Macro-Aspartate Aminotransferase: A Benign Cause of Abnormal Laboratory Findings.

Isolated, persistent elevations of aspartate aminotransferase (AST) without plausible explanation may lead to diagnostic confusion. Macro-enzyme aspartate aminotransferase (macro-AST) is an uncommon and benign cause of persistently elevated AST levels in the absence of other diseases. We present a case of macro-AST in an otherwise healthy adult male which was confirmed by polyethylene glycol (PEG) precipitation.

An Unusual Presentation of Crohn's Disease and Primary Sclerosing Cholangitis.

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory gastrointestinal bowel disorders that may affect any part of the alimentary tract. Classically, these two diseases have hallmark associations, such as UC with primary sclerosing cholangitis (PSC). We present a case of a healthy 21-year-old white female with concomitant CD and PSC, complicated by a biliary stricture requiring stent placement. We discuss shared risk factors, disease pathogenesis, and hallmark pathological associations. To the best of our knowledge, there are a limited number of reported cases that demonstrate the dual phenotype of CD and PSC.

A Rare Case of Gastrointestinal Amyloidosis Presenting as Dysphagia.

A 74-year-old male with an unintentional 20-pound weight loss over the past year presented with new-onset dysphagia to solid foods. Esophagogastroduodenoscopy showed a subtle stricture with ill-defined scar tissue-like findings in the distal esophagus and erosions in the antrum of the stomach without masses. Pathologic findings showed the presence of amyloidosis involving the proximal and distal esophagus, as well as gastric mucosa with chronic inflammation and reactive epithelial changes. We present a rare case of dysphagia as the initial presentation of gastrointestinal amyloidosis.

Butterfly in the Esophagus: A Case Report on a Rare Esophageal Manometry Catheter Malposition.

We report the case of a 75-year-old man who underwent high-resolution manometry (HRM) testing for solid food dysphagia after an unrevealing upper endoscopy and biopsies. A barium esophagogram confirmed nonspecific motility disorder. A subsequent HRM study was performed, but when all swallow studies were noted to fail, and the manometric images revealed a butterfly wings appearance, it was found that the manometry catheter was actually coiled and folded back cephalad. As there are only a few other case reports with similar presentations, we believe this case would serve as a good reminder for clinicians to practice caution when cannulating the manometry catheter.

Improving Fecal Immunochemical Testing Rates for Colon Cancer Screening in the Outpatient Setting.

OBJECTIVES: The amount of colorectal cancer (CRC) screening using the noninvasive fecal immunochemical test (FIT) at a federally qualified health center, Five Rivers Health Clinic (Dayton, Ohio), has been low historically. Our quality improvement (QI) project aimed to improve CRC screening adherence in eligible patients who opted for FIT. METHODS: Three hundred ninety-two patients with FIT orders for CRC were screened during an 11-month period. The preintervention group (pre-I) was enrolled from December 1, 2018 to May 31, 2019, and the postintervention group (post-I) from June 1, 2019 to October 31, 2019. Three interventions were used: resident physicians trained during clinic meetings regarding FIT education for patients, posters displayed in patient rooms outlining the benefits of CRC screening, and standardized US mail reminder letters sent to FIT patients. Patient demographics and clinical variables were collected along with return rate. RESULTS: The return rate for post-I was twice that of pre-I (74.4%, 95% confidence interval 64.6-82.3 vs 31.1, 95% confidence interval 26.2-36.6; P < 0.001). The pre-I/post-I groups did not differ on demographic and clinical characteristics, and, except for race, none of these variables was associated with returning the FIT screening card. CONCLUSIONS: The compliance rate for FIT completion and return more than doubled among our clinic patients after using a three-component QI intervention. Except for a difference in race, the lack of association between demographic and clinical characteristics with either pre-I/post-I group or return/no return of the FIT card leads us to conclude that our QI program for increasing FIT compliance is effective. Other settings where CRC screening is a prominent component of preventive care may benefit from adopting a similar QI intervention.

Kayexalate-induced colitis and rectal stricture.

