Incidence of Kidney Stones After Bariatric Surgeries: Comparing Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

INTRODUCTION/PURPOSE: The two most common procedures performed to treat obesity are Roux-En-Y gastric bypass (RNYGB) and laparoscopic sleeve gastrectomy (LSG). Due to changes in enteric absorption, bariatric surgery increases rates of nephrolithiasis. As population-based data are limited, we aimed to compare the incidence of kidney stones after RNYGB and LSG. MATERIALS AND METHODS: We queried Explorys (Cleveland, OH), a database that aggregated data from 26 healthcare systems. We identified patients who were newly diagnosed with nephrolithiasis 3, 6, and 12 months after their RNYGB or LSG. Additionally, a multivariate analysis was conducted to investigate the association of nephrolithiasis with RNYGB as compared to LSG. This analysis adjusted for other risk factors, including age above 65, male gender, Caucasian race, diabetes mellitus, hypertension, primary hyperparathyroidism, gout, and obesity. RESULTS: From 1999 to 2019, there were 11,480 patients who underwent RNYGB and 22,770 patients who underwent LSG. The incidence of nephrolithiasis in the RNYGB cohort at all three time points was higher than in the LSG cohort (3 months, 7.1% vs. 2.4%; 6 months, 6.6% vs. 2.0%; 1 year, 5.8% vs. 1.4%; P < 0.001). After the multivariate analysis, it was found that, though both RNYGB and LSG were independently associated with the development of nephrolithiasis, the risk of nephrolithiasis was higher in those who underwent RNYGB compared to those who underwent LSG (OR 1.594, 95% CI 1.494 to 1.701, P < 0.001). CONCLUSION: RNYGB is associated with a higher risk of nephrolithiasis when compared to LSG.

Vitamin D Receptor Expression in Chronic Plaque Psoriasis Before and After Narrowband Ultraviolet B Phototherapy.

Background/Purpose: Psoriasis is a multifactorial disease. It is a combination of genetic, immunological, and environmental factors. Vitamin D receptor (VDR) is a nuclear receptor that regulates epidermal cell growth through the inhibition of proliferation and induction of keratinocytes terminal differentiation. Aim of the study was to investigate the effect of Narrow-band UVB (NB-UVB) therapy on VDR expression in the skin of psoriasis patients. Materials and Methods: Forty patients with different severities of psoriasis were assessed using the psoriasis area and severity index (PASI) score. Lesional and non-lesional skin biopsies were obtained from each patient before NB-UVB therapy, and then a third lesional biopsy was performed after completing 24 sessions of NB-UVB. Immunohistochemistry for VDR was performed on all specimens. Results: There was a significant decrease in VDR expression in psoriatic lesions compared to that in non-lesional skin before treatment. A statistically negative correlation was detected between the degree of VDR expression before treatment and PASI score, family history, and duration of psoriasis. There was a significant increase in VDR expression at the sites of psoriasis lesions post-NB-UVB therapy compared to pretreatment lesional skin. Conclusion: VDR expression was down-regulated in psoriatic lesions compared to non-lesional skin, and NB-UVB therapy improved VDR expression in psoriasis skin lesions.

Perigastric Hematoma Masquerading as a Gastric Tumor.

Perigastric and intramural gastric hematomas rarely occur, with most cases associated with trauma, coagulopathy, and peptic ulcer disease. Furthermore, hematomas in the upper gastrointestinal tract are commonly located in the esophagus and duodenum. In this case report, we describe a hematoma masquerading as a gastric tumor on esophagogastroduodenoscopy (EGD) in a 54-year-old male presenting with melena. Initial computed tomography (CT) imaging suggested gastrointestinal stromal tumor (GIST) as the probable cause. We performed endoscopic ultrasound (EUS) with findings consistent with a perigastric hematoma, which aligned with the patient's diagnosis of splenic vein thrombosis (SVT) and numerous collateral vessels communicating with the hematoma. Interventional radiology (IR) was consulted for further management, although we ultimately chose a conservative approach.

Mycophenolate Mofetil-Induced Colonic Injury Manifesting Endoscopically As Ischemic Colitis.

