Small bowel diverticula in elderly patients: a case report and review article.

BACKGROUND: Small intestine diverticula are rare findings that were mostly reported in the elderly population as asymptomatic findings. However, they can also present with a wide range of symptoms (bloating, early satiety, chronic abdominal discomfort, and diarrhea/steatorrhea) or complications (gastrointestinal bleeding, small bowel obstruction, acute diverticulitis, or perforation) which in turn warrant medical treatment or urgent surgical intervention. CASE PRESENTATION: This is a case report of an 84-year-old female who presented with an acute surgical abdomen. An exploratory laparotomy revealed complicated small bowel diverticula with a jejunal diverticulum perforation, for which a diverticulectomy was performed. CONCLUSIONS: Throughout this paper, we are aiming to outweigh the consideration of the possibility of complicated small bowel diverticula as a differential in the evaluation of any acute abdomen, especially in the elderly, which warrants emergency surgical management.

Evaluation of Sleep Quality Among People Living With Type 2 Diabetes Mellitus in Taif, Saudi Arabia: A Cross-Sectional Study.

BACKGROUND:  Type 2 diabetes mellitus (T2DM) is characterized by high blood glucose levels, which are highly associated with poor sleep quality, cardiovascular disease, and pathological changes. This research examines the relationship between sleep quality and T2DM and compares it with nondiabetics within the Taif community. The findings of this study will provide valuable insights and recommendations to enhance the overall health quality in Taif, Saudi Arabia. METHODOLOGY:  A cross-sectional study was conducted on 547 patients with T2DM between December 1, 2023, and April 1, 2024, in Taif. The sleep quality was assessed using the Sleep Quality Questionnaire (SQQ). Data were collected using an online questionnaire with two parts: primary demographic data and an assessment of sleep quality using the SQQ. RESULTS:  Our study enrolled 814 participants, including 547 with T2DM and 267 nondiabetics. Participants with T2DM had poorer sleep quality, with a median score of 21 vs. 25 (P < 0.001). Significant factors affecting sleep quality included gender (P = 0.002), marital status (P = 0.023), and job status (P = 0.023). Nondiabetics had better sleep quality (76%) than participants with T2DM (61.1%). Males, married, and employed individuals reported higher sleep quality scores. CONCLUSIONS:  Research indicates that individuals with T2DM experience lower sleep quality than the general population, particularly among female, unmarried, and unemployed individuals. To enhance sleep quality in patients with T2DM, it is essential to increase awareness, provide education on proper sleep habits, and highlight the importance of effective diabetes management, screening for sleep disorders, and consistent monitoring.

Statistical analysis plan for the Steppedwedge Cluster Randomized trial of Electronic Early Notification of sepsis in hospitalized ward patients (SCREEN).

BACKGROUND: It is unclear whether screening for sepsis using an electronic alert in hospitalized ward patients improves outcomes. The objective of the Stepped-wedge Cluster Randomized Trial of Electronic Early Notification of Sepsis in Hospitalized Ward Patients (SCREEN) trial is to evaluate whether an electronic screening for sepsis compared to no screening among hospitalized ward patients reduces all-cause 90-day in-hospital mortality. METHODS AND DESIGN: This study is designed as a stepped-wedge cluster randomized trial in which the unit of randomization or cluster is the hospital ward. An electronic alert for sepsis was developed in the electronic medical record (EMR), with the feature of being active (visible to treating team) or masked (inactive in EMR frontend for the treating team but active in the backend of the EMR). Forty-five clusters in 5 hospitals are randomized into 9 sequences of 5 clusters each to receive the intervention (active alert) over 10 periods, 2 months each, the first being the baseline period. Data are extracted from EMR and are compared between the intervention (active alert) and control group (masked alert). During the study period, some of the hospital wards were allocated to manage patients with COVID-19. The primary outcome of all-cause hospital mortality by day 90 will be compared using a generalized linear mixed model with a binary distribution and a log-link function to estimate the relative risk as a measure of effect. We will include two levels of random effects to account for nested clustering within wards and periods and two levels of fixed effects: hospitals and COVID-19 ward status in addition to the intervention. Results will be expressed as relative risk with a 95% confidence interval. CONCLUSION: The SCREEN trial provides an opportunity for a novel trial design and analysis of routinely collected and entered data to evaluate the effectiveness of an intervention (alert) for a common medical problem (sepsis in ward patients). In this statistical analysis plan, we outline details of the planned analyses in advance of trial completion. Prior specification of the statistical methods and outcome analysis will facilitate unbiased analyses of these important clinical data. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. METHODS: The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of "possible sepsis alert" to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. DISCUSSION: The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Colonic mucosal concentrations of folate correlate well with blood measurements of folate status in persons with colorectal polyps.