A 57-year-old man underwent emergency laparoscopic loop colostomy for acute recto-sigmoid obstruction. He was hospitalised 2 months previously, at another facility for diabetic ketoacidosis (DKA) and hyperkalaemia. He had no gastrointestinal symptoms prior to the hospitalisation. Both surgical exploration and intraoperative sigmoidoscopy showed ulcerations of sigmoid colon and proximal rectum with a pinhole stricture in mid-rectum. After ruling out all aetiologies, and due to persistence of the colonic ulcerations on a follow-up colonoscopy, a diagnosis of Crohn's colitis was made, and the patient was started on infliximab and 6-mercaptopurine (6-MP). Six months later, on rereview of all the biopsies, it was noted that a key element of presence of crystals suggestive of Kayexalate on the initial colorectal biopsies was missed. It was later found out that the patient had received rectal Kayexalate for treatment of DKA at the other facility. Hence, infliximab and 6-MP were both discontinued. All the colonoscopies, following the discontinuation of the medications, showed complete resolution of colitis but persistence of the mid-rectum stricture. This was treated with a fully covered metal stent for 12 weeks with only partial improvement of the stricture. He was hence referred for ultra-low anterior resection of rectum and take down of colostomy.

The Relationship Between Number of Comorbidities and Age of Colorectal Cancer Diagnosis in US Male Veteran Population: A Single-Center Experience.

BACKGROUND: Comorbidities of tobacco and alcohol abuse and obesity are major risk factors for colon carcinogenesis. These risk factors are considered the most prevalent modifiable risk factors linked to malignancies including colorectal cancer (CRC) in both high- and low-income countries. The aim of this study was to investigate the relationship between number of comorbidities and age of CRC diagnosis in US male veteran population. METHODS: A retrospective single-center study using chart review and the International Classification of Diseases, Ninth Revision (ICD-9) codes to identify patients with a diagnosis of CRC and comorbidities of tobacco abuse, alcohol abuse, hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD). The primary aim was to study effect of these comorbidities on age of CRC diagnosis. Univariable and then multivariable logistic regression models were fit to age at diagnosis for each patient variable. RESULTS: A total of 362 patients were included in the study. The mean age of CRC diagnosis was 66.8. Eighty percent were Caucasians, and 20% were African Americans. African Americans were diagnosed with CRC 3.8 years younger compared to Caucasians (P = 0.01). Controlling for other variables in the multivariable model, age at CRC diagnosis was significantly lower for African Americans and for patients with higher total counts for tobacco and alcohol abuse and obesity. HTN, DM and CKD were not associated with a lower age of CRC diagnosis. CONCLUSIONS: Tobacco and alcohol abuse and obesity have negative cumulative effect on age of CRC diagnosis in US male veteran population. Patients with increasing number of these comorbidities are associated with significantly lower age of CRC diagnosis. It is important to identify veterans with these comorbidities and encourage CRC screening.

Differential MicroRNA Signatures in the Pathogenesis of Barrett's Esophagus.

OBJECTIVES: Barrett's esophagus (BE) is the precursor lesion and a major risk factor for esophageal adenocarcinoma (EAC). Although patients with BE undergo routine endoscopic surveillance, current screening methodologies have proven ineffective at identifying individuals at risk of EAC. Since microRNAs (miRNAs) have potential diagnostic and prognostic value as disease biomarkers, we sought to identify an miRNA signature of BE and EAC. METHODS: High-throughput sequencing of miRNAs was performed on serum and tissue biopsies from 31 patients identified either as normal, gastroesophageal reflux disease (GERD), BE, BE with low-grade dysplasia (LGD), or EAC. Logistic regression modeling of miRNA profiles with Lasso regularization was used to identify discriminating miRNA. Quantitative reverse transcription polymerase chain reaction was used to validate changes in miRNA expression using 46 formalin-fixed, paraffin-embedded specimens obtained from normal, GERD, BE, BE with LGD or HGD, and EAC subjects. RESULTS: A 3-class predictive model was able to classify tissue samples into normal, GERD/BE, or LGD/EAC classes with an accuracy of 80%. Sixteen miRNAs were identified that predicted 1 of the 3 classes. Our analysis confirmed previous reports indicating that miR-29c-3p and miR-193b-5p expressions are altered in BE and EAC and identified miR-4485-5p as a novel biomarker of esophageal dysplasia. Quantitative reverse transcription polymerase chain reaction validated 11 of 16 discriminating miRNAs. DISCUSSION: Our data provide an miRNA signature of normal, precancerous, and cancerous tissue that may stratify patients at risk of progressing to EAC. We found that serum miRNAs have a limited ability to distinguish between disease states, thus limiting their potential utility in early disease detection.

microRNA involvement in the onset and progression of Barrett's esophagus: a systematic review.

