A Rare Case of Squamous Cell Carcinoma of the Esophagus in a Patient With Goltz Syndrome.

Esophageal squamous cell carcinoma (ESCC) is the predominant type of esophageal carcinoma worldwide. It occurs mostly in the upper and middle thirds of the esophagus. We present the case of a young African American woman with Goltz syndrome who presented with dysphagia and weight loss and was found to have distal esophageal papillomatosis and squamous cell carcinoma. This occurrence of ESCC in an atypical location in a young woman without traditional risk factors is suggestive of malignant transformation of underlying papillomatosis. Goltz syndrome is a rare disorder, occasionally associated with esophageal papillomatosis. Although esophageal papillomatosis is considered to be benign, our case shows that it could have malignant potential and hence is likely worthy of surveillance.

Injury pattern recognition to discriminate competing causes of liver injury.

BACKGROUND: Competing causes of liver injury may be difficult to discriminate. Characterization of the typical phenotype of each injury defined by latency, time to improvement and biochemical pattern, could be helpful to identify the most likely of competing causes. METHODS: Liver injury characteristics of both bortezomib-associated drug-induced liver injury (DILI) and hepatitis B virus (HBV) reactivation associated with bortezomib are derived from PubMed listed publications. RESULTS: Bortezomib-associated DILI has very short latency of days and AP is found elevated, while liver injury due to HBV reactivation occurs after several months of bortezomib therapy. Therefore, a patient's liver injury pattern occurring 3 months into bortezomib therapy should be attributed to HBV reactivation. DISCUSSION: Identification of liver injury characteristics for competing causes of liver injury can be helpful to identify the most likely cause and improve clinical outcome.

Assessing risk of fibrosis progression and liver-related clinical outcomes among patients with both early stage and advanced chronic hepatitis C.

OBJECTIVE: Assessing risk of adverse outcomes among patients with chronic liver disease has been challenging due to non-linear disease progression. We previously developed accurate prediction models for fibrosis progression and clinical outcomes among patients with advanced chronic hepatitis C (CHC). The primary aim of this study was to validate fibrosis progression and clinical outcomes models among a heterogeneous patient cohort. DESIGN: Adults with CHC with ≥3 years follow-up and without hepatic decompensation, hepatocellular carcinoma (HCC), liver transplant (LT), HBV or HIV co-infection at presentation were analyzed (N = 1007). Outcomes included: 1) fibrosis progression 2) hepatic decompensation 3) HCC and 4) LT-free survival. Predictors included longitudinal clinical and laboratory data. Machine learning methods were used to predict outcomes in 1 and 3 years. RESULTS: The external cohort had a median age of 49.4 years (IQR 44.3-54.3); 61% were male, 80% white, and 79% had genotype 1. At presentation, 73% were treatment naïve and 31% had cirrhosis. Fibrosis progression occurred in 34% over a median of 4.9 years (IQR 3.2-7.6). Clinical outcomes occurred in 22% over a median of 4.4 years (IQR 3.2-7.6). Model performance for fibrosis progression was limited due to small sample size. The area under the receiver operating characteristic curve (AUROC) for 1 and 3-year risk of clinical outcomes was 0.78 (95% CI 0.73-0.83) and 0.76 (95% CI 0.69-0.81). CONCLUSION: Accurate assessments for risk of clinical outcomes can be obtained using routinely collected data across a heterogeneous cohort of patients with CHC. These methods can be applied to predict risk of progression in other chronic liver diseases.

Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin.

BACKGROUND AND STUDY AIMS: Arab-Americans (ArA) in Michigan, USA had the lowest colorectal cancer screening (CRCS) in 2008 compared to the state's general population (45.6% vs. 60.8%). The adherence rate and barriers to CRCS have been identified in a previous study; however, these differences have been not examined among ArA from different countries of origin. PATIENTS AND METHODS: Community-based study through a survey filled by 130 Arab-Americans aged ⩾50years. Demographic information and information about CRC screening knowledge were obtained. Responses were compared between the two largest population groups (Lebanese and Yemenis). RESULTS: The majority of the participants (80%) were from Lebanon (52.3%) and Yemen (27.7%). Majority of the Yemenis group have never been screened for CRC (72.2% vs. 27.9%, p<0.001). Majority of the unscreened Yemenis were males (100% vs. 63.2%, p=0.002). Both unscreened groups had similar length of residence in U.S., citizenship status, education level, health insurance and access to primary care physicians. Unscreened Lebanese had a higher family history of CRCS (31.6% vs. 0%, p=0.002). The most common reported barrier for both groups was the misconception that CRCS is not necessary (62% for Yemenis & 42% for Lebanese, p=0.197). Unscreened Yemenis were more unaware about CRCS (46% vs. 11%, p=0.002). CONCLUSION: CRC screening rates vary among Arab-Americans from different countries of origin. Physicians should consider the country of origin when recommending CRC screening to Arab-Americans.

