Nonalcoholic fatty liver disease and atrial fibrillation: possible pathophysiological links and therapeutic interventions.

Atrial fibrillation (AF) and nonalcoholic fatty liver disease (NAFLD) share common risk factors and appear to have an association. Independently, the incidence and prevalence of both diseases are on the rise. Epidemiological evidence, experimental studies and various randomized clinical trials suggest a link between the 2 entities, delineating cumulative risks and clinical strategies to improve outcomes. Dyslipidemia, insulin resistance, inflammatory milieu, and activation of the renin-angiotensin system are likely common pathophysiological mechanisms linking AF and NAFLD. In this article we review the known pathways and pathophysiology that link the 2 conditions. This review also discusses therapies that target both NAFLD and AF, such as angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, metformin, and vitamin E. We further discuss other potential medications that have shown effects in NAFLD or AF through anti-inflammatory, antidiabetic, lipid-lowering, or renin-angiotensin system inhibiting effects. Future epidemiological studies are needed to establish a direct causal relationship between NAFLD and AF.

How to increase proximal adenoma detection rate: a meta-analysis comparing water exchange, water immersion and air/CO2 insufflation methods for colonoscopy.

BACKGROUND: Recent meta-analyses have demonstrated a higher adenoma detection rate using the water exchange method (WE), compared to water immersion (WI) and air/CO2 insufflation (ACI). Proximal adenomas have a high miss rate owing to their location and appearance. We performed a systematic review and meta-analysis of studies comparing the WE and WI methods to the ACI method, with a primary focus on proximal adenoma detection rate. METHODS: The following databases were searched for our systematic review: Medline, Embase, Cochrane Library, CINAHL, and Web of Sciences. We included both randomized controlled trials and cohort studies. The primary outcome was proximal adenoma detection rate, and secondary outcomes were right adenoma detection rate and cecal intubation rate. RESULTS: A total of 12 studies (17 arms) with 5660 patients (2260 ACI, 2281 WE, and 1119 WI) were included. A higher proximal adenoma detection rate (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.11-1.53; P=0.001) and right adenoma detection rate (RR 1.43, 95%CI 1.19-1.71; P≤0.001; I 2=0%) were noted for the WE group compared to the ACI group. The WI group did not demonstrate a better detection rate of proximal or right adenomas. CONCLUSIONS: The water exchange method for colonoscopy holds promise and should be encouraged in the clinical setting to increase proximal and right adenoma detection rates. This will in turn decrease the incidence of colorectal cancer.

Improving Internal Medicine Residents' Colorectal Cancer Screening Knowledge Using a Smartphone App: Pilot Study.

BACKGROUND: Colorectal cancer (CRC) is the third most common type of cancer and the second leading cause of cancer death in the United States. About one in three adults in the United States is not getting the CRC screening as recommended. Internal medicine residents are deficient in CRC screening knowledge. OBJECTIVE: The objective of our study was to assess the improvement in internal medicine residents' CRC screening knowledge via a pilot approach using a smartphone app. METHODS: We designed a questionnaire based on the CRC screening guidelines of the American Cancer Society, American College of Gastroenterology, and US Preventive Services Task Force. We emailed the questionnaire via a SurveyMonkey link to all the residents of an internal medicine department to assess their knowledge of CRC screening guidelines. Then we designed an educational intervention in the form of a smartphone app containing all the knowledge about the CRC screening guidelines. The residents were introduced to the app and asked to download it onto their smartphones. We repeated the survey to test for changes in the residents' knowledge after publication of the smartphone app and compared the responses with the previous survey. We applied the Pearson chi-square test and the Fisher exact test to look for statistical significance. RESULTS: A total of 50 residents completed the first survey and 41 completed the second survey after publication of the app. Areas of CRC screening that showed statistically significant improvement (P<.05) were age at which CRC screening was started in African Americans, preventive tests being ordered first, identification of CRC screening tests, identification of preventive and detection methods, following up positive tests with colonoscopy, follow-up after colonoscopy findings, and CRC surveillance in diseases. CONCLUSIONS: In this modern era of smartphones and gadgets, developing a smartphone-based app or educational tool is a novel idea and can help improve residents' knowledge about CRC screening.

The Traumatic Tube: Bleeding Rectal Ulcer Caused by Flexi-Seal Device.

