Celiac Disease Presenting in a Community-Based Gastroenterology Practice: Obesity and Bone Disease Are Common.

BACKGROUND: The description of the clinical presentation of celiac disease (CeD) has usually come from studies at referral centers. Data about CeD presentation in the community are sparse. AIMS: We aim to describe the clinical presentation of patients with biopsy-proven CeD at a community-based adult gastroenterology practice and compare it to a referral center. METHODS: We performed a retrospective study of two cohorts of patients diagnosed with CeD between 2000-2007 (n = 117) and 2013-2016 (n = 91) in a community practice, and a third cohort (n = 188) diagnosed between 2000 and 2007 in a tertiary referral center. The clinical presentation, body mass index, tissue-transglutaminase levels, DEXA scan, vitamin D levels, and vaccine recommendations were assessed. RESULTS: Celiac disease presentation changed over time in the two community cohorts. Recently, fewer patients presented with diarrhea and anemia, but constipation and neurologic symptoms were more common. The most recent cohort had a higher proportion of patients who were overweight or obese than the first cohort. However, the body mass index in both community cohorts was higher than in the tertiary referral center. The frequency of osteopenia and osteoporosis was high in both community cohorts. The tertiary referral center patients were younger, presented with a higher proportion of diarrhea and a lower body mass index. CONCLUSIONS: The clinical presentation of CeD differs between the community setting and a tertiary referral center. Patients with CeD presenting to the community setting tended to be older, overweight, and to have a high proportion of mineral bone disease.

Coexisting Primary Sclerosing Cholangitis and Autoimmune Hepatitis: Overlapping Challenges in Diagnosis and Treatment.

Introduction: Hepatobiliary overlap syndromes describe the coinciding presentation of more than one immune-mediated biliary and liver disease in a single patient and present complex challenges in diagnosis and treatment. We report a case of ulcerative colitis with primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome responsive to vancomycin. Case Presentation: The patient is a 30-year-old female with known ulcerative pancolitis and autoimmune hepatitis. She presented to the emergency department with a constellation of gastrointestinal symptoms, including diffuse lower abdominal pain, bloody diarrhea, and nausea with bilious vomiting. Subsequent imaging revealed the additional diagnosis of primary sclerosing cholangitis, and she was diagnosed with overlap syndrome. Multiple treatment regimens were trialed with minimal improvement. She eventually achieved normalization of both clinical status and biochemical markers after the addition of vancomycin. Conclusion: Vancomycin is an underutilized therapy; its potential role in primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome has not been previously reported.

Misrepresentation of mild traumatic brain injury research in press releases.

BACKGROUND: Press releases from academic medical centers often form the basis for health and science news stories. Press release coverage of mild traumatic brain injury (mTBI) research has not been formally appraised in the literature. OBJECTIVE: To perform a systematic content analysis of mTBI-based press releases. DESIGN: Retrospective database study. SETTING: EurekAlert! (eurekalert.org), the main distribution engine for scientific press releases. PARTICIPANTS: Press releases indexed between January 1, 2012 and December 31, 2019 containing a minimum of 150 words. INTERVENTIONS: Pre-established, investigator-generated criteria delineating aspects of misinformation. MAIN OUTCOME MEASUREMENTS: Press releases were evaluated for manifestations of "spin," including misleading title, misleading reporting, misleading claims, and inappropriate extrapolation. RESULTS: Our database search yielded 125 entries within the specified time period. Of these, 66 met inclusion criteria. Fifty-five of 66 (83%) press releases exhibited at least one manifestation of spin. We identified 38 (58%) with misleading titles, 49 (74%) with misleading reporting, 44 (67%) with misleading claims, and 38 (58%) with inappropriate extrapolation. CONCLUSIONS: Our analysis revealed a high degree of spin in recent press releases dedicated to mTBI research. The reports often overstated the strengths and practical impact of the study, publicize substandard research without clinical relevance, while downplaying or failing to report limitations and caveats. Misrepresentation in press releases can affect real-life medical decisions and outcomes.

Web-based portrayal of platelet-rich plasma injections for orthopedic therapy.

OBJECTIVE: Previous studies on Internet sites indicate that some Web-based material on sport-related orthopedic disorders is biased, misleading, and conveying inaccurate health messages. Our hypothesis was that Web-based content on platelet-rich plasma (PRP) therapy from commercial sites is frequently imbalanced, biased, and incorrect. DESIGN: In this descriptive epidemiological study, an Internet search was performed using the search engine Google using keywords "platelet-rich plasma" and "platelet-rich plasma therapy." Exclusion criteria were medical or scientific journal, encyclopedia, or medical reference articles. SETTING: Publicly available Internet resources were examined. PARTICIPANTS: Web-based resources identified through an Internet search engine. MAIN OUTCOMES MEASURES: Using content analysis, we assessed each reference for factual accuracy, themes depicted, opinions, and recommendations. RESULTS: Our search yielded a total of 44 articles, of which 26 unique articles met the inclusion criteria. Twenty of 26 articles (77%) made inappropriate statements regarding evidence, treatment, efficacy, or safety of PRP injections. Twenty-three articles (88%) were medically imbalanced, discussing only perspectives of physicians favoring the treatment. Only 8 articles (31%) discussed alternative treatment options. Twenty-two articles (85%) used individual dramatized patient experiences to demonstrate the effectiveness of PRP. Nineteen articles (73%) made unsubstantiated promises regarding health outcomes of PRP injections. Many accessed Internet sites were from medical practices or institutions where PRP therapy was used. CONCLUSIONS: Our data indicate that some Web-based references to PRP therapy are biased and inaccurate. We are concerned that some readers will misinterpret such easily available, but poorly controlled, information, potentially leading to use of unproven therapies.

