Risk factors for local recurrence of large gastrointestinal lesions after endoscopic mucosal resection.

BACKGROUND: Endoscopic mucosal resection (EMR) is the primary treatment modality for superficial gastrointestinal mucosal lesions > 2 cm. However, the procedure carries some risk of complications including bleeding, perforation, and local recurrence. This study aimed to examine factors associated with EMR outcomes, especially in terms of local recurrence. METHODS: This study retrospectively evaluated patients who underwent EMR and full closure with prophylactic clips for upper and lower gastrointestinal lesions > 2 cm at Cleveland Clinic Florida, between January 2013 and December 2018 with follow-up endoscopic evaluation for recurrence. RESULTS: A total of 2031 endoscopic polypectomy cases were examined; 307 EMR procedures among 271 patients (52% were female, mean age 65.6 ± 11.1 years) who satisfied the inclusion criteria were included in the study. There were no perforations reported. The rate of post-polypectomy delayed bleeding was 1.6%, and the local recurrence rate in this cohort was 7.1%. Recurrent cases were successfully endoscopically managed. In the multivariate regression analysis, age > 70 years (OR = 3.20, 95% CI 1.17-8.76, p = .023), body mass index (OR = 1.12, 95% CI 1.03-1.23 p = .008), and lesion size ≥ 35 mm (OR = 11.51, 95% CI 3.54-37.40, p = < .001) were independent predictors for recurrence. CONCLUSIONS: Age > 70 years, increased lesion size, and obesity were found to be independent predictors of local recurrence among EMR procedures for gastrointestinal lesions > 2 cm. However, there is a need for larger-scale studies on this topic.

Hyperbaric Oxygen Therapy in Chronic Inflammatory Conditions of the Pouch.

BACKGROUND: Pouchitis can be a chronic complication of ileal pouch-anal anastomosis. We aimed to determine the efficacy and safety of hyperbaric oxygen therapy (HBOT) for chronic antibiotic-refractory pouchitis (CARP) and other inflammatory conditions of the pouch. METHODS: This was a retrospective case series of adults with inflammatory bowel disease (IBD) who underwent ileal pouch-anal anastomosis and then developed CARP and received HBOT between January 2015 and October 2019. A modified Pouchitis Disease Activity Index (mPDAI) score was used to quantify subjective symptoms (0-6) and endoscopic findings (0-6) before and after HBOT. RESULTS: A total of 46 patients were included, with 23 (50.0%) being males with a mean age of 43.6 ± 12.9 years. The median number of HBOT sessions was 30 (range 10-60). There was a significant reduction in the mean mPDAI symptom subscore from 3.19 to 1.91 after HBOT (P < 0.05). The pre- and post-HBOT mean mPDAI endoscopy subscores for the afferent limb were 2.31 ± 1.84 and 0.85 ± 1.28 (P = 0.006); for the pouch body, 2.34 ± 1.37 and 1.29 ± 1.38 (P < 0.001); and for the cuff, 1.93 ± 1.11 and 0.63 ± 1.12 (P < 0.001), respectively. Transient side effects included ear barotrauma in 5 patients (10.9%) and hyperbaric myopic vision changes in 5 patients (10.9%). CONCLUSIONS: Despite minor adverse events, HBOT was well tolerated in patients with CARP and significantly improved symptoms and endoscopic parameters.

Association of Complicated Diverticulitis With Development of De Novo Inflammatory Bowel Disease.

BACKGROUND: There has been a historic similarity in the epidemiology and pathophysiology of diverticular disease and inflammatory bowel disease (IBD). Because there are limited to no data on the role of diverticulitis as a potential risk factor for de novo IBD, we aimed to evaluate the role of diverticulitis and complicated diverticulitis as a potential predictor of IBD. METHODS: We performed a retrospective, single-center study including patients older than age 18 years who were diagnosed with diverticulitis from January 2012 until December 2018 without a prior diagnosis of IBD. These patients were then evaluated for development of IBD. Univariate and multivariate analyses were conducted to compare the characteristics and outcomes between patients who did or did not develop IBD. RESULTS: A total of 2770 patients were diagnosed with diverticulitis from 2012 until 2018. Of these patients, 17 were diagnosed with IBD, resulting in an incidence rate of 0.23% per patient-year. The incidence rate among patients who required surgery for diverticulitis was 0.44% per patient-year, and patients with complicated diverticulitis had an incidence rate of 0.91% per patient-year. Univariate analysis showed that the need for surgery related to diverticulitis (hazard ratio [HR], 6.27; P = 0.003) and complicated diverticulitis was associated with the development of IBD (HR, 14.71; P < 0.001). Multivariate analysis showed that complicated diverticulitis was the sole factor associated with IBD (HR, 10.34; P < 0.001). CONCLUSIONS: Patients with diverticulitis are at a higher risk of developing de novo IBD. This risk is highest in patients with complicated diverticulitis.