Diarrhea and fecal incontinence are common in critically ill patients and present a challenging problem in patient management. The Flexi-Seal® Fecal Management System is a device to divert the stools away from the patient, thus improving the care to patients with fecal incontinence. There have been only few case reports describing the complications with the use of this device. Here, we present a case of a 77-year-old woman who was admitted due to massive hematochezia while on anticoagulation. She was found to have a large rectal ulcer caused by the Flexi-Seal device, used during the last hospital stay for fecal incontinence. Flexi-Seal device can be effective for the management of incontinence; however, caution should be exercised during handling and pressure from the retention balloon should be relieved periodically.

Unusual Clinical Presentation of Hemobilia with Recurrent Vasovagal Episodes.

Hemobilia is caused by the abnormal connection between a blood vessel and the bile duct, which is usually iatrogenic and caused by hepatobiliary procedures. The classic triad of hemobilia includes biliary colic, obstructive jaundice, and gastrointestinal bleeding. We present the case of an 80-year-old man who had laparoscopic cholecystectomy complicated by hemobilia. He had an unusual presentation of hemobilia in the form of transient vasovagal episodes in addition to abdominal pain and hematochezia.

Transient Descending Colocolonic Intussusception Due to a Large Fecaloma in an Adult.

Intussusception typically occurs in infants and children, with adults representing 5% of cases. A 53-year-old African American woman presented with lower abdominal pain and tenderness. Computed tomography of the abdomen and pelvis demonstrated a 3.5 cm colocolonic intussusception in the descending colon. Emergent colonoscopy found solid stool in the mid descending colon. Water-soluble rectal enema showed a filling defect in the mid descending colon. Repeat colonoscopy demonstrated presence of a large fecaloma in left colon. Laxatives were initiated, and abdominal pain subsided. To our knowledge, this is the first report of colocolonic intussusception secondary to fecaloma.

Recognition of Extraperitoneal Colonic Perforation following Colonoscopy: A Review of the Literature.

Colon perforation is an uncommon but serious complication of colonoscopy. It may occur as either intraperitoneal or extraperitoneal perforation or in combination. The majority of colonic perforations are intraperitoneal, causing air and intracolonic contents to leak into the peritoneal space. Rarely, colonic perforation can be extraperitoneal, leading to the passage of air into the retroperitoneal space causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. A literature review revealed that 31 cases of extraperitoneal perforation exist, out of which 20 cases also reported concomitant intraperitoneal perforation. We report the case of a young female with a history of ulcerative colitis who developed combined intraperitoneal and extraperitoneal perforation after colonoscopy. We also report the duration of onset of symptoms, clinical features, imaging findings, site of leak, and treatment administered in previously reported cases of extraperitoneal colonic perforation.

A Case of Suggested Ibuprofen-Induced Acute Pancreatitis.

Drug-induced acute pancreatitis (DIP) is uncommon and may account for 2%-5% of cases, although the incidence may be increasing nowadays. DIP has been documented for more than 160 drugs in the literature. The most common nonsteroidal anti-inflammatory drugs (NSAIDs) that have been reported to cause pancreatitis are sulindac and salicylates. In this report, we present a case of probable ibuprofen-induced pancreatitis. A 60-year-old white woman presented with the sudden onset of mild acute pancreatitis (AP) 5 hours following the ingestion of 6 tablets of ibuprofen (Advil) 200 mg (equivalent to 20.4 mg/kg). She denied any history of alcohol abuse, tobacco smoking, or any other medication use. She has no history of gallstones, choledocholithiasis, abdominal trauma, or hypertriglyceridemia. Laboratory workup revealed elevated amylase and lipase levels more than 3 times the normal limits with complete resolution within 15 hours. Computed tomography scan of abdomen and pelvis and endoscopic ultrasound of the pancreaticobiliary system were within the normal limits. Ibuprofen-induced mild DIP was the most probable diagnosis. She was discharged on her second day of hospitalization with significant improvement in her symptoms. Physicians need to be aware that DIP may occur in patients taking NSAIDs, including ibuprofen. Therefore, all patients with AP of an unknown etiology should be carefully questioned about the usage of NSAIDs, and all patients with idiopathic AP restarted on their medications should be closely monitored, and the drug must be immediately discontinued if symptoms recur.

Two Cases of Type Va Extrahepatic Bile Duct Duplication With Distal Klatskin Tumor Surgically Treated with Whipple Procedure and Hepaticojejunostomy.