Outcomes of patients with chronic hepatitis B who do not meet criteria for antiviral treatment at presentation.

BACKGROUND & AIMS: The availability of potent, well-tolerated, oral antivirals with low rates of resistance has led many experts to recommend liberalizing indications for the treatment of chronic hepatitis B (CHB). This study sought to determine the rate of transitions to an active phase of infection, the frequency of treatment initiation, and the clinical outcomes of patients with CHB who did not meet treatment criteria at presentation. METHODS: We reviewed medical records of patients with CHB, seen in the liver clinics at the University of Michigan Health System from 1999 through 2010, who did not receive antiviral treatment within 6 months of presentation. We collected data on transitions between different phases of CHB, hepatitis B e antigen (HBeAg) seroconversion, loss of hepatitis B surface antigen (HBsAg), and the development of hepatocellular carcinoma (HCC). Data analyses were censored or truncated at the time of treatment initiation or development of an outcome. RESULTS: Of the 234 patients analyzed, 52.1% were men (median age, 35 y), 72.2% were Asian, and 81.2% were HBeAg-negative. During a median follow-up period of 51 months, 19.2% of patients transitioned to a more active disease phase and 18.8% started antiviral therapy. Of the 44 HBeAg-positive patients, 4 patients (9%) had spontaneous HBeAg seroconversion. Nine HBeAg-negative patients but none of the HBeAg-positive patients lost HBsAg. The cumulative probability of HBsAg loss among HBeAg-negative patients was 1% at year 5 and 21% by year 10. No patients had flares of icteric hepatitis or hepatic decompensation. None of the HBeAg-positive patients developed HCC, whereas 2 HBeAg-negative patients developed HCC. CONCLUSIONS: Careful monitoring of patients with CHB who did not meet treatment criteria at presentation permits timely initiation of treatment, with a low risk of adverse clinical outcomes, based on a retrospective study with a median follow-up period of 4.3 years. These findings indicate that current guidelines for initiating treatment are appropriate.

Management of hepatitis B: our practice and how it relates to the guidelines.

Seven drugs have been approved for the treatment of chronic hepatitis B. Antiviral treatment has been shown to be effective in suppressing hepatitis B virus replication, decreasing inflammation and fibrosis in the liver, and preventing progression of liver disease. However, current medications do not eradicate hepatitis B virus; therefore, a key question is which patients need to start treatment and which patients can be monitored. Professional societies have developed guidelines to assist physicians in recognition, diagnosis, and optimal management of patients with chronic hepatitis B. These guidelines suggest preferred approaches, and physicians are expected to exercise clinical judgment to determine the most appropriate management based on the circumstances of the individual patient. This article reviews recommendations in hepatitis B guidelines and the basis for those recommendations, and we discuss what we do in our practice to illustrate factors that may influence decisions regarding hepatitis B management.

Reluctance to screening colonoscopy in Arab Americans: a community based observational study.

To explore compliance of Arab-Americans to colorectal cancer (CRC) screening and identify the barriers for non-compliance. An observational community based study. Arab-American Friday prayer attendees' ≥50 years in three mosques in Dearborn, MI volunteered. Demographics, health insurance status, screening history, availability of a primary care physician (PCP) and the ability to communicate in Arabic were inquired. The responses were compared using a student t test between respondents who have had CRC screening with colonoscopy and those who have not had any screening tests. A p value of 0.05 or lower was considered statistically significant. Total number surveyed was 130. Average age is 64 years. Males were 76 % (99) and females 24 % (31). More than 50 % were Lebanese and 28 % were from Yemen. Majority had health insurance (89 %), and 86 % had a primary care physician of which 79 % of them spoke Arabic. Half of the participants had colonoscopy mostly for screening purposes. Fifty-eight (45 %) participants did not have CRC screening. Majority of the females (72.4 %) had colonoscopy compared to 46.8 % of the males (p value = 0.016). The mean length of stay in the U.S was 39.16 years in the colonoscopy group compared to 30.77 years in the non-screening group (p value = 0.006). Participants without a PCP did not have CRC screening (77.8 %) (p value = 0.005). Participants with a non-Arabic speaking PCP had more colonoscopy rates (77.3 %) compared to those with an Arabic speaking PCP (50 %) (p value = 0.027). More Lebanese had colonoscopy (71.9 %) compared to 25.7 % of the surveyed Yemenis (p value = 0.00). Discomfort, unawareness about CRC screening, and nonrecommendation by PCP were reported barriers. Arab-Americans have lower screening colonoscopy rates. Unfamiliarity of the importance of screening is a principal issue. Having a non-arabic speaking PCP is beneficial. Better education to this population about the benefits and ease of screening could increase adherence to screening for this population.