Ahmed Akhter

Seasonal variation of manic and depressive symptoms in bipolar disorder

Analyses of seasonal variation of manic and depressive symptoms in bipolar disorder in retrospective studies examining admission data have yielded conflicting results. We examined seasonal variation of mood symptoms in a prospective cohort with long‐term follow‐up: the Collaborative Depression Study (CDS).

Chryptochrome 2 variants, chronicity, and seasonality of mood disorders

Departments of Psychiatry and Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa and College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA Correspondence to Jess G. Fiedorowicz, MD, PhD, University of Iowa Hospitals and Clinics, 200 Hawkins Drive W278GH, Iowa City, IA 52242, USA Tel: + 1 319 384 9267; fax: + 1 319 353 8656; e-mail: jess-fiedorowicz@uiowa.edu

Meta-Analysis of Randomized Controlled Trials of Pharmacologic Agents in Non-alcoholic Steatohepatitis

BACKGROUND Currently, there is no standardized treatment regimen for non-alcoholic steatohepatitis. AIM We performed a metaanalysis of high quality randomized controlled trials that evaluated treatment response to metformin, thiazolidinediones (TZDs), and vitamin E in adult patients with non-alcoholic steatohepatitis. Outcome measures were improvement in liver histology, biochemical, and anthropometric measures. MATERIAL AND METHODS Nine trials met inclusion criteria (3 with TZD, 3 with Metformin, 2 with Vitamin E and 1 with both TZD and Vitamin E.). RESULTS With metformin, weighted liver histologic scores for steatosis, ballooning, and fibrosis did not demonstrate significant improvement and lobular inflammation worsened significantly (weighted mean increase 0.21, 95% CI 0.11 to 0.31, P < 0.0001). The liver histology score including steatosis (OR 3.51, 95% CI 2.14 to 5.78) and lobular inflammation (OR 2.65, 95% CI 1.69 to 4.15) improved with TZDs. Hepatic fibrosis (OR 1.58, 95% CI 0.98 to 2.54) and ballooning scores (OR 1.84, 95% CI 0.94 to 3.58) did not demonstrate significant improvement. With Vitamin E, weighted liver histologic scores for steatosis (weighted mean decrease -0.60, 95% CI -0.85 to -0.35, P < 0.0001), lobular inflammation (weighted mean decrease - 0.40, 95% CI -0.61 to -0.20, P = 0.0001) and ballooning (weighted mean decrease -0.30, 95% CI -0.54 to -0.07, P = 0.01) demonstrated significant improvement compared to placebo. Fibrosis did not significantly change. CONCLUSION In patients with NASH, TZDs and Vitamin E improve liver histologic scores but metformin does not. Insulin resistance also improves with both TZDs and metformin. Fibrosis does not improve with any of the agents.BACKGROUND Currently, there is no standardized treatment regimen for non-alcoholic steatohepatitis. AIM We performed a meta-analysis of high quality randomized controlled trials that evaluated treatment response to metformin, thiazolidinediones (TZDs), and vitamin E in adult patients with non-alcoholic steatohepatitis. Outcome measures were improvement in liver histology, biochemical, and anthropometric measures. MATERIAL AND METHODS Nine trials met inclusion criteria (3 with TZD, 3 with Metformin, 2 with Vitamin E and 1 with both TZD and Vitamin E.). RESULTS With metformin, weighted liver histologic scores for steatosis, ballooning, and fibrosis did not demonstrate significant improvement and lobular inflammation worsened significantly (weighted mean increase 0.21, 95% CI 0.11 to 0.31, P < 0.0001). The liver histology score including steatosis (OR 3.51, 95% CI 2.14 to 5.78) and lobular inflammation (OR 2.65, 95% CI 1.69 to 4.15) improved with TZDs. Hepatic fibrosis (OR 1.58, 95% CI 0.98 to 2.54) and ballooning scores (OR 1.84, 95% CI 0.94 to 3.58) did not demonstrate significant improvement. With Vitamin E, weighted liver histologic scores for steatosis (weighted mean decrease -0.60, 95% CI -0.85 to -0.35, P < 0.0001), lobular inflammation (weighted mean decrease -0.40, 95% CI -0.61 to -0.20, P = 0.0001) and ballooning (weighted mean decrease -0.30, 95% CI -0.54 to -0.07, P = 0.01) demonstrated significant improvement compared to placebo. Fibrosis did not significantly change. CONCLUSION In patients with NASH, TZDs and Vitamin E improve liver histologic scores but metformin does not. Insulin resistance also improves with both TZDs and metformin. Fibrosis does not improve with any of the agents.