Mycophenolate mofetil (MMOF) is a commonly used immunosuppressive prodrug in kidney transplant patients. However, it is not without side effects. The most common of these is diarrhea which inadvertently leads to colonoscopic and endoscopic evaluation when all other workup returns negative. Colonoscopies often show diffuse ulcers and colitis changes depending on the degree of diarrhea. In rare situations, MMOF-induced ischemic colitis may occur on gross endoscopy. We describe an unusual phenomenon of an adult male status post renal transplant with histopathologically diagnosed MMOF-induced colitis who developed gross endoscopic findings concerning ischemic colitis. Our case highlights the importance of recognizing that MMOF-induced colonic changes can rarely mimic ischemic colitis. With this in mind, we aim for gastroenterologists to better understand the varying endoscopic colonic findings of this immunosuppressive drug.

Evidence-Based Cognitive Endoscopy Simulators: Do They Exist? A Systematic Search and Evaluation of Existing Platforms.

BACKGROUND: The development of guidelines by gastroenterology societies increasingly stresses evidence-based endoscopic practice. AIMS: We performed a systematic assessment to determine whether endoscopic video teaching platforms incorporate evidence-based educational strategies and methods in order to disseminate guideline-based endoscopic management strategies. METHODS: Platforms with a video component were systematically identified using the Google search engine, Apple and Android application stores, and searching four major gastroenterology society websites and three known platforms, to identify all relevant platforms. Two video samples from each teaching platform were reviewed independently by two authors and assessed for use of a priori defined principles of evidence-based medicine, as determined by consensus agreement and for the use of simulation. RESULTS: Fourteen platforms were included in the final analysis, and two videos from each were analyzed. One of the 14 platforms used simulation and incorporated evidence-based medicine principles consistently. Nine of the 14 platforms were not transparent in regard to citation. None of the platforms consistently cited the certainty of evidence or explained how evidence was selected. CONCLUSIONS: Education of guideline-based endoscopic management strategies using principles of evidence-based medicine is under-utilized in endoscopic videos. In addition, the use of cognitive simulation is absent in this arena. There is a paucity of evidence-based cognitive endoscopy simulators designed for fellows that incorporate systematic evaluation, and efforts should be made to create this platform.

The role of autologous micrografts injection from the scalp tissue in the treatment of COVID-19 associated telogen effluvium: Clinical and trichoscopic evaluation.

The clinical presentation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2 COVID-19) varies from asymptomatic infection to a life-threatening, multiorgan disease. One of these manifestations is telogen effluvium (TE) which is characterized by diffuse hair loss occurring in patients previously infected with SARS-CoV-2 and lasts ~3 months, after which excessive hair loss follows. Hair follicles are known to contain a well-characterized niche for adult stem cells which is the bulge containing epithelial and melanocytic stem cells. Stem cells in the hair bulge, a demarcated structure within the lower permanent portion of hair follicles, can generate the interfollicular epidermis, hair follicle structures, and sebaceous glands. This study aims to evaluate autologous micrografts from scalp tissues as a therapeutic modality in the management of TE caused by COVID-19. Twenty patients of previous COVID-19 infection suffered from TE were included in this study for human follicle stem cells micrograft scalp treatment and they were evaluated after 3 months of treatment and after 6 months. There was significant improvement of the hair thickness and density compared with the start of the treatment and 6 months of follow-up. Autologous micrograft of the scalp showed marked improvement in the treatment of COVID-19 TE.

Study of interleukin-1 beta expression in acne vulgaris and acne scars.

BACKGROUND: Acne vulgaris is a multifactorial disease that mostly heals by scarring. Interleukin-1 beta (IL-1ß) is a proinflammatory cytokine, suggested to play a key role in acne pathogenesis. OBJECTIVE: To study the immunohistochemical (IHC) expression of IL1ß in acne vulgaris and acne scars to evaluate its possible role in their pathogenesis and to study the relation between the expression of IL1ß and the clinicopathological parameters. PATIENTS AND METHODS: This study was conducted on sixty subjects (twenty patients with acne vulgaris and twenty patients with acne scars), and twenty healthy volunteers as controls. Skin biopsies were taken from patients and controls for routine histopathological examination with hematoxylin and eosin stain and IHC staining of IL-1ß. RESULTS: There was a statistically significant increase in expression of IL-1ß in acne vulgaris compared with post-acne scars and controls, (p < 0.001) for both. IL-1ß expression was significantly positively correlated with both clinical severity of acne vulgaris (p = 0.022) and severity of histopathological inflammation (p = 0.011). CONCLUSION: Interleukin-1ß expression was associated with acne vulgaris and post-acne scars with significant positive correlation to clinical and histopathological severity of acne vulgaris. Thus, IL-1ß could be a key player cytokine in acne pathogenesis, its severity and development of post-acne scars.