Treatment outcomes with pegylated interferon and ribavirin for male prisoners with chronic hepatitis C.

GOALS: To report our experience with pegylated interferon and ribavirin treatment of hepatitis C virus (HCV) RNA-positive inmates at the Rhode Island Department of Corrections. BACKGROUND: An estimated 1 out of 3 HCV-infected individuals will spend time in a jail or prison within a 1-year period, making prisons a unique setting for management of chronic HCV. STUDY: Chart review of all inmates identified as having initiated HCV treatment between October 2000 and April 2004. HCV-infected individuals were identified by HCV antibody screening at intake for known risk factors, elevated aminotransferase levels, or per individual request. Treatment followed standard guidelines with weight-based dosing of pegylated interferon-alpha2b and ribavirin. End points were completion of therapy plus 6 months for sustained virologic response (SVR), therapy discontinuation, and loss to follow-up. RESULTS: The cohort included 71 male patients, was mostly white (80%), and genotype 1 (65%). All 9 African Americans (AA) had genotype 1. Of 59 patients having liver biopsy, 41 had early stage disease. Overall SVR was 28%. Response rate was lower for genotype 1 compared with genotypes 2 and 3 (SVR 18% vs. 60% and 50%). Of inmates with genotype 1, no difference existed in treatment response by race (SVR 22% AA vs. 18% white). Thirty-three patients completed treatment, 26 stopped for side effects, and 5 for initial nonresponse. Eleven were lost to follow-up. CONCLUSIONS: Acceptable HCV treatment outcomes can be achieved in prisons. Our small study indicates no difference in treatment response by AA versus white race for genotype 1.

Why do doctors overprescribe antibiotics?

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Deceit, lies and plagiarism in residency applications.

[Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Gastric Heterotopic Pancreas Presenting as Abdominal Pain with Acute and Chronic Pancreatitis in the Resected Specimen.

Heterotopic pancreas, also known as ectopic pancreas, is pancreatic tissue located outside the pancreatic parenchyma without vascular or ductal communication with the gland. Ectopic pancreas is rarely symptomatic, typically detected incidentally at surgery or autopsy. Eighty-five to 90% are in the upper GI tract, especially the gastric antrum. We report a 54-year-old man with symptomatic gastric heterotopic pancreas presenting as recurrent, initially undiagnosed, abdominal pain. Surgery revealed heterotopic pancreas including excretory ducts, acini, and islet cells. Evidence of acute pancreatitis was present, marked by inflammation and abscess formation. Chronic pancreatitis was diagnosed by fibrosis and dilated ducts containing proteinaceous material. Submucosal location with normal overlying mucosa on endoscopy increases risks of delayed or missed diagnosis. Complications include GI bleeding, acute or chronic pancreatitis, pancreatic necrosis, pseudocyst, gastric outlet obstruction, perforation, and, rarely, pancreatic carcinoma. This rare disorder mimics more common diseases. Low suspicion, nondiagnostic imaging or endoscopy contribute to frequent diagnostic delay.

A Case Report of Basal Cell Carcinoma in a Non-Sun-Exposed Area: A Rare Presentation Mimicking Recurrent Perianal Abscess.

Basal cell carcinoma (BCC), a common malignancy, arises most often in sun-exposed areas but does rarely occur in non-sun-exposed sites. Prior tissue injury, especially sharp trauma and chronic inflammation, increases the risk of BCC. We describe a 66-year-old male patient with recurrent perianal abscesses who was found to have a large pigmented basal cell carcinoma. The mass was excised without recurrence at two-year follow-up. Perianal BCC is commonly larger at the time of diagnosis than tumors in sun-exposed sites, likely related to delay in diagnosis. Increased size can lead to increased surgical complexity and more pronounced effects on nearby structures. Early detection is important for optimal patient outcomes. In selected patients presenting with a perianal mass, basal cell carcinoma should be included on the differential diagnosis.

Metastatic Gallbladder Melanoma Presenting as Acute Emphysematous Cholecystitis.