BACKGROUND: Estimates of habitual dietary folate intake are known to be imprecisely correlated with systemic measures of folate status. Furthermore, measurements of blood folate concentrations may not accurately reflect the concentration of folate in tissues of interest. This issue is important for assessing folate status in the colorectal mucosa because low dietary intake or blood concentrations of folate are associated with an increased risk of colorectal neoplasia. OBJECTIVE: We examined whether conventional measures of folate in blood and a more sensitive, inverse indicator of systemic folate status, serum homocysteine, accurately reflected folate concentrations in human colonic mucosa obtained by endoscopic biopsy. DESIGN: In 30 persons with colorectal polyps, blood samples were taken and biopsies of normal rectosigmoid mucosa performed at the time of colonoscopic polypectomy. Serum, red blood cell, and colonic mucosal folate and serum homocysteine concentrations were measured. RESULTS: Serum and red blood cell folate and serum homocysteine concentrations accurately reflected colonic mucosal folate concentrations; among these, serum homocysteine correlated best with mucosal concentrations. Folate concentrations in the normal rectosigmoid mucosa were significantly lower in persons with adenomatous polyps than in those with hyperplastic polyps (P=0.04). Conventional measures of systemic folate status were not significantly lower in those with adenomas, although serum homocysteine was mildly elevated (P=0.04). CONCLUSIONS: Our data underscore the ability of systemic measures of folate status, particularly serum homocysteine, to reflect folate concentrations in the colonic mucosa. Nevertheless, future studies that examine the ability of folate to modulate colorectal carcinogenesis may benefit from direct measurement of folate in the colon.

Colonic mucosal concentrations of folate are accurately predicted by blood measurements of folate status among individuals ingesting physiologic quantities of folate.

Folate status is inversely related to the risk of colorectal cancer. Whether conventional blood measurements of folate status accurately reflect folate concentrations in the colorectal mucosa has been a controversial topic. This is an important issue because accurate measures of folate status in the colorectal mucosa are important for ascertaining the risk of colorectal cancer in epidemiological studies and for determining the effects of folate supplementation in clinical trials. We examined whether conventional blood measurements of folate and a more sensitive, inverse indicator of systemic folate status, serum homocysteine, accurately reflect folate concentrations in human colonic mucosa obtained by endoscopic biopsy. Study subjects (n = 20) were participants in a randomized trial that investigated the effect of folate supplementation (5 mg daily for 1 year) on provisional molecular markers of colon cancer. Blood samples and biopsies of normal rectosigmoid mucosa were obtained at baseline, at 6 months, and at 1 year. Serum, RBC, and colonic mucosal folate and serum homocysteine concentrations were determined. Colonic mucosal folate concentrations correlated directly with serum folate concentrators at each time point (r = 0.572-0.845; P < 0.015) and with RBC folate concentrations at 6 months and 1 year (r = 0.747-0.771; P < 0.001). Colonic mucosal folate concentrations correlated inversely with serum homocysteine concentrations at each time point (r = -0.622-0.666; P < 0.008). Systemic measures of folate status did not correlate with colonic mucosal folate concentrations among individuals receiving supplemental folate. Our observations indicate that colonic mucosal concentrations of folate may be predicted accurately by blood measurements of folate status only among individuals not ingesting supraphysiological quantities of folate.

Association of physicians' knowledge and behavior with prostate cancer counseling and screening in Saudi Arabia.

OBJECTIVE: To investigate the knowledge, attitudes and practices of primary care physicians towards prostate cancer counseling and screening. METHODS: This cross sectional study was conducted in May 2009 to October 2009 through a survey questionnaire, which was distributed to all licensed primary care physicians in Riyadh, Saudi Arabia. The study took place in the Princes Al-Johara Al-Ibrahim Center for Cancer Research, King Saud University, Saudi Arabia. Data was obtained from 204 primary care physicians using self-reports of prostate cancer screening practices, knowledge, attitudes towards prostate cancer screening, and continuous medical education preferences. Respondents' characteristics were also collected. RESULTS: Approximately 54.7% of the respondents were practicing counseling and referring prostate cancer patients. The mean correct knowledge score was 54.3%, their attitude was not strong; the only statement that approximately 70% of physicians agreed upon was about the value of screening, however, the reliability and evidence to support digital rectal examination and prostatic specific antigen were in question. Our primary care physicians had self-confidence in suspecting and referring high-risk patients for screening, but not for management and treatment. CONCLUSION: Knowledge and attitude were found to be the most significant predictors that determine physicians' self practice. Physicians' practice towards a screening procedures or early detection of diseases should rely on a good background of information, which in turn enhances their self-efficacy and develops a good and positive attitude towards their practice skills.

