholic fatty liver (NAFL) and NASH. AIMS: We investigated the rate of progression to NASH and advanced fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) and assessed the factors associated with such progression. METHODS: Histological assessment was performed in 36 patients with NAFLD with paired liver biopsies (≥1 year apart; median, 3.8 years; range, 1-10.33 years). NASH Clinical Research Network (NASH CRN) criteria were used to assess NAFLD Activity Score (NAS). RESULTS: At baseline, 26 (72%) patients had NAFL and 10 (28%) patients had NASH. At follow-up, 27% NAFL progressed to NASH (NAS score ≥5), and 50% of patients with NASH no longer met the criteria of NASH. Fibrosis progressed in 15 (42%), regressed in 9 (25%), and remained stable in 12 (33%) patients overall. Thirty-five percent of patients with NAFL had fibrosis progression. The incidence of type 2 diabetes mellitus (T2DM) was higher in patients with NASH versus NAFL (40% vs. 27%). Both at the time of baseline and follow-up, liver biopsies, composite models of noninvasive scores such as Fibrosis-4 (FIB-4) score and NAFLD fibrosis score, and ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) were all significantly higher in progressors than in nonprogressors. CONCLUSIONS: NAFLD is a dynamic liver disease with varying degrees of progression and regression. T2DM was strongly associated with fibrosis progression. Noninvasive fibrosis scores such as AST/ALT ratio, FIB-4 score, and NAFLD fibrosis score can identify those at risk of fibrosis progression.

Accuracy of Noninvasive Fibrosis Scoring Systems in African American and White Patients With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: Nonalcoholic fatty liver disease fibrosis score (NFS), fibrosis-4 (FIB-4) score, aspartate aminotransferase (AST)-to-platelet ratio index (APRI) score, and AST-alanine aminotransferase (ALT) ratio are noninvasive fibrosis scoring systems for the staging of liver fibrosis in patients with chronic liver disease. METHODS: In a large cohort of patients with nonalcoholic fatty liver disease, we compared AST-ALT ratio, NFS, FIB-4 score, and APRI score in predicting advanced fibrosis (defined as fibrosis stage ≥ 3) in histologically confirmed African American (AA) and white patients. We identified 907 patients: 677 (74.6%) white and 230 (25.3%) AA patients with nonalcoholic fatty liver disease. RESULTS: Of the 907 patients, 115 (12.8%) patients had advanced fibrosis (stages 3 and 4) in the total cohort: 6 (2.6%) AAs, and 109 (16.2%) whites. In AAs, the area under the receiver operating characteristic (area under the curve) for predicting advanced fibrosis was 0.58 by NFS, 0.86 by APRI score, 0.77 by FIB-4 score, and 0.65 by AST-ALT ratio. In whites, the area under the receiver operating characteristic for predicting advanced fibrosis was 0.82 by NFS, 0.82 by APRI score, 0.88 by FIB-4 score, and 0.76 by AST-ALT ratio. In the AA population, NFS > 0.675, FIB-4 score > 2.67, and APRI score > 1.5 each has a negative predictive value of 98%, whereas the negative predictive values in whites are 91%, 88%, and 85%, respectively. DISCUSSION: Noninvasive fibrosis scoring systems can reliably exclude advanced fibrosis in both AAs and whites and have acceptable discriminatory ability to predict advanced fibrosis in whites. The utility of noninvasive fibrosis scoring systems in predicting advanced fibrosis in AAs needs further validation in a larger multicenter cohort.

Hyperammonemic encephalopathy associated with 5-fluorouracil in a patient with previous orthotopic liver transplantation.

5-Fluorouracil (5-FU)-based chemotherapy is the most common regimen used to treat metastatic or advanced colon cancer. Neurotoxicity is a rare but serious adverse effect of 5-FU-based therapy. We report an unusual case of 5-FU-induced hyperammonemic encephalopathy in a patient with recurrent colon cancer that metastasized to the liver and lung. Two days after receiving the third dose of FOLFOX, he presented with altered mental status, agitation, abdominal pain, nausea, and vomiting. His total ammonia level was 434 µmol/L, for which he was treated with lactulose retention enema and lactulose via nasogastric tube. Over the next 24 hours, his condition improved significantly.

Mirtazapine for Refractory Gastroparesis.

Gastroparesis is a chronic condition of delayed gastric emptying in the absence of mechanical outlet obstruction. We report a 47-year-old African American woman with diabetic gastroparesis who presented with intractable nausea, vomiting, and decreased oral intake with electrolyte disturbances. The patient's symptoms were difficult to control with antiemetic and conventional prokinetic agents, and she was started on mirtazapine 15 mg nightly. She experienced an almost complete symptom relief and was able to tolerate solid food within 24-48 hours. We highlight the role of mirtazapine, a 5-HT1a agonist, as an effective therapy for refractory gastroparesis.

Incidence and predictors of acute coronary syndrome within a year following a negative stress test-a false sense of security: is routine screening any useful?

One of the major issues in management of the acute coronary syndrome (ACS) is classification of patients with atypical presentation who have low risk of having a coronary episode at presentation. There have been multiple studies on the stratification of high risk patients and medical management of such cases, however, there is a sub-class of patients who do not fit any category. In this paper, we have looked at the current literature on stratification of patients based on the study tools available and the risk of having a coronary episode during the following year. In our overview, we have found that the current methods in place namely, cardiac stress test and stress echocardiogram have a good prognostic factor in terms of mortality in the next one year and can safely stratify the patients at low risk when correlated with clinical presentation and laboratory studies. However, such data are limited for computerized tomography or magnetic resonant imaging and their application might be limited due to accessibility and cost of studies. Current guidelines for classification of high risk patient do an excellent job and we believe that proper application of stress tests together with other imaging modalities together with laboratory, clinical judgment, and proper use of medical management can help with safe discharge of patients from the emergency department (ED) and reduction of burden from healthcare.