Split-face comparative study between intradermal tranexamic acid injection alone versus intradermal tranexamic acid injection combined with Q-switched Nd:YAG laser in melasma treatment: dermoscopic and clinical evaluation.

Melasma is a chronic, dark brown-pigmented patches and macules commonly on the face. Many treatment modalities for melasma have been used as hydroquinone, laser treatment, and recently tranexamic acid. Dermoscopy is used to diagnose and follow up the treatment of melasma and to detect underlying invisible vessels and their change with treatment. Melasma treatment evaluation by using combined Q-switched Nd:YAG laser with intradermal tranexamic acid injection versus tranexamic acid intradermal injection alone. This study was conducted on 40 female patients aged 35-45 years. It was a split-face study; for 12 weeks, the right side of the face was treated with low fluence Q-switched Nd:YAG laser combined with intradermal injection of tranexamic acid, while the left side was treated with an injection of tranexamic acid intradermal alone. The patients were clinically evaluated by using the modified melasma area and severity index (mMASI) score, and underwent dermoscopic evaluation before treatment, at the end of the treatment (12 weeks), and at (24 weeks) as follow-up. The efficacy, adverse effects, and recurrence after treatment were reported. There was a statistically significant decrease in mMASI score with combination treatment than with intradermal injection of tranexamic acid alone after treatment at 12 weeks and at the end of follow-up at 24 weeks. Combination of an injection of tranexamic acid intradermal and low fluence Q-switched Nd:YAG laser is an effective and safe treatment for melasma with minimal side effects more than the intradermal tranexamic acid injection alone.

Treatment of stable nonsegmental vitiligo using transdermal delivery of 5-fluorouracil by fractional CO2 laser versus intralesional injection of 5-fluorouracil, both followed by narrow-band type ultraviolet B (UVB): A comparative study.

BACKGROUND: Updates of treatment methods of stable vitiligo are needed to give better outcomes with a shorter duration of treatment. OBJECTIVE: To test the effect of transdermal 5-fluorouracil (5-FU) delivery using fractional CO2 (FrCO2 ) laser versus intralesional 5-FU injection, with narrow-band type ultraviolet B (UVB) (NB-UVB) therapy after both, in the treatment of stable vitiligo. PATIENTS AND METHODS: The present study comprised 40 patients with nearly symmetrical stable vitiligo lesions. The left side was treated with FrCO2  laser followed by topical 5-FU (FrCO2  + 5-FU), while the right side was treated with 5-FU intradermal injection. Both procedures were done at 2-week intervals for 3 sessions followed by 24 sessions of narrow-band UVB for both sides. RESULTS: Repigmentation was demonstrated on the left side of 90% of patients and the right side of 85% of patients. As much as >50% improvement was demonstrated on the left side of 50% of patients, and the right side of 55% of patients. Intralesional 5-FU showed a statistically significant difference in repigmentation compared to FrCO2  + 5-FU. CONCLUSION: Both 5-FU injection and FrCO2  + 5-FU were effective therapeutic modalities for vitiligo. Patients were more compliant with FrCO2  + 5-FU.

Obesity prevalence in celiac disease in the United States from 2014 to 2018.

Celiac disease (CD) is not commonly associated with obesity; however, many patients are overweight or obese at time of diagnosis. As the number of people in the United States with obesity continues to rise, it is not known if the prevalence of obesity among patients with CD has also increased. This study utilized an electronic health record database incorporating over 360 individual hospitals in the United States (Explorys Incorporated, Cleveland, OH). Adult patients who had an esophagogastroduodenoscopy at least 1 day prior to reporting of CD from the years 2014 to 2018 formed the study population. From 2014 to 2018, 13,410 patients had a diagnosis of CD. The prevalence of obesity was 45,000/100,000 persons in this CD population. Prevalence of class I (BMI 30-34.9), II (BMI 35-39.9), and III (BMI > 40) obesity in patients with CD continued to rise over the 5-year span. Class I obesity had the highest prevalence and Class II the highest prevalence increase when obesity classes were compared. Clinicians should be aware of obesity as a comorbidity of increasing prevalence when providing longitudinal care for patients with CD.