A rare association of Takotsubo cardiomyopathy with neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is a potentially fatal neurological condition secondary to antipsychotic medication. It is characterized by distinctive clinical findings and autonomic disturbances. NMS has not been associated with Takotsubo cardiomyopathy (TCM). TCM is an abnormal response to physiological stressors resulting from the autonomic abnormalities which at times can mimic myocardial infarction (MI). We present a unique case of a 54-year-old female with bipolar disease presenting with lithium and haloperidol-induced NMS complicated by TCM. The purpose of this case is to make clinicians aware of this rare association.

A giant coronary artery ectasia successfully managed conservatively.

Coronary artery aneurysms (CAA) is a rare condition characterized by abnormal dilatation of the coronary arteries. We present a case of a 77-year-old gentleman who presented with atypical chest pain and was found to have elevated cardiac enzymes. He underwent diagnostic left heart catheterization which revealed left main CAA and significant left circumflex stenosis. The patient was administered medical therapy and was discharged home in a stable condition. The purpose of this report is to highlight a rare case of a large CAA which was successfully managed conservatively.

Rare case of acute on chronic hepatic failure in a patient with multiple myeloma-associated amyloidosis.

Amyloidosis is the extracellular deposition of unique protein fibrils in different tissue organs. It is most commonly associated with B-cell malignancy such as multiple myeloma or Waldenstrom macroglobulinaemia. It involves the liver, heart, kidney, peripheral nerves and soft tissues. Liver however is affected, but clinically apparent disease is very rare. Hepatomegaly and mild elevation of alkaline phosphatase is the most common presentation in patients with liver involvement. Acute hepatic failure is a rare presentation with myeloma-induced amyloidosis. The diagnosis can be difficult requiring biopsy or sometimes special staining of the tissue. Management is still very challenging.

Blue rubber bleb nevus: a rare cause of GI bleeding-review of management.

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital vascular anomaly syndrome characterised by multifocal venous vascular malformations. It involves skin, central nervous systems, liver, muscles and gastrointestinal (GI) tract resulting in intestinal haemorrhage and anaemia. Patients with BRBNS experience severe chronic anaemia without any diagnosis requiring multiple transfusions and hospitalisations. BRBNS has a propensity for severe life-threatening bleeding. Skin and GI tract are the most commonly affected organs.

The chemistry and pharmacology of alkaloids and allied nitrogen compounds from Artemisia species: A review.

Several reviews have been published on Artemisia's derived natural products, but it is the first attempt to review the chemistry and pharmacology of more than 80 alkaloids and allied nitrogen compounds obtained from various Artemisia species (covering the literature up to June 2018). The pharmacological potential and unique skeleton types of certain Artemisia's alkaloids provoke the importance of analyzing Artemisia species for bioactive alkaloids and allied nitrogen compounds. Among the various types of bioactive Artemisia's alkaloids, the main classes were the derivatives of rupestine (pyridine-sesquiterpene), lycoctonine (diterpene), pyrrolizidine, purines, polyamine, peptides, indole, piperidine, pyrrolidine, alkamides, and flavoalkaloids. The rupestine derivatives are Artemisia's characteristic alkaloids, whereas the rest are common alkaloids found in the family Asteraceae and chemotaxonomically links the genus Artemisia with the tribes Anthemideae. The most important biological activities of Artemisia's alkaloids are including hepatoprotective, local anesthetic, ß-galactosidase, and antiparasitic activities; treatment of angina pectoris, opening blocked arteries, as a sleep-inducing agents and inhibition of HIV viral protease, CYP450, melanin biosynthesis, human carbonic anhydrase, [3H]-AEA metabolism, kinases, and DNA polymerase ß1 . Some of the important nitrogen metabolites of Artemisia include pellitorine, zeatin, tryptophan, rupestine, and aconitine analogs, which need to be optimized and commercialized further.

Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis.

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33-85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4-18 months), 12 months (IQR, 6-19 months) and 14 months (IQR, 6-20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.

An Esophagogram or Tracheobronchogram? A Review of Barium Sulfate Aspiration.

The barium swallow is an important radiological investigation used for the diagnosis of upper gastrointestinal anatomical disorders like esophageal cancer, diverticulum, achalasia, foreign body, among others. Generally, it is believed to be a safe technique with rare complications, but few cases of barium sulfate aspiration have been reported in the literature with multiple complications. We are reporting a case of an elderly male who underwent esophagogram for the workup of chronic dysphagia, aspirated barium sulfate, and went into respiratory failure and circulatory shock several hours later. Moreover, we also did a systematic literature search and reviewed all available articles on aspiration of barium sulfate and its potential complications. We focused on predisposing factors for aspiration, clinical presentation, complications after aspiration, and prognosis with the aim to better understand and manage this condition.

Another "D" in MUDPILES? A Review of Diet-Associated Nondiabetic Ketoacidosis.

