Referral for Dietary Intervention in Celiac Disease Is Low among Gastroenterologists and Primary Care Providers.

BACKGROUND: Strict adherence to a gluten-free diet is the only known effective treatment for celiac disease currently. Multiple organizations recommend follow-up with a dietitian and guideline-directed management after diagnosis. Few studies have evaluated follow-up post diagnosis. However, these do not include a systematic process for monitoring dietary referral among celiac disease patients. We sought to evaluate and compare the frequency of early dietary referral and guideline-directed preventive care and management for celiac disease patients managed by gastroenterologists and primary care providers. METHODS: A retrospective chart review of celiac disease patients receiving care at a single tertiary care facility. Our primary outcome was to compare the frequency of dietary intervention between gastroenterologists and primary care providers in an outpatient setting after initial diagnosis. Multivariate analysis was performed to determine associated factors for referral for dietary intervention and recommended follow-up lab work. RESULTS: 261 patients were included in the study, 81.6% were followed by gastroenterologist and only 51% were seen by a dietitian. Patients following up with gastroenterologists had higher odds of referral for dietary intervention on multivariate analysis (OR 3.29, p value <0.003). Only 16% of all patients completed appropriate guideline-directed follow-up care. CONCLUSIONS: Dietary intervention and follow-up of preventive care lab work were low in celiac disease patients. There is an opportunity for further education of both primary care providers and gastroenterologists on the importance of early dietary referral and appropriate medical management at follow-up.

Acute Esophageal Necrosis Secondary to a Paraesophageal Hernia.

Acute esophageal necrosis (AEN) or "black esophagus" is a rare clinical entity caused by necrosis of distal esophageal mucosa stemming from esophageal ischemia. Possible etiologies are broad but most commonly include possible triggers of low-flow vascular states in the esophagus, including infections, broad-spectrum antibiotic use, and gastric volvulus, among others. Patients most commonly present clinically with acute onset hematemesis and melena. Here, we describe a patient who initially presented with multiple nonspecific gastrointestinal symptoms, including abdominal pain and nausea, that progressed over a 10-day period, culminating in multiple episodes of hematemesis prior to presentation. Endoscopic evaluation confirmed the diagnosis of AEN and unveiled a possible paraesophageal hernia (PEH) as the causative factor. A subsequent videofluoroscopic barium swallow was utilized to better characterize the upper gastrointestinal anatomy and confirmed the PEH as a likely etiology. Esophagogastroduodenoscopy (EGD) can often identify PEH independently, but in patients with AEN secondary to a possible, but unclear, PEH on EGD, a videofluoroscopic barium swallow is an appropriate and useful next step in confirming the diagnosis. While treatment of AEN traditionally involves fluid resuscitation, intravenous protein pump inhibitors, and total parenteral nutrition, surgical intervention is often indicated in patients who have a contributing and symptomatic PEH.

Clostridium difficile Infection of a Total Hip Arthroplasty: Case Report and Review of the Literature.

CASE: We describe the case of an 85-year-old woman who presented with worsening right hip pain after a conversion hip replacement. Subsequent imaging demonstrated a gas-containing collection in the lateral thigh. She was taken to the operating room for irrigation and debridement, where intraoperative cultures returned positive for Clostridium difficile. Surgical management was followed by a prolonged course of antibiotics. CONCLUSIONS: Clostridium difficile as the etiology of infection in a conversion arthroplasty is exceedingly rare. Orthopaedic surgeons and infectious disease specialists should consider C. diff as a potential cause of infection in conversion hip arthroplasty because management options will need to be tailored.

Castleman flare or COPD exacerbation- can biomarkers override availability bias?

Effective treatments for human herpes virus 8 (HHV-8) associated multicentric Castleman disease (MCD) have led to prolonged survival for this complex systemic lymphoproliferative inflammatory disease. Nonetheless, significant challenges remain for the recognition of disease exacerbations, particularly when overlapping with common comorbid conditions. We present a case of a 60-year-old man with a 22-year history of MCD, current advanced COPD, and medication-controlled HIV. His recurrent presentations with flares of fatigue, worsening dyspnea, and productive cough were confusing to clinicians who were attempting to distinguish between exacerbations of MCD or COPD. Published biomarkers of MCD flare include HHV-8 and CRP, which were proposed by the patient to his clinicians as useful in guiding treatment. This case illustrates the value of patient insight as an antidote to the problem of availability bias.

STEMI: rare initial presentation of a mediastinal mass supplied by the RCA.

In the setting of severe septic shock, a 70-year-old woman had an ST segment myocardial infarction with ST elevations in the inferolateral leads. On cardiac catheterisation, no obstructive pathology was noted. Chest imaging revealed a large mediastinal mass measuring 8.5×6.5×7.5 cm in the visceral compartment of the mediastinum, with contrast enhancement from the right coronary artery (RCA). A biopsy was preformed and cytology was consistent with a well-differentiated neuroendocrine neoplasm. On review of the cardiac catherisation, it was noted that the mass was deriving blood supply from the RCA. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare but well-documented phenomenon. In this case, MINOCA was caused by coronary steal syndrome in the setting of profound hypotension. Immediate management is with haemodynamic support; there is no role for coronary intervention.