Viral hepatitis in homosexual men.

We studied 33 episodes of acute viral hepatitis in homosexual men to determine the type of hepatitis seen in this population. Seventy percent were caused by type A hepatitis, and 30% by type B hepatitis. None were due to non-A, non-B hepatitis. A high proportion of patients presenting with either type of acute hepatitis had evidence of previous infection with the other type: Seventy percent of patients with type B hepatitis had previous infection with type A, and 74% of patients with type A hepatitis had previous infection with type B. This study shows that, in homosexual men, hepatitis A, like hepatitis B, is a sexually transmitted disease.

Recurrent acute pancreatitis as a manifestation of Wegener's granulomatosis.

We report a case of recurrent acute pancreatitis in a 57-year-old man with reactivation of Wegener's granulomatosis. An association between acute pancreatitis and Wegener's granulomatosis has not been reported previously. Six episodes of abdominal pain and hyperamylasemia occurred and were complicated by development of a pancreatic pseudocyst. New cavitary lung lesions typical of Wegener's granulomatosis led to treatment with increased glucocorticoid dosage, resulting in rapid resolution of the pancreatitis and pulmonary lesions. Acute pancreatitis may be a clinical manifestation of the histologic pancreatic vasculitis observed in Wegener's granulomatosis. Reactivation of Wegener's granulomatosis should be considered when a patient with the disorder develops otherwise unexplained acute pancreatitis.

Cirrhosis and portal hypertension in a patient with adult Niemann-Pick disease.

A woman with known Niemann-Pick disease, type B, presented at age 33 with upper gastrointestinal bleeding, ascites, and peripheral edema. Evaluation showed massive hepatosplenomegaly, infiltration of the liver with Niemann-Pick cells, cirrhosis, and evidence of portal hypertension. Chronic gastrointestinal bleeding, thrombocyctopenia, and platelet dysfunction were treated successfully by splenectomy. Cirrhosis and portal hypertension have not been reported previously in adult Niemann-Pick disease in the absence of some other cause.

Prolonged cholestasis due to trimethoprim sulfamethoxazole.

Drug-induced liver injury due to trimethoprim sulfamethoxazole is rare and classified as an unpredictable or idiosyncratic type of hepatotoxic reaction. Early reports suggested that the pattern of liver injury in the majority of cases is mixed hepatocellular-cholestatic. The current report describes two cases of severe, prolonged cholestasis after treatment with trimethoprim sulfamethoxazole; intractable pruritus and abnormal liver test results lasted for 1-2 years after discontinuation of the drug. Liver biopsy specimens showed a cholestatic pattern of liver injury and only minimal hepatocellular necrosis or inflammation. Recent case reports suggest that cholestasis alone may occur after the use of trimethoprim sulfamethoxazole; these two additional cases show that cholestasis may be quite prolonged.

Extrahepatic biliary stricture associated with cytomegalovirus in a liver transplant recipient.

We describe a patient who developed a stricture in the distal common bile duct 6 weeks after orthotopic liver transplantation. Histopathologic examination of the bile duct epithelium in the region of the stricture showed characteristic cytomegalovirus (CMV) inclusions. CMV was also identified in pulmonary alveoli and in the duodenum. Although CMV has been demonstrated in the biliary epithelium of AIDS patients with extrahepatic biliary strictures and biliary obstruction, this entity has not, to our knowledge, been described in liver transplant recipients. This report confirms that CMV infection should be included as a probable cause of extrahepatic biliary strictures and bile duct obstruction in liver transplant patients.

Intraabdominal variceal bleeding.

A patient with known liver cirrhosis, but no previous variceal bleeding, presented with sudden abdominal pain and distention, hypotension, and bloody ascitic fluid. At exploration, he was found to be bleeding from varices in the gastrohepatic omentum and perisplenic area. Pathology of the liver showed cirrhosis and metastatic undifferentiated carcinoma.

Chronic erosive gastritis resulting in cachexia.

Nine patients are reported who presented with severe weight loss of up to 13.6 kg (30 lb) as a result of chronic erosive gastritis. In many the cachexia was sufficient to prompt a search for malignancy but no other lesion was found. The importance of the radiological pursuit of this diagnosis is emphasised. Illustrative case histories are presented.

A novel histological lesion in glucocorticoid-responsive chronic hepatitis.