Meet EBE: The Development of an Evidence-Based Endoscopy Simulator.

BACKGROUND AND AIMS: In the digital era of evidence-based medicine, there is a paucity of video endoscopy teaching platforms that use evidence-based medicine principles, or that allow for cognitive simulation of endoscopic management strategies. We created a guideline-based teaching platform for fellows that incorporates these features, and tested it. METHODS: A pilot video module with embedded questions was drafted, and after incorporation of feedback from several attending gastroenterologists, an additional 2 modules were created. The embedded questions were designed to simulate cognitive management decisions as if the viewer were doing the endoscopy procedure in the video. A narrator explained the evidence behind the task being performed, and its certainty based on endoscopic guidelines. Quizzes and surveys were developed and administered to a sample of attendings and fellows who completed the video modules to test efficacy, usability, and likeability. RESULTS: Three video modules, named evidence-based endoscopy (EBE), incorporating low fidelity simulation, and utilizing evidence-based medicine principles, were created. Eight fellows and 10 attendings completed the video modules and all quizzes and surveys. Mean test scores improved from before to after completing the video modules (56% to 92%; mean difference = -35%; 95% confidence interval, 27%-47%). Surveys indicated that the product was viewed favorably by participants, and that there is a strong desire for this type of educational product. CONCLUSIONS: The EBE simulator is a unique, desirable, and effective educational platform based on evidence-based medicine principles that fills a gap in available tools for endoscopy education. Further studies are needed to assess whether EBE can aid in long-term knowledge retention and increase adherence to guideline recommendations.

Severe Cholestatic Drug-Induced Liver Injury With Cephalosporin Use.

Drug-induced liver injury (DILI) is a phenomenon that occurs with nearly all classes of medications. Cholestatic DILI represents a fraction of these cases and can present as bland cholestasis, cholestatic hepatitis, secondary sclerosis cholangitis, and vanishing bile duct syndrome. Risk factors have been identified for cholestatic DILI, including older age, genetic determinants, and certain medications such as amoxicillin-clavulanate. Here, we describe a complicated case of severe cholestatic DILI secondary to cephalosporin use. A 27-year-old female presented to the hospital initially with fever and abdominal pain for four weeks after an emergency C-section for pre-eclampsia and hemolysis, elevated liver enzymes, lowered platelets (HELLP) syndrome. She was found to have a retroperitoneal abscess and underwent bilateral drain placement. She was initially started on cefazolin, and then coverage was broadened to cefepime. Shortly after, alkaline phosphatase (ALP) rose and peaked at 3498 IU/L, with aspartate aminotransferase (AST) and alanine transaminase (ALT) elevated at 274 IU/L and 122 IU/L, respectively. Extensive testing for secondary causes and a liver biopsy were consistent with DILI. Liver enzymes down-trended with the cessation of cefepime. This case report highlights that prompt recognition of the culprit medication is paramount to recovering normal liver function.

Post-Liver Transplant Lymphoproliferative Disorder Presenting as Biliary Stricture.

A 63-year-old man with nonalcoholic steatohepatitis cirrhosis who underwent orthotopic liver transplant presented 1 year later with obstructive jaundice because of a biliary stricture. This anastomotic stricture was initially believed to be ischemic, but further investigation revealed malignant biliary obstruction because of encasement of the bile duct by a mass arising from liver segment VII, later determined to be post-transplant lymphoproliferative disorder with widespread metastasis. After reduction of immunosuppression and systemic chemotherapy, he experienced complete remission. This case illustrates the need to consider post-transplantation lymphoproliferative disorder-related biliary stricture in any postorthotopic liver transplantation transplant patient presenting with obstructive jaundice.

Evaluation of adding platelet-rich plasma to combined medical therapy in androgenetic alopecia.