We describe the diagnostic and therapeutic challenges of a type Va extrahepatic bile duct duplication coexistent with distally located hilar cholangiocarcinoma (Klatskin tumor). We present 2 cases that were diagnosed preoperatively and treated with a modified surgical technique of a combined pylorus-preserving Whipple procedure and hepaticojejunostomy.

Evaluation and enhancement of medical knowledge competency by monthly tests: a single institution experience.

BACKGROUND: In-training examination (ITE) has been used as a predictor of performance at the American Board of Internal Medicine (ABIM) certifying examination. ITE however may not be an ideal modality as it is held once a year and represents snapshots of performance as compared with a trend. We instituted monthly tests (MTs) to continually assess the performance of trainees throughout their residency. OBJECTIVE: To determine the predictors of ABIM performance and to assess whether the MTs can be used as a tool to predict passing the ABIM examination. METHODS: The MTs, core competencies, and ITE scores were analyzed for a cohort of graduates who appeared for the ABIM examination from 2010 to 2013. Logistic regression was performed to identify the predictors of a successful performance at the ABIM examination. RESULTS: Fifty-one residents appeared for the ABIM examination between 2010 and 2013 with a pass rate of 84%. The MT score for the first year (odds ratio [OR] =1.302, CI =1.004-1.687, P=0.04) and second year (OR =1.125, CI =1.004-1.261, P=0.04) were independent predictors of ABIM performance along with the second-year ITE scores (OR =1.248, CI =1.096-1.420, P=0.001). CONCLUSION: The MT is a valuable tool to predict the performance at the ABIM examination. Not only it helps in the assessment of likelihood of passing the certification examination, it also helps to identify those residents who may require more assistance earlier during their residency. It may also highlight the areas of weakness in program curriculum and guide curriculum development.

Efficacy and safety of, and patient satisfaction with, colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection.

OBJECTIVE: To report the efficacy and safety of, and patient satisfaction with, colonoscopic fecal microbiota transplantation (FMT) for community- and hospital-acquired Clostridium difficile infection (CDI). METHODS: A retrospective medical records review of patients who underwent FMT between July 1, 2012 and August 31, 2013 was conducted. A total of 22 FMTs were performed on 20 patients via colonoscopy. The patients were divided into 'community-acquired' and 'hospital-acquired' CDI. Telephone surveys were conducted to determine procedure outcome and patient satisfaction. Primary cure rate was defined as resolution of diarrhea without recurrence within three months of FMT, whereas secondary cure rate described patients who experienced resolution of diarrhea and return of normal bowel function after a second course of FMT. RESULTS: Nine patients met the criteria for community-acquired CDI whereas 11 were categorized as hospital-acquired CDI. A female predominance in the community-acquired group (88.89% [eight of nine]) was found (P=0.048). The primary cure rate was 100% (nine of nine) and 81.8% (nine of 11 patients) in community- and hospital-acquired CDI groups, respectively (P=0.189). Two patients in the hospital-acquired group had to undergo a repeat FMT for persistent symptomatic infection; the secondary cure rate was 100%. During the six-month follow-up, all patients were extremely satisfied with the procedure and no complications or adverse events were reported. CONCLUSION: FMT was a highly successful and very acceptable treatment modality for treating both community- and hospital-acquired CDI.

Multidrug resistant pneumonia treated with aerosolized amikacin in a patient with acute renal insufficiency.

Multidrug resistant pneumonia is an entity, which is difficult to treat, and in a patient with acute renal insufficiency, it leaves a physician with a handful of antibiotics to be considered. Aerosolized administration of antibiotics is one option that can be contemplated for a patient with acute renal insufficiency to avoid the nephrotoxic effect of the antibiotics.

Hepatitis C virus treatment with pegylated interferon-alfa therapy leading to generalized interstitial granuloma annulare and review of the literature.

We discuss the diagnosis and management of a case of generalized granuloma annulare (GA) occurring in a 49-year-old man when being treated with pegylated interferon-alfa for hepatitis C infection. In our case, the GA lesions remained despite an undetectable hepatitis C viral load. The GA resolved only with treatment cessation.

Acute liver failure: an uncommon complication of commonly used medication.

The incidence of drug-related acute liver failure is approximately 14 per 100,000 populations. Drug-induced liver injury may take place through a variety of mechanism. Withdrawal of the offending agent may result in complete recovery. Clindamycin is known to cause mild derangement of liver function; however, acute liver injury causing severe derangement of liver function associated with encephalopathy is uncommon.