Cutaneous Manifestations of Viral Hepatitis

There are several extrahepatic cutaneous manifestations associated with hepatitis B and hepatitis C virus infection. Serum sickness and polyarteritis nodosa are predominantly associated with hepatitis B infection, whereas mixed cryoglobulinemia associated vasculitis and porphyria cutanea tarda are more frequently seen in hepatitis C infection. The clinico-pathogenic associations of these skin conditions are not completely defined but appear to involve activation of the host immune system including the complement system. Management of the aforementioned cutaneous manifestations of viral hepatitis is often similar to that done in cases without viral hepatitis, with control of immune activation being a key strategy. In cases associated with hepatitis B and C, control of viral replication with specific antiviral therapy is also important and associated with improvement in most of the associated clinical manifestations.

A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer

Background and Objectives: Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1–T2). Methods: Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data. Results: There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (P = 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection. Conclusions: This study identified only a small number of T1–T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.

Gallbladder Scalloping, Mammillated Caudate Lobe, and Inferior Vena Cava Scalloping: Three Novel Ultrasound Signs of Cirrhosis

PURPOSE We aimed to present three new ultrasound signs-gallbladder scalloping, mammillated caudate lobe, and inferior vena cava scalloping-and determine their accuracy in diagnosing liver cirrhosis. MATERIALS AND METHODS A total of 201 consecutive patients with a history of chronic liver disease who had undergone ultrasound imaging and liver biopsy were identified. A senior ultrasound radiologist blindly reviewed the ultrasound examinations. Specificity, sensitivity, positive predictive value, and negative predictive value of diagnosing cirrhosis were calculated for all evaluated ultrasound signs and selected combinations of signs, using the liver biopsy results as the reference standard. RESULTS Of the 201 patients, 152 (76%) had either pathology-proven cirrhosis or significant fibrosis. Caudate lobe hypertrophy was the most specific (88%) and most positive predictor (90%) for cirrhosis, whereas mammillated caudate lobe was the most sensitive (78%). Inferior vena cava scalloping was the most specific (78%) of the three proposed ultrasound signs. When signs were combined, the presence of either gallbladder scalloping or liver surface nodularity was highly sensitive for cirrhosis (87%), whereas the presence of either gallbladder scalloping or inferior vena cava scalloping with caudate lobe hypertrophy was highly specific (93%). CONCLUSIONS Gallbladder scalloping, mammillated caudate lobe, and inferior vena cava scalloping are three novel signs that improve the accuracy of ultrasound in diagnosing cirrhosis.

EMR of large periampullary neuroendocrine tumor

A 74-year-old man with a history of hypertension, chronic kidney disease, and diabetes mellitus type 2 presented with a 2-day history of melena. His hemoglobin level remained unchanged during hospitalization. He underwent an upper endoscopy that showed a 2to 3-cm periampullary mass (Fig. 1A) concerning for malignancy just distal to the ampulla (Figs. 1B and C). Examination of initial pinch biopsy specimens showed negative results. Subsequent EUS showed a 21by 11-mm mass that was mucosal in origin without invasion through the muscularis propria. Examination of core biopsy specimens revealed a neuroendocrine (carcinoid) tumor. The patient was referred to surgery; however, he declined surgical intervention and requested attempts for endoscopic removal. He underwent upper endoscopy under general anesthesia with a plan for EMR (Video 1, available online at www.VideoGIE.org). Injection of 5 mL of epinephrine (1:20,000) was performed in and around the tumor, and a large hexagonal snare was used to remove the tumor in 1 piece with the use of 30 W set to

An Unusual Case of Polymicrobial Bacteremia

DIS 5.4.0 DTD YGAST60703 proof 2 March 2017 12:58 am ce Gastroe 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 Question: A 75year-old woman with a history of chronic obstructive lung disease, alcoholic cirrhosis, and a recent episode of polymicrobial bacteremia (Enterococcus avium and Bacteroides) at an outside hospital 2 months before presentation was admitted with short85 86 87 88 89 90 91 92 93 94 95 96 97 ness of breath and abdominal pain. Blood cultures on hospital day 1 demonstrated vancomycin-resistant enterococcus bacteremia. She was placed on daptomycin but developed hypotension, oliguria, and altered mental status. She was diagnosed with septic shock. Review of a recent computed tomography (CT) of the abdomen and pelvis at the time of polymicrobial bacteremia demonstrated an intrauterine device (IUD) that hadmigrated out of the uterus (Figure A). The IUDwas removed the next day. A barium enema performed the following day was reported to demonstrate a contained perforation (Figure B). Evaluation of potential infectious source was performed, including esophagogastroduodenoscopy, small bowel capsule endoscopy, chest radiography, whole body positron emission tomography/CT, hepatobiliary scan, transthoracic echocardiogram, CT angiogram of the abdomen and pelvis, flexible sigmoidoscopy, paracentesis, endoscopic retrograde cholangiopancreatography, and indium-tagged white blood cells. However, all tests were either negative or noncontributory to the etiology of polymicrobial bacteremia. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 98 99 100 101 102 103 104 Conflicts of interest The authors disclose no conflicts.