BACKGROUND: Androgenetic alopecia (AGA) is a common hair loss disorder. OBJECTIVES: To evaluate the therapeutic effects of platelet-rich plasma (PRP) in androgenetic alopecia. METHODS: This study was done on 126 AGA patients, 42 patients survived as control group who received medical treatment, only other 84 patients were subdivided into two groups, and they received PRP sessions as co-adjuvant therapy using different methods administration. Patients were evaluated clinically, by dermoscopy and by digital dermoscopy to measure hair density and diameters before and after treatment. RESULTS: PRP-treated patients showed statistically significant increase in hair density and diameter measurements than control group. These results increased by using microneedling as a method of PRP administration. CONCLUSION: In AGA, the addition of "PRP with microneedling" to the combined medical treatment increases its efficacy and shortens the time needed for optimum improvement. STUDY DESIGN: Single-blinded randomized controlled study.

Role of interventional radiology in intractable bleeding rectal varices.

In the setting of portal hypertension, intractable bleeding from anorectal varices is a rare occurrence. In this review, clinical presentation and management of this dilemma are presented in a case-based fashion. Bleeding may occur in the absence of prior history of cirrhosis or gastroesophageal varices and measurement of hepatic venous pressure gradient and liver biopsy could help to establish the diagnosis. Successful treatment outcome necessitates tailoring treatment to the patient's anatomy and imaging findings. A multidisciplinary algorithmic approach is also proposed to aid clinicians in this regard.

Study the effect of erbium:YAG laser plus topical 5-flurouracil in stable vitiligo resistant to NB-UVB phototherapy.

BACKGROUND: NB-UVB phototherapy is still an effective treatment in vitiligo but requires more than 1 year for its completion. Topical 5-flurouracil could improve the proliferation and migration of melanocytes. Laser-assisted dermabrasion results in stimulation of the inactive melanocytes present at the outer root sheath of the lower portion of the hair follicle, which migrates upward until they reach the surface of the skin. OBJECTIVE: To evaluate the effect of Er:YAG laser skin ablation followed by topical 5-flurouracil on the outcome of NB-UVB phototherapy as a short term technique in resistant and stable vitiligo. METHODS: The current study included 40 patients suffering from bilateral stable vitiligo resistant to NB-UVB. For each patient, one side of the body subjected to 4 months NB-UVB sessions (control side). While the other side of the body subjected to one session of Er:YAG laser ablation combined with topical 5% 5-flurouracil application under occlusion followed by NB-UVB sessions for 4 months after complete re-epithelization. Outcomes were evaluated objectively based on standard digital photographs, histopathological examination, patient satisfaction, and adverse effects. RESULTS: There was a statistically significant improvement in the repigmentation in laser side compared with control side. Histopathological examination revealed expression of prominent melanin pigmentation, with marked expression for Melan-A in laser side, whereas these findings were negative in control side. CONCLUSION: Er:YAG laser ablation, followed by 5FU application before NB-UVB phototherapy for vitiligo, is a safe and tolerable technique that improves the outcome of short-term NB-UVB therapy and is expected to increase patient compliance.

Evaluation Of The Efficacy Of Fluorescent Staining And Chicago Sky Blue Staining As Methods For Diagnosis Of Dermatophytosis In Hair And Nails.

PURPOSE: Dermatophytes are fungi that cause infections affecting hair, nail, and skin; in nails they cause onychomycosis, while in hair they lead to tinea capitis. Detection of dermatophytes using traditional methods, including potassium hydroxide (KOH) and culture on agar-based media leads to high rates of false-negative results. Here, we investigated more accurate diagnostic techniques, including Chicago sky blue staining and Calcofluor white fluorescent staining and compared them with traditional KOH and culture methods for the diagnosis of fungi causing onychomycosis and tinea capitis. PATIENTS AND METHODS: This study was conducted using samples from 50 patients with dermatophytosis of the hair or nail. Samples were subjected to all the following laboratory investigations: KOH wet mount, culture on Sabouraud's dextrose agar, Chicago sky blue staining, and Calcofluor white staining. The results of the new diagnostic techniques were compared with those of the traditional methods. RESULTS: Calcofluor white stain and Chicago sky blue stain for dermatophytosis of hair and nail are more specific and sensitive as compared to traditional diagnostic methods. KOH wet mount is simple, rapid, and inexpensive test but lacks color contrast and gave more false positive (artifacts) and false-negative results as compared to these new stain methods. CONCLUSION: Chicago sky blue and Calcofluor white staining are excellent methods for diagnosis of fungal infections, including those that cannot be confirmed using conventional methods.