Charles P. Koczka

Strongyloidiasis: a diagnosis more common than we think.

Strongyloides stercoralis is endemic to many tropical regions; however, there is limited knowledge concerning the clinical implication of this helminth, particularly in urban medical centers. We report a case series of strongyloidiasis in our urban medical center in New York City. Patients over the age of 18 years who were examined in our institution from January 1998 to May 2011 were identified by electronic medical record search using International Classification of Diseases, 9th Revision codes. We identified 22 cases of S. stercoralis. Eleven patients were men and 11 were women, with the average age at diagnosis being 62.4 years. Fourteen patients emigrated from the Caribbean, one from Nepal, five were blacks born in the USA, and two did not have their birthplace documented. The main presenting complaints were diarrhea (9/22), abdominal pain (6/22), vomiting (7/22), and weight loss (8/22). Seventeen patients demonstrated eosinophilia. Four patients were positive for human T-lymphotropic virus-1 antibodies, and three patients were infected with HIV. Diagnosis was made with stool examination (19/22), bronchoalveolar lavage (1/22), gastric biopsy (1/22), and duodenal biopsy (3/22). Among six patients who had upper endoscopy performed, the findings commonly included gastritis and gastric and duodenal ulcers. After treatment, 12/22 showed resolution of symptoms. Although a diagnostic approach tends to start with stool collections, consideration of upper endoscopy with biopsy in symptomatic patients is advisable. The absence of eosinophilia should not deter the clinician from seeking a diagnosis. Although often not done, ascertaining HIV and human T-lymphotropic virus-1 status should be part of the work-up.

A Nationwide Survey of Gastroenterologists and Their Acquisition of Knowledge

OBJECTIVES:The Gastroenterology (GI) Core Curriculum is a culmination of efforts from the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy to develop a review of knowledge and skills for those training in a gastrointestinal subspecialty. Fellows are expected to conduct scholarly activity, attend seminars, and read textbooks and syllabus materials. While efforts to standardize education across the nation are welcomed, we sought to ascertain the learning preferences of GI fellows and attending physicians.METHODS:A national online survey was e-mailed to directors of US adult GI programs, who were also asked to invite their colleagues and fellows to participate.RESULTS:While majorities of both fellows and attendings affirmed regular attendance at national conferences, more attendings affirmed that their knowledge was improved by their participation. Asked how they acquire knowledge best, 45 fellows and 67 attendings responded; 42% of attendings favored journal articles, and 40% of fellows favored conferences. More attendings than fellows felt that writing a manuscript and belonging to a GI society improved knowledge.CONCLUSIONS:We believe the Gastroenterology Core Curriculum provides trainees with essential tools for becoming an autonomous gastroenterologist who can appreciate various learning modalities.

Underutilization of evidence-based strategies in the diagnosis and treatment of venous thromboembolism among trainees.

BACKGROUND The knowledge and attitude of trainees toward the use of prediction rules in the diagnosis of venous thromboembolism (VTE) is understudied. The extent of knowledge as far as imaging strategies in the setting of VTE and use of low molecular weight heparin (LMWH) among trainees is also understudied. METHODS This was a cross-sectional study; between October, 2006 and March, 2008, surveys were distributed at grand rounds and national medicine board review courses. Respondents returning completed surveys included 43 medicine attendings, 139 residents, and 134 medical students Emergency physicians were called at work and 46 completed an abbreviated version of the survey. Attending and trainee responses were compared. RESULTS Over 60% of students and 40% of residents did not use any prediction rules. Most attendings (>60%) did not use a prediction rule. Among attendings, 48% of emergency physicians and 30% of medicine attendings felt that prediction rules were too complex to use. Knowledge about imaging techniques and diagnostic protocols for VTE were worse for students than for residents. A substantial minority of all respondents (17% of students, 12% of residents and 13% of medicine attendings) would not use LMWH in the therapy of non-massive pulmonary embolism. In general, level of training did not translate into a greater proportion of correct responses to clinical scenarios or greater knowledge about imaging systems and strategies. CONCLUSION Trainees do not use a structured approach to VTE diagnosis. LMWH therapy is underutilized by a large minority of trainees and attendings. A top-down approach is needed to revitalize evidence-based management of VTE.