In patients with chronic hepatitis, the diagnosis of autoimmune hepatitis is made on the basis of increased gamma-globulin levels and the presence of circulating autoantibodies. Because these test results are not abnormal universally in patients with autoimmune hepatitis, liver biopsy remains an important part of the evaluation. The classical histological finding in autoimmune hepatitis is lymphocytic infiltration of the portal triads and periportal zone (zone 1) with periportal hepatocyte necrosis. This case report describes 4 patients with glucocorticoid-responsive hepatitis, presumably autoimmune in nature, who had pericentral necrosis (zone 3) with relative sparing of the portal areas in their liver biopsy specimens, a previously undescribed histological finding in autoimmune hepatitis.

Multifocal malignant hemangioendothelioma presenting as acute hepatitis. A clinicopathologic study.

A patient with malignant hemangioendothelioma of the liver is described. The patient's clinical presentation and course were that of fulminant hepatic necrosis. Complications included upper gastrointestinal hemorrhage, hepatic encephalopathy, abnormal coagulation parameters and the hepatorenal syndrome. The duration of the illness from the onsetof symptoms to its fatal outcome was five weeks.

Adult intussusception presenting with transient intestinal ischemia.

A 71-year old woman initially presented with abdominal pain and an x-ray picture of ischemia of the terminal ileum. The ischemic changes were transient and reversed spontaneously. Six months later, she presented with the same complaint and an x-ray picture of ileocolic intussusception. At operation, a lipoma of the ileum was the leading point of the intussusception and ischemic changes of the ileum were evident.

Chronic intestinal ischemia associated with oral contraceptive use.

A 48-yr-old woman with chronic intestinal ischemia and a long history of oral contraceptive use is reported. She presented with a 6-month history of severe diarrhea, abdominal pain, and weight loss. Abdominal arteriography revealed occlusion of the celiac axis at its origin and 90% stenosis of the superior mesenteric artery. This chronic arterial lesion has not been previously noted in association with the use of oral contraceptive agents in otherwise healthy women. The patient's isolated arterial lesions proved amenable to successful surgical bypass. Postoperatively she became completely asymptomatic and has remained so on long-term follow-up.

Practice patterns and costs of hospitalization for upper gastrointestinal hemorrhage.

We conducted an observational study at three hospitals in Boston to examine the patterns of practice and the costs involved in the medical management of noncirrhotic, upper gastrointestinal bleeding. A total of 111 patients were identified and studied: 42 from hospital 1, 38 from hospital 2, and 31 from hospital 3. There were no significant differences in the management of the patients, except for the more frequent use of upper gastrointestinal radiography at hospital 3 and the more frequent use of cimetidine at hospital 2. Only a small percentage (3-7%) of patients required surgery, and overall mortality (0-8%) was low. The average cost of hospitalization, determined by using the New England Medical Center cost model, was calculated for direct costs ($3,180). The majority of costs incurred were for hospital bed or intensive care unit stay (63%) and transfusion of blood products (14%), with costs for physicians' services (9%), endoscopy (2%), and upper gastrointestinal radiography (1%) accounting for only a small percentage. This study demonstrates remarkable similarity in practice patterns and resource utilization at three different hospitals and provides data on the actual costs involved in hospitalization for noncirrhotic, upper gastrointestinal hemorrhage.

Ulcerative colitus and Crohn's disease of the colon - a comparison of the long term postoperative courses.

Patients with colitis and ileocolitis of unknown etiology from two previously reported series have been combined and the follow-up studies have been extended to compare the long term postoperative courses of ulcerative colitis (UC) and Crohn's disease of the colon (CDC). The combined and updated series of 176 patients, 99% of whom could be traced, provided a mean postoperative follow-up period for UC of 14 years (5 to 31) and CDC of 13.1 years (5 to 36). There were highly significant associations between generally accepted clinical and distributional features of UC and CDC and microscopic findings generally regarded as reliable for each. However, because of spectrum of features was found in each entity, neither clinical and distributional nor microscopic features alone are sufficient for diagnosis in every case. There were no differences in gross or disease-related mortality in UC and CDC whatever the method of diagnosis. After anastomotic procedures in CDC a recurrence rate of 73% was found. After proctocolectomy the ileostomy revision rate (considering all types of those which required further excision of ileum) was higher in CDC than UC whether the diagnoses were based on microscopic, clinical, or combined criteria, but the differences reached statistical significance only in the comparison of "clinical UC", with "clinical CDC". Moreover, after the first 2 postoperative years, the risk of having an ileostomy revision in UC and CDC (combined criteria) per patient year follow-up was virtually identical and there were no cases of short bowel syndrome. Differences in the clinical courses of UC and CDC after colectomy and ileostomy are of degree and do not reflect the ultimate course or potential for rehabilitation. Decisions regarding surgical therapy should be made independent of the diagnosis of UC or CDC.