The black esophagus and duodenum: a rare case report.

Acute esophageal necrosis is a rare esophageal disease, typically characterized by the circumferential black appearance of the esophagus mucosa that usually affects the distal esophagus. It commonly affects elderly men with multiple comorbidities. In the medical literature, some cases have been reported regarding acute necrotizing esophagus, but according to our knowledge, only one case has been reported concerning a patient with ischemic duodenum and esophagus. The case of a 71-year-old man with upper gastrointestinal bleeding and subsequent acute necrotizing esophagus and duodenum has been described below.

CMV gastric ulcer in a patient with pauci immune crescentic glomerulonephritis on rituximab - a rare combination.

Cytomegalovirus (CMV) infections are asymptomatic in immunocompetent patients but in immunocompromised patients, CMV infections have varying manifestations depending on their location. Patient who are organ transplant recipients, taking immunosuppressive therapy for a long time are at increased risk of CMV infections. CMV-induced gastric ulcer is very rare but many cases have been reported in the literature. No case describing association between CMV-related gastric ulcer and glomerulonephritis has been reported in the literature so far. In this article, we describe a case of pauci immune crescentic glomerulonephritis in a patient who was on rituximab and long-term steroid therapy and found to have CMV-related gastric ulcer. The association of small vessel vasculitis and CMV-related gastrointestinal infection has not been studied in the literature. Pauci immune crescentic glomerulonephritis is a subtype of rapidly progressive glomerulonephritis manifested by continuous loss of renal functions with features of dysmorphic red blood cells and glomerular proteinuria. Treatment of such condition is a genetically engineered chimeric murine/human monoclonal IgG1 kappa antibody directed against the CD20 antigen known as Rituximab. We also discussed the pathogenesis of CMV- induced gastric ulcer after rituximab therapy. This case emphasizes the importance of opportunistic infections in glomerulonephritis patients and raises the awareness that glomerunephritis patients are at increased risk of opportunistic infections as well. Rituximab was considered to be a safer drug but over the years, the incidence if opportunistic infections in patients on rituximab has been increasing.

Risk factors for coronary artery disease and acute coronary syndrome in patients ≤40 years old.

OBJECTIVE: In this study, we assessed the risk factor profile in premature coronary artery disease (CAD) and acute coronary syndrome for adults ≤40 years old. METHODS: A retrospective chart analysis of 397 patients ≤40 years old admitted from 2005 to 2014 for chest pain and who underwent coronary arteriography. RESULTS: Of 397 patients that had undergone coronary arteriography, 54% had CAD while 46% had normal coronary arteries. When compared with patients with normal coronary arteries, patients with CAD were more likely to smoke tobacco, have dyslipidemia, be diabetic, have BMI >30 kg/m(2), have a family history of premature CAD and be male in gender. CONCLUSION: Healthcare intervention in the general population through screening, counseling and education regarding the risk factors is warranted to reduce premature CAD.

Morbidity and Mortality of Congestive Heart Failure in Trauma Patients.

BACKGROUND: Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay (LOS) are considered. With increasing average life expectancy, HF prevalence continues to rise. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggest that HF is the most common cause for hospital admission in patients older than 65 years. OBJECTIVE: In this study, we sought out to compare the 30-day readmission rate in trauma patients who have a preexisting history of HF to those who do not have a history of HF. Additionally, we emphasized the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] versus HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic versus nonischemic). METHODS: A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005 and 2013 secondary to trauma with an Injury Severity Score <30. Data were extracted using International Classification of Diseases, Ninth Revision codes. Neurotrauma patients were excluded. RESULTS: Of 8,137 trauma patients, 334 had preexisting HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology versus 44 nonischemic. Of 334 HF patients, 81 patients (24%) were readmitted within 30 days versus 1,068 (14%) of the non-HF patients (95% CI: 1.52-2.25, relative risk: 1.85, P < 0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus HFrEF groups. Mortality, 30-day readmission and LOS were all significantly higher in the ischemic versus nonischemic HFrEF group. CONCLUSIONS: In our trauma population, HF patients had a significantly higher 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF versus HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and LOS were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with preexisting HF.

Primary squamous cell carcinoma of the rectum: a case report and literature review.

Squamous cell carcinoma (SCC) of the rectum is a rare occurrence with an incidence rate of 0.1-0.25% per 1,000 cases. Herein, we report a case of a 52-year-old female who presented with a 2-month history of diffuse lower abdominal pain and hematochezia. Abdominal CT scan revealed a 7-cm irregular rectal mass, and the biopsy showed SCC.

Serum vitamin D levels correlate to coronary artery disease severity: a retrospective chart analysis.

BACKGROUND: The pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. We further emphasized and evaluated the severity of coronary artery disease (CAD) with varying levels of vitamin D in relation to age, gender, ethnicity and baseline confounders. METHODS: A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed levels of 25(OH)D and extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). RESULTS: Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis of the extent of coronary disease, we identified 20% of patients having normal coronaries, 55% having obstructive CAD and 25% having non-obstructive CAD. Baseline clinical risk factors and co-morbidities did not differ between the groups. Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2 - 9.5, p < 0.0001). Comparing patients with normal 25(OH)D levels, patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 62% were found to have obstructive CAD (n = 624, OR: 2.9, 95% CI: 2.3-3.7, p < 0.0001) and 25% had non-obstructive CAD (n = 249, OR: 1.5, 95% CI: 1.1-2, p = 0.02). CONCLUSION: Normal coronaries and CAD were shown to correlate with normal and low levels of 25(OH)D, respectively. There is an inverse relationship between the percentage of coronary artery occlusion and serum 25(OH)D concentrations. Vitamin D may provide benefits in risk stratification of patients with CAD and serve as a possible risk factor.