Esophageal adenocarcinoma (EAC) is a highly aggressive malignancy that develops from Barrett's esophagus (BE), an intestinal metaplasia of the distal esophagus. microRNAs (miRNAs), short non-coding regulatory RNAs, are frequently dysregulated in BE and are thought to play key roles in the onset of BE and its progression to EAC. miRNAs thus have potential diagnostic and prognostic value and are increasingly being used as cancer biomarkers. This review summarizes the current literature related to miRNAs that are dysregulated in BE within the context of Hedgehog, Notch, MAPK, NF kappa-B, Wnt and epithelial-mesenchymal transition (EMT) signaling which are thought to drive BE onset and progression. This comprehensive analysis of miRNAs and their associated signaling in the regulation of BE provides an overview of vital discoveries in this field and highlights gaps in our understanding of BE pathophysiology that warrant further investigation.

The relationship between aspirin use and mortality in colorectal cancer.

BACKGROUND: Aspirin use lengthens survival in patients with colorectal cancer (CRC). We aimed to add to the evidence examining this relationship and to compare the survival benefit between aspirin started before CRC diagnosis with those started after CRC diagnosis. METHODS: The study involved 173 consecutive patients who had a histopathologic diagnosis of colorectal carcinoma between 1996 and 2014. The electronic medical record was used to collect data on demographic characteristics (age, sex, and race), family history of cancer, use or non-use of aspirin before and after cancer diagnosis, cancer stage at diagnosis, and days from cancer diagnosis to death. Patients were divided into aspirin using and non-aspirin using groups. RESULTS: Aspirin users (ASAU, n=90) were older than non-aspirin users (NASAU, n=83; 70.8±9.1 vs. 66.2±10.2 years; P=0.004). The two groups were similar in sex, race, and family history of cancer, but the non-users of aspirin were more likely to have stage III or stage IV CRC (NASAU =57.5%; ASAU =38.6%; P=0.014). Aspirin users survived more than twice the number of days than non-users (ASAU median =941 days; NASAU median =384 days; P=0.003). Patients who used aspirin only before their CRC diagnosis had a short survival period from diagnosis to death (median =149). CONCLUSIONS: Our findings support the relationship of aspirin use and duration of use with enhanced survival in patients with CRC. Physicians may want to recommend that patients at increased risk for CRC and those already diagnosed, but not yet on aspirin, start an aspirin regimen.

Evaluating alcohol use among Russian women at risk for an alcohol-exposed pregnancy: A comparison of three measures of alcohol use.

The Quick Drinking Screen (QDS) and Timeline Followback (TLFB), measures of alcohol use, have yielded similar reports of drinking with English speakers. The present study, a secondary data analysis, compared three measures of alcohol use (i.e., QDS, TLFB, and AUDIT) among Russian-speaking women. This is the first study to compare all three measures. This study replicated the findings of studies with English speakers and demonstrated that brief screening measures (QDS, AUDIT) provide reliable summary measures of alcohol use when compared to a detailed drinking measure (TLFB). The use of brief screening measures is recommended for use with Russian women.

Reducing alcohol consumption to minimize weight gain and facilitate smoking cessation among military beneficiaries.

INTRODUCTION: Smoking cessation-related weight gain can have significant negative health and career consequences for military personnel. Alcohol reduction combined with smoking cessation may decrease weight gain and relapse. METHOD: A randomized clinical trial of military beneficiaries compared a standard smoking cessation (i.e., brief informational) intervention (N=159), with a brief motivational smoking cessation intervention that emphasized reduced drinking to lessen caloric intake and minimize weight gain (N=158). RESULTS: Participants who received the motivational intervention were significantly more likely to quit smoking at the 3-month follow-up (p=0.02), but the differences were not maintained at 6 (p=0.18) or 12months (p=0.16). Neither weight change nor alcohol reduction distinguished the 2 groups. Smoking cessation rates at 12months (motivational group=32.91%, informational group=25.79%) were comparable to previous studies, but successful cessation was not mediated by reduced drinking. CONCLUSIONS: Alcohol reduction combined with smoking cessation did not result in decreased weight gain or improved outcomes.

Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial of a Self-Administered Version of Project CHOICES with College Students and Nonstudents.

BACKGROUND: Alcohol-exposed pregnancies (AEPs) are a preventable cause of birth defects and developmental disabilities for which many women are at risk. The initial 5-session Project CHOICES intervention was found to prevent AEPs. In the ensuing decade, there have been several additional CHOICES-like studies. This study, Project Healthy CHOICES, had 2 objectives: (i) to compare outcomes for students versus nonstudents; and (ii) to test a self-administered mail-based version of the Project CHOICES intervention. METHODS: A randomized controlled trial (RCT) compared 2 interventions for women of childbearing age (18 to 44) who were at risk of an AEP: (i) motivational feedback based on Project CHOICES and (ii) information only. Advertisements recruited 354 women (145 college students; 209 nonstudents) at risk of an AEP. Intervention and study materials were available in English and Spanish. Of the 354 women, 44% were minorities (25% identified as Hispanics). RESULTS: At the 6-month follow-up, the interventions did not differ and there was no Intervention by Student Study interaction. However, over the entire 6-month follow-up, significantly more students (68%) than nonstudents (46%) were not at risk of an AEP (2.1 odds ratio; confidence interval = 1.47 to 2.95). For all groups, risk reduction occurred primarily through effective contraception. CONCLUSIONS: There was no significant difference between the 2 interventions. However, over the entire 6-month follow-up interval, college students were significantly more likely than nonstudents to not be at risk of an AEP and to use effective contraception. While the student groups had significantly higher reduced risk of AEP outcomes, there was also substantial risk reduction for women in the information only condition. These results suggest that the most effective AEP prevention efforts would be to inform women at risk that they could become pregnant. Because about half of all pregnancies are unplanned, identifying women at risk and preventing the risk of AEPs should be a public health priority.

Acute pancreatitis as a complication of trans-arterial chemoembolization of hepatocellular cancer-case report and review of literature.

Transarterial chemoembolization (TACE) is a therapeutic procedure often performed for hepatocellular carcinoma (HCC). Local complications, though generally uncommon, can arise from arterial ischemia and local cytotoxicity from the chemotherapeutic delivery. We present a case of acute pancreatitis as a rare complication of the TACE procedure along with a review of literature of this uncommon adverse effect.

Two Brief Measures of Alcohol Use Produce Different Results: AUDIT-C and Quick Drinking Screen.

BACKGROUND: Several psychometrically sound measures of alcohol use have been developed to assess drinking. The Alcohol Use Disorders Identification Test (AUDIT) and its shorter counterpart the AUDIT-C, which contains the first 3 AUDIT questions, were developed by the World Health Organization and have become the preferred brief measures for screening and evaluating problem severity. This study compared the first 3 questions on the AUDIT with another psychometrically sound brief measure of alcohol use, the Quick Drinking Screen (QDS). METHODS: Data were obtained from a randomized controlled trial of a mail-based intervention promoting self-change with 472 alcohol abusers (n = 280, no prior alcohol treatment; n = 192, prior alcohol treatment). Participants' retrospective self-reports of alcohol consumption were collected using the QDS and the 3 AUDIT-C questions and compared. Although both measures contain similar questions (2 quantity-frequency and 1 binge drinking), they differ in 2 important ways: (i) temporal interval over which data are collected, and (ii) formatting of response options (i.e., a continuous number vs. categorical). RESULTS: Intraclass correlations for drinking variables were moderate to moderately high. A repeated-measures MANOVA using treatment condition and gender as variables revealed significant differences in absolute values between the 2 drinking measures with the QDS showing greater consumption on almost all variables. Participants' numerical answers on the QDS were compared to their categorical answers to the similar alcohol use questions on the AUDIT-C. The comparison revealed that participants' answers on the AUDIT-C were associated with extreme variability compared to their QDS answers. This variability suggests the AUDIT-C would be unreliable as a quantitative measure of alcohol consumption. CONCLUSIONS: The differences between the 3 alcohol use questions on the AUDIT-C and the same questions on the QDS may reflect the imprecision of the AUDIT-C's drinking response categories. Results suggest that the QDS can be used to identify risky drinking and to provide a more informative characterization of a drinker's alcohol consumption than that provided by the AUDIT-C.

Is exposure to Agent Orange a risk factor for hepatocellular cancer?-A single-center retrospective study in the U.S. veteran population.

BACKGROUND: Approximately 15% to 35% of those with chronic hepatitis C (CHC) related cirrhosis will develop hepatocellular cancer (HCC). With this burden increasing across the globe, identification of risk factors for HCC has become imperative. Exposure to Agent Orange has been implicated as a possible risk factor for liver cancer in a study from the Republic of Korea. However, there has been no study in U.S. veterans with CHC and cirrhosis that has evaluated exposure to Agent Orange as a risk factor for HCC. We conducted a retrospective study of U.S. military veterans diagnosed with CHC and cirrhosis over a period of 14 years to evaluate potential risk factors for HCC including exposure to Agent Orange. METHODS: We retrospectively reviewed 390 patients with confirmed CHC-related cirrhosis between 2000 and 2013 and identified patients with HCC. We compared demographic, laboratory, and other clinical characteristics of patients with and without HCC. RESULTS: The mean age of the cohort was 51 years (SD =7.5), with the majority being male (98.5%). Seventy-nine of 390 (20.2%) patients developed HCC, diagnosed on average 8 (SD =4.8) years after diagnosis of CHC. Nearly half (49.4%) were Childs A, 40.5% were Childs B, and 10.1% were Childs C. HCC patients were more likely to be African American than non-HCC patients (40.5% vs. 25.4%, P=0.009) and to be addicted to alcohol (86.1% vs. 74.3%, P=0.027). A trend toward significance was seen in the HCC group for exposure to Agent Orange (16.5% vs. 10.0%, P=0.10) and smoking addiction (88.6% vs. 80.7%, P=0.10). Consequently, race, alcohol addiction, Agent Orange exposure, and smoking addiction were included in the multivariable logistic regression (MLR) analysis. Alcohol addiction [odds ratio (OR) =2.17; 95% confidence interval (CI), 1.07-4.43] and African American race (OR =2.07; 95% CI, 1.22-3.51) were found to be the only two definitive independent risk factors for HCC in our sample. CONCLUSIONS: African American race and alcohol addiction were independent risk factors for HCC development in this U.S. veteran population. There was no significant association between exposure to Agent Orange and HCC, although larger studies are needed in the U.S. military veteran population to evaluate further this toxic herbicide from the Vietnam War era.

Craigslist versus print newspaper advertising for recruiting research participants for alcohol studies: Cost and participant characteristics.

INTRODUCTION: Technology has transformed our lifestyles in dramatic and significant ways, including new and less expensive options for recruiting study participants. This study examines cost and participant differences between two recruitment sources, Craigslist (CL), and print newspapers (PNs). This paper also reviewed and compared studies involving clinical trials published since 2010 that recruited participants using CL alone or in combination with other methods. METHOD: Secondary data analyses from a parent study involving a randomized controlled trial of a mail-based intervention to promote self-change with problem drinkers. RESULTS: Significant differences were found between CL and PN participants on most demographic and pretreatment drinking variables. While all participants had AUDIT scores suggestive of an alcohol problem and reported drinking at high-risk levels, CL participants had less severe drinking problem histories, were considerably younger, and had a higher socioeconomic status than PN participants. The total advertising costs for the 65 CL ads ($275) were significantly less than the 69 PN ads ($33, 311). The recruiting cost per eligible participant was vastly less expensive using CL ($1.46) compared to print newspaper ads ($116.88). CONCLUSIONS: Using CL is a viable recruitment method for soliciting participants, particularly those that are younger, for alcohol intervention studies. It is also less expensive than newspaper ads. When CL participants were recruited, they reported being slightly more confident to change their drinking than PN participants. Limitations of using CL are discussed, including that some initial ad responders gave inconsistent answers to similar questions and a few tried to enter the study more than once.

Risk Factors for 30-Day Readmissions of Individuals with Decompensated Cirrhosis.

OBJECTIVES: Patients with cirrhosis have a high rate of 30-day hospital readmission that affects their quality of life and contributes to increased healthcare-related costs. The aim of our study was to identify frequency, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis. METHODS: We retrospectively reviewed electronic medical records of all patients with a confirmed diagnosis of decompensated cirrhosis admitted to Dayton VA Medical Center between 2009 and 2013. Demographics, clinical factors, laboratory values, and outcomes were recorded. Univariate analysis was performed using independent samples t tests and Wilcoxon rank sums tests for continuous variables and χ(2) or Fisher exact tests for categorical variables. A multiple logistic regression analysis was performed for variables found to be significant by univariate analysis to predict the risk factors for 30-day readmission. A detailed chart review was conducted for all patients readmitted within 30 days by a single gastroenterologist to identify the reason for readmission and to decide whether any of these readmissions were preventable. RESULTS: The 30-day readmission rate for decompensated cirrhotic patients was 27.03%. The risk factors for 30-day readmission were higher body mass index (BMI), lower body temperature, higher blood urea nitrogen, higher creatinine, more cirrhosis-related complications, and more readmissions per year per univariate analysis. Multivariable analysis revealed only BMI as a significant predictor of 30-day readmission (P = 0.023). A total of 36.7% of 30-day readmissions were possibly preventable. CONCLUSIONS: The independent variable that predicted 30-day readmission in patients with decompensated cirrhosis was higher BMI. Approximately one-third of 30-day readmissions were possibly preventable. These findings support the need to develop specific interventions for disease management to improve patient care and save on extraneous healthcare costs.