Hepatitis B Reactivation in a Patient Receiving Chemotherapy for Breast Cancer: A Case Report.

Hepatitis B virus (HBV) reactivation is a known complication of immunosuppressive therapy. While patients who are undergoing treatment with anti-CD20 agents or stem cell transplantation are commonly screened for chronic HBV infection prior to treatment, there are no consensus guidelines regarding HBV screening for patients undergoing chemotherapy for solid tumors. We present a rare case of fulminant liver failure due to HBV reactivation in a patient receiving chemotherapy for breast cancer. Our case highlights the importance of developing definitive guidelines regarding HBV screening in patients receiving chemotherapy for solid tumors and raises the question of the need for universal screening.

A low-volume polyethylene glycol solution was associated with an increased suboptimal bowel preparation rate but had similar recommendations for an early repeat colonoscopy, procedure times, and adenoma detection rates.

BACKGROUND/AIMS: Low-volume polyethylene glycol (PEG) bowel preparations are better tolerated by patients than high-volume preparations and may achieve similar preparation quality. However, there is little data comparing their effects on a recommendation for an early repeat colonoscopy (because of a suboptimal preparation), procedure times, adenoma detection rate (ADR), and advanced adenoma detection rate (AADR). METHODS: This is a retrospective cohort study of outpatient colonoscopies performed during a one-year period at a single academic medical center in which low-volume MoviPrep® (n = 1841) or high-volume Colyte® (n = 1337) was used. All preparations were split-dosed. Appropriate covariates were included in regression models assessing suboptimal preparation quality (fair, poor, or inadequate), procedure times, recommendation for an early repeat colonoscopy, ADR, and AADR. RESULTS: MoviPrep® was associated with an increase in having a suboptimal bowel preparation (OR 1.36; 95% CI: 1.06-1.76), but it was not associated with differences in insertion (p = 0.43), withdrawal (p = 0.22), or total procedure times (p = 0.10). The adjusted percentage with a suboptimal preparation was 11.7% for patients using MoviPrep® and 8.8% for patients using Colyte®. MoviPrep® was not associated with a significant difference in overall ADR (OR 0.93; 95% CI: 0.78-1.11), AADR (OR 1.18; 95% CI: 0.87-1.62), or recommendation for early repeat colonoscopy (OR 1.16; 95% CI: 0.72-1.88). CONCLUSIONS: MoviPrep® was associated with a small absolute increase in having a suboptimal preparation, but did not affect recommendations for an early repeat colonoscopy, procedure times, or adenoma detection rates. Mechanisms to reduce financial barriers limiting low-volume preparations should be considered because of their favorable tolerability profile.

Medicare Under Age 65 and Medicaid Patients Have Poorer Bowel Preparations: Implications for Recommendations for an Early Repeat Colonoscopy.

BACKGROUND/AIMS: Colonoscopy is performed on patients across a broad spectrum of demographic characteristics. These characteristics may aggregate by patient insurance provider and influence bowel preparation quality and the prevalence of adenomas. The purpose of this study was to evaluate the association of insurance status and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, adenoma detection rate (ADR), and advanced ADR (AADR). METHODS: This is a cohort study of outpatient colonoscopies (n = 3113) at a single academic medical center. Patient insurance status was categorized into five groups: 1) Medicare < 65y; 2) Medicare ≥ 65y; 3) Tricare/VA; 4) Medicaid/Colorado Indigent Care Program (CICP); and 5) commercial insurance. We used multivariable logistic or linear regression modeling to estimate the risks for the association between patient insurance and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, ADR, and AADR. Models were adjusted for appropriate covariates. RESULTS: Medicare patients < 65y (OR 4.91; 95% CI: 3.25-7.43) and Medicaid/CICP patients (OR 4.23; 95% CI: 2.65-7.65) were more likely to have a suboptimal preparation compared to commercial insurance patients. Medicare patients < 65y (OR 5.58; 95% CI: 2.85-10.92) and Medicaid/CICP patients (OR 3.64; CI: 1.60-8.28) were more likely to receive a recommendation for an early repeat colonoscopy compared to commercial insurance patients. Medicare patients < 65y had a significantly higher adjusted ADR (OR 1.50; 95% CI: 1.03-2.18) and adjusted AADR (OR 1.99; 95% CI: 1.15-3.44) compared to commercial insurance patients. CONCLUSIONS: Understanding the reasons for the higher rate of a suboptimal bowel preparation in Medicare < 65y and Medicaid/CICP patients and reducing this rate is critical to improving colonoscopy outcomes and reducing healthcare costs in these populations.

Impact of an incomplete colonoscopy referral program on recommendations after incomplete colonoscopy.

BACKGROUND: There are limited data on recommendations and adherence to complete colon evaluation (CCE) after incomplete colonoscopy (IC). AIMS: Our objectives were to (1) identify recommendations and adherence to recommendations after IC, (2) determine the diagnostic yield of CCE after IC, and (3) determine the effect of an IC referral program on recommendations for CCE. METHODS: We conducted a retrospective review of IC procedures at a teaching hospital over two time periods (January 1 to May 1 2004 and July 1 to November 1 2010). A referral process for repeat colonoscopy after IC was instituted in April 2009. Outcomes included (1) recommendations (2) adherence, and (3) yield of CCE after IC. RESULTS: A total of 222 patients underwent at least one IC (overall rate of 2.5 %). In 120 patients (54.1 %), CCE was recommended within 1 year; the rate did not change from 2004 to 2010. Patients with IC due to poor preparation were more likely to have specific CCE recommendations (85.5 vs. 72.2 %, P = 0.03) and recommendations of endoscopic follow-up (76.3 vs. 10.4 %, P < 0.0001) than those with IC due to difficult anatomy. When IC was due to difficult colonoscopy, there was increase in endoscopic follow-up recommended (16.3 vs. 2.8 %, P = 0.01) in 2010 compared to 2004. Adherence to recommendations was similar regardless of modality recommended, inpatient/outpatient status, polyps on initial exam, or extent of initial exam. Polyp detection rate was greater utilizing colonoscopy than barium enema (34.3 vs. 3.6 %, P < 0.0001). CONCLUSIONS: There is a lack of consensus in management strategies for patients after IC. Implementation of a referral program has had minimal impact on provider recommendations.