Comparison of esophageal placement of Bravo capsule system under direct endoscopic guidance with conventional placement method.

BACKGROUND/AIMS: Conventional placement of a wireless esophageal pH monitoring device in the esophagus requires initial endoscopy to determine the distance to the gastroesophageal junction. Blind placement of the capsule by the Bravo delivery system is followed by repeat endoscopy to confirm placement. Alternatively, the capsule can be placed under direct vision during endoscopy. Currently there is no published data comparing the efficiency of one method over the other. The objective of this study was to compare the method of Bravo wireless pH device placement under direct visualization with the conventional method. METHODS: This retrospective study involved 58 patients (29 patients with indirect and 29 patients with direct visualization) who underwent Bravo capsule placement. The physician's endoscopy procedure notes, nurse's notes, post-procedure notes, recovery notes, and pH monitoring results were reviewed. The safety of the procedure, length of the procedure and patient tolerability were evaluated. RESULTS: None of the 58 patients had early detachment of the device or any immediate procedure-related complications. Overall incidence of complications in both groups was similar. No failures due to the technique were noted in either group. The average amount of time taken for the procedure was similar in the two groups. CONCLUSIONS: The technique of placing Bravo pH device under direct visualization is as safe and effective as the conventional method. In addition, the direct visualization technique has an added advantage of avoiding a second endoscopic intubation. The length of the procedure is similar between the two techniques.

Neural network analysis to predict mortality in end-stage renal disease: application to United States Renal Data System.

We examined whether we could develop models based on data provided to the United States Renal Data System (USRDS) to accurately predict survival. Records were obtained from patients beginning dialysis in 1990 through 2007. We developed linear and neural network models and optimized the fit of these models to the actual time to death. Next, we examined whether we could accurately predict survival in a dataset containing censored and uncensored patients. The results with these models were contrasted with those obtained with a Cox proportional hazards model fit to the entire dataset. The average C statistic over a 6-month to 10-year time range achieved with these models was approximately 0.7891 (linear model), 0.7804 (transformed dataset linear model), 0.7769 (neural network model), 0.7774 (transformed dataset neural network model), 0.8019 (Cox model), and 0.7970 (transformed dataset Cox model). When we used the Cox proportional hazards model, superior C statistic results were found at time points between 2 and 10 years but at earlier time points, the Cox model was slightly inferior. These results suggest that data provided to the USRDS can allow for predictive models which have a high degree of accuracy years following the initiation of dialysis.

Comparison of esophageal placement of Bravo capsule system under direct endoscopic guidance with conventional placement method.

BACKGROUND: Conventional placement of a wireless esophageal pH monitoring device in the esophagus requires initial endoscopy to determine the distance to the gastroesophageal junction. Blind placement of the capsule by the Bravo delivery system is followed by repeat endoscopy to confirm placement. Alternatively, the capsule can be placed under direct vision during endoscopy. Currently there are no published data comparing the efficiency of one method over the other. The objective of this study was to compare the method of Bravo wireless pH device placement under direct visualization with the conventional method. METHODS: A retrospective study involving 58 patients (29 patients with indirect and 29 patients with direct visualization) who had Bravo capsule placement. The physician endoscopy procedure notes, nurse's notes, postprocedure notes, recovery notes, and pH monitoring results were reviewed. The safety of the procedures, length of the procedures, and patient tolerability were evaluated. RESULTS: None of the 58 patients had early detachment of the device and had no immediate procedure-related complications. The overall incidence of complications in both the groups was similar. No failures due to the technique were noted in either group. Average amount of time taken for the procedure was similar in both groups. CONCLUSION: The technique of placing a Bravo pH device under direct visualization is as safe and effective as the conventional method. In addition, there is an added advantage of avoiding a second endoscopic intubation in the direct visualization technique.

The Unusual Suspect: A Case of Non-occlusive Mesenteric Ischemia in a Patient With Cirrhosis.

Acute mesenteric ischemia has a variety of etiologies. Non-occulusive mesenteric ischemia accounts for 20-30% of patients with acute mesenteric ischemia. We describe a case of non-occulusive jejunal ischemia leading to infarction that occurred in a patient with cirrhosis and no previous history of cardiovascular disease.