Malignant melanoma is an aggressive tumor with a high potential for distant metastases, including spread to the gallbladder where it represents more than half of all metastases detected at autopsy. Yet, it is rarely symptomatic in life and is a rare cause of acute cholecystitis. Emphysematous cholecystitis is a rare, potentially fatal variant of acute cholecystitis characterized by the presence of gas in the gallbladder lumen or wall. We report a 77-year-old woman with acute emphysematous cholecystitis as the initial feature of recurrent melanoma metastatic to the gallbladder. This exceptional association highlights the need to consider a relapse of malignancy when assessing unexplained abdominal symptoms in any patient with a prior history of melanoma.

A Woman with Black Beads in Her Stomach: Severe Gastric Ulceration Caused by Yttrium-90 Radioembolization.

Radioembolization (RE) is a selective internal radiation therapy (SIRT) delivering targeted, high-dose, intra-arterial radiation directly to the vascular supply of liver tumors. Complications can occur due to aberrant deposition or migration of radiation microspheres into nontarget locations, including normal hepatic parenchyma, lungs, pancreas, and upper gastrointestinal (UGI) tract. We report a case of gastric ulcers due to yttrium-90 (90Y) seed migration to the stomach to alert clinicians to this rare cause of gastric injury. A 57-year-old woman with stage IV breast cancer with liver and lung metastases presented to the hospital with 2 months of worsening nausea and vomiting. Two months prior, she had received SIRT with 90Y microspheres without complications. Upper GI endoscopy showed diffuse gastritis and extensive antral ulceration. Biopsies revealed black, spherical foreign bodies, consistent with 90Y microspheres, documenting radiation injury. Radiation-induced UGI ulceration is caused by direct radiation injury from beta-radiation. Delay in diagnosis may be due to the nonspecificity of symptoms and temporal delay of symptom onset from SIRT, which was 2 months in our patient. Also, complaints may be attributed erroneously to adjuvant chemotherapy or widespread metastatic disease. Clinicians must consider radiation-associated toxicity in any SIRT-treated patient developing abdominal symptoms.

Predicting Mortality in Diabetic ICU Patients Using Machine Learning and Severity Indices.

Diabetes constitutes a significant health problem that leads to many long term health issues including renal, cardiovascular, and neuropathic complications. Many of these problems can result in increased health care costs, as well risk of ICU stay and mortality. To date, no published study has used predictive modeling to examine the relative influence of diabetes, diabetic health maintenance, and comorbidities on outcomes in ICU patients. Using the MIMIC-III database, machine learning and binomial logistic regression modeling were applied to predict risk of mortality. The final models achieved good fit with AUC values of 0.787 and 0.785 respectively. Additionally, this study demonstrated that robust classification can be done as a combination of five variables (HbA1c, mean glucose during stay, diagnoses upon admission, age, and type of admission) to predict risk as compared with other machine learning models that require nearly 35 variables for similar risk assessment and prediction.

Menstrual hygiene plight of homeless women, a public health disgrace.

[Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

Junk science for sale Sham journals proliferating online.

A new danger threatens the integrity of scholarly publishing: predatory journals. Internet-only, "open-access" publishing is a valid way for researchers to reach the public without a paywall separating them. But, of thousands of open-access scientific journals today, as many as twenty-five percent are believed to be fake, existing only to make money by charging authors high processing fees. In sham journals, peer review is cursory or absent: as many as eighty to ninety percent of submitted manuscripts are accepted, many within days, without any editorial comment. Predatory journalism can be remarkably good at mimicking reputable publishers. Sham journals use names and logos that closely resemble those of legitimate journals, intentionally confusing site visitors. Untrustworthy publications have not received the widespread, damning publicity they deserve. If junk science is not confronted and eliminated, it will continue to tarnish and undermine ethical, open-access scholarly publishing. [Full article available at http://rimed.org/rimedicaljournal-2017-07.asp].

A rare case of amelanotic anorectal melanoma.

We report an exceedingly rare case of amelanotic anorectal melanoma misdiagnosed as hemorrhoids. A 74-year-old man presented with a week's history of "blood on toilet tissue" without bowel complaints or history of cutaneous melanoma. Skin evaluation was normal. Rectal exam was negative for blood, but revealed an anal nodule, interpreted as a hemorrhoid. Hemoglobin was normal; bleeding persisted. After one month, colonoscopy detected a non-pigmented anal lesion. Biopsy showed melanoma. Noncutaneous mucosal melanoma represents 0.03% of new cancer diagnoses Anorectal melanoma accounts for 1% of melanomas and 0.4% of anal malignancies. Uncommonly, this malignancy lacks melanin pigment, complicating detection. Presenting complaints are non-specific rectal bleeding, pain, itching or incontinence, mimicking more common disorders. Dangerous misdiagnosis occurs when benign disease, not malignancy, is suspected. Risk factors for cutaneous melanoma are less frequent. Mucosal melanoma has different genetics. Clinicians must be aware of diagnostic difficulties of anorectal melanoma, especially when amelanotic. [Full article available at http://rimed.org/rimedicaljournal-2017-09.asp].