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of "dietary ketosis" in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless "dietary ketosis" can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling the safety of ketogenic diet into question. In this article, we chronicle a unique case of ketogenic (Atkins) diet-associated ketoacidosis, and we present a comprehensive literature review on the etiology of ketoacidosis.

NMR, Novel Pharmacological and In Silico Docking Studies of Oxyacanthine and Tetrandrine: Bisbenzylisoquinoline Alkaloids Isolated from Berberis glaucocarpa Roots.

Urease enzyme is responsible for gastric cancer, peptic ulcer, hepatic coma, and urinary stones in millions of people across the world. So, there is a strong need to develop new and safe antiurease drugs, particularly from natural sources. In search for new and effective drugs from natural sources bioassay-guided fractionation and isolation of Berberis glaucocarpa Stapf roots bark resulted in the isolation and characterization, on the basis of 1D and 2D NMR data, of two bisbenzylisoquinoline alkaloids, oxyacanthine (1) and tetrandrine (2), followed by urease inhibition studies. Crude extract, all the subfractions and the isolated compounds 1 and 2 displayed excellent urease enzyme inhibition properties in vitro. The antiurease nature and possible mode of action for compounds 1 and 2 were verified and explained through their molecular docking studies against jack-bean urease enzyme. Half-maximum inhibitory concentration (IC50) was calculated for compounds 1 and 2. The IC50 value was found to be 6.35 and 5.51 µg/mL for compounds 1 and 2, respectively. Both compounds 1 and 2 have minimal cytotoxicity against THP-1 monocytic cells.

EXPERIENCE WITH TITANIUM CAGES IN ANTERIOR CERVICAL DISCECTOMY AND FUSION.

BACKGROUND: Anterior cervical discectomy is a common procedure for treating patients for cervical disc prolapse. This study was conducted to study the surgical outcome and demographic characteristics of patients who were treated for anterior cervical disc prolapse. METHODS: Study was conducted in the combined military hospital (CMH) Peshawar. Study interval was 3 years from 1st September, 2011 to 31st August, 2014. Total numbers of patients were 84. Males were 54 (64.28%) and females were 30 (35.71%). All the patients had undergone the procedure of anterior cervical discectomy and fusion with titanium cages (ACDF). All the patients had plain MRI cervical spine done for diagnosis of anterior cervical disc prolapse. RESULTS: Total 84 patients were operated. In the patients who complained of brachialgia, 100% improvement was seen after the operation. Three (3.5%) of the patients, who presented with axial neck pain, continued to complain of pain and 2 (2.5%) of the patients complained of pain at the donor site after the operation. One of the patients had dural tear which resulted in subcutaneous cerebrospinal fluid (CSF) accumulation and was treated conservatively with repeated aspiration. Fusion rate was 100% with titanium cages used for fusion after anterior cervical discectomy. No complications were noted after the surgery at 1 year of interval. CONCLUSION: Results with titanium cages are expectedly good. Symptoms resolved and fusion rate was 100% at 1 year follow up.

EXPLORING DEMOGRAPHICS AND OUTCOMES FOR SPINAL TUMOURS FOLLOWING SURGERY IN COMBINED MILITARY HOSPITAL, PESHAWAR.

BACKGROUND: Tumours of the spinal cord, spinal meninges and cauda equina are relatively rare and their spectrum has not been studied extensively in Khyber Pakhtun Khawa province. We describe here the cases of spinal tumours treated in our setup over a period of two years. METHODS: This Descriptive Case Series was carried out with of 80 patients operated in our centre from January 2013 to January 2015. The clinical presentation of these tumours as well as demographic findings was analysed. Patients who underwent surgery for their tumours were included in the study. Patients were selected for surgery depending on their radiological and clinical findings. Lesions that were suggestive of metastasis were biopsied and further care was shared between specialized departments depending on the primary source. RESULTS: Male to female ratio was 1.5:1. Most of the spinal tumours were secondary tumours while meningiomas were the most common primary tumours. Most commonly patients belonged to young age group A (below 30 years.) 32.5%. Most common presentation was with paraparesis (27.5%) and paralysis (25%). A majority of patients regained good neurological function and did not show signs of recurrence at 1 year follow up. CONCLUSION: Given the limited experience at our centre, we believe that a wide range of spinal tumours can be successfully treated provided that clinical end points are kept in mind and treatment is individualized. Frankel grading is useful to assess surgical outcome in the patients.

VON HIPPEL LINDAU SYNDROME AND SURVEILLANCE: A FIVE YEAR FOLLOW UP CASE REPORT.

Von Hipple Lindau disease is a rare genetic autosomal dominant disorder, characterized by formation of tumors and fluid-filled cysts (sacs) in multiple organs of the body, which also carry a potential for malignancy. We are reporting a case of a young 20 years old female who presented to our department with von Hipple Lindau disease.