The study of bone demineralization and its risk factors in an Afro-Caribbean subset of patients with inflammatory bowel disease.

Introduction Bone demineralization has been increasingly recognized as a disease process concurrent with inflammatory bowel disease (IBD). Racial variation in osteoporosis in IBD patients has been poorly described. We sought to identify the risk factors for demineralization in Afro-Caribbeans (AC) with IBD. Methods A retrospective chart review was performed from a 10-year prospectively collected database of IBD patients seen at an urban medical center. Data on dual-energy X-ray absorptiometry (DXA) scanning, use of steroids, bisphosphonates, calcium, and vitamin D, as well as blood chemistries were collected. Results One hundred and fifteen charts of AC IBD patients were reviewed, of which 24 patients had undergone DXA scanning. Fourteen patients with a T-score of less than −1 were compared with 10 patients with DXA scores of more than −1. Two patients with T-scores of less than −1 had fractures, whereas none were observed in the comparison group (P=0.5). The mean BMI for those with T-scores of less than −1 was 23.9 kg/m2 compared with 31.5 kg/m2 in those with T-scores of more than −1 (P=0.0034). Conclusion Screening for bone demineralization in ethnic populations with IBD is lacking as only 21% of AC IBD patients seen in our institution had undergone a DXA scan. Of those who were scanned, more than half of the patients had T-scores suggestive of bone demineralization. Although those who were obese did not have demineralization, our sample sizes were small and the results from this study should prompt further investigation to determine the prevalence and significance of bone demineralization in minority populations with IBD.

Metastatic signet ring colon cancer in a Caribbean young adult and review of the literature.

Colorectal cancer is the third most common neoplasm diagnosed in the USA, with less than 3% of patients younger than 40 years. Although most of the literature indicates that younger patients present with a higher stage and grade of cancer, mortality is not clearly correlated. Furthermore, the literature pertaining to colorectal cancer in the nonwhite youth is limited. In this case report, we report a case of aggressive colorectal cancer metastasizing in a young Afro-Caribbean woman with no known risk factors. The aim of this report is to raise awareness of this entity in the younger population, particularly in Afro-Caribbeans, which remains a highly understudied group compared with the rest of the US population.

Primary sclerosing cholangitis and its relationship to the colon in a black cohort of inflammatory bowel disease patients.

Background: Recent studies have identified subgroups of inflammatory bowel disease (IBD) patients at increased likelihood for developing primary sclerosing cholangitis (PSC). Most studies look at predominantly white populations. Goals: The aim of our study was to determine the characteristics of PSC in a black cohort of patients and its relationship to disease location in IBD. Study: A retrospective analysis was performed on IBD patients over the age of 18 years. Results: Of the 209 black patients identified as having IBD, 7 (3.5%) had a concomitant diagnosis of PSC; 5/138 (3.6%) ulcerative colitis (UC) patients, and 2/71 (2.8%) Crohn’s disease patients (CD). Numerically, more males developed PSC in both the UC and CD subgroups. Age at diagnosis of IBD tended to be younger among PSC cohorts. All PSC-UC patients had pancolitis (P<0.0001), and all PSC-CD patients had a colonic component to their disease. In the UC cohort, PSC patients were statistically more likely to be on immunosuppressive therapy (P<0.0001). Conclusions: With greater research, physicians will better recognize IBD phenotypes at highest risk of PSC and hopefully identify complications of PSC, including cholangiocarcinoma.

P-071 YI High Rates of Clostridium Difficile Infection in Afro-Caribbean Patients with Crohnʼs Disease

BACKGROUND: The incidence of Clostridium difficile infection (CDI) has been increasing over the past decade. Patients with Crohns disease (CD) and ulcerative colitis (UC) who acquire CDI have worse outcomes with higher rates of hospitalization, surgery and mortality when compared to non-IBD CDI patients. Racial variation in IBD patients infected with C. difficile has been poorly described. The aim of our present study is to assess the risk of CDI in Afro-Caribbean patients hospitalized with a suspected IBD flare. METHODS: A retrospective cohort analysis was conducted for all Afro-Caribbean IBD patients admitted with suspected flare to an