Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial.

Background and Aim: Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed. Methods: Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months. Results: From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition. Conclusion: Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.

Prior hospital attendances in deceased Australian patients with alcohol-related liver disease: a multicentre project.

BACKGROUND AND AIMS: To establish the hospital visit history of patients who die with alcohol-related liver disease (ArLD). To determine if patients with ArLD present to hospital early or in the terminal phase of their disease. METHODS: Retrospective cohort study of patients with a history of ArLD who died as an inpatient at three tertiary Western Australian hospitals from February 2015 to February 2017. Hospital records were reviewed to identify the number and cause of emergency department (ED), inpatient and outpatient attendances in all Western Australian public hospitals in the 10 years prior to death. RESULTS: One hundred fifty-nine patients (23% female) had a total of 753 ED, 3535 outpatient appointments, 1602 hospital admissions and 10 755 admission days. Twelve months prior to death, 82% of patients had a public hospital contact and 74% an admission. Patients who had their first hospital contact within 12 months prior to death were significantly more likely to have a liver-related cause of death (P < 0.01). Aboriginal and Torres Strait Islander patients (15% of cohort) died at a significantly younger age (M = 49.2, SD = 10.5 years) than non-Aboriginal and Torres Strait Islander patients (M = 59.9, SD = 10.2 years, P < 0.01). Despite having more ED attendances and hospital admissions, Aboriginal and Torres Strait Islander patients had significantly less (P = 0.04) outpatient appointments (Mdn = 5.5, interquartile range [IQR] = 1-18 vs Mdn = 11, IQR = 3-33). CONCLUSIONS: Most patients with ArLD have multiple early attendances, which present an opportunity for early interventions. There are missed opportunities for Aboriginal and Torres Strait Islander patients for outpatient hospital engagement.

Successful Liver Retransplantation in a Patient With Disseminated Aspergillosis and Nocardiosis: A Case Report.

BACKGROUND: Clinical guidelines list active fungal infection and sepsis as contraindications to liver transplantation due to the risk of worsening infection with immunosuppression postoperatively. Mortality from systemic opportunistic infections in transplant recipients is high, approaching 100% for disseminated aspergillosis. However, the optimal duration of treatment required before transplant is unclear. Additionally, delaying surgery while the infection is treated risks death from hepatic decompensation and physical deconditioning, preventing progression to transplantation. CASE REPORT: Here, we present a patient who underwent successful repeat liver transplantation for recurrent autoimmune hepatitis and graft rejection while undergoing treatment for disseminated aspergillosis and nocardiosis. He had pulmonary, hepatic, and central nervous system involvement. He had received 2 months of antimicrobials but had ongoing radiologic evidence of infection when listed for retransplantation. He remains well and infection-free 1 year postoperatively. CONCLUSION: Few cases of successful liver transplantation in the setting of disseminated aspergillosis have been reported previously. To our knowledge, this is the first successful liver transplant in a patient with disseminated nocardial infection.

Prevalence of gastrointestinal malignancy in non-anemic iron deficiency and significance for endoscopic screening: A Western Australian multicenter cohort study.

BACKGROUND AND AIM: There is a paucity of evidence regarding non-anemic iron deficiency as a predictor for colorectal cancer and therefore the indication for endoscopic evaluation. This study explores the rates of malignancy in adults with iron deficiency with and without anemia. METHODS: A retrospective multicenter diagnostic cohort study was conducted across two Australian health services. All cases that underwent both esophagogastroduodenoscopy and colonoscopy between September 1, 2018, and December 31, 2019, for the investigation of iron deficiency were included, and the cohort was divided into anemic and non-anemic arms. Multivariate binomial logistic regression was performed to establish clinical characteristics associated with neoplasia. RESULTS: Five hundred eighty-four patients underwent endoscopic evaluation over a 16-month period. There was a significantly higher rate of malignancy in the iron deficiency anemia arm as compared with those without anemia (8.76% vs 1.20%, P < 0.01). Gastrointestinal pathology to account for iron deficiency was identified in > 60% of the total cohort. The presence of anemia (odds ratio [OR] 6.87, P < 0.01) and male gender (OR 3.01, P = 0.01) were significant predictors of malignancy. CONCLUSION: This study demonstrates that anemic iron deficiency confers a significantly greater risk of gastrointestinal cancer compared with non-anemic iron deficiency. Additionally, over 60% of patients had gastrointestinal pathology to account for iron deficiency overall, supporting the need to perform baseline endoscopy in patients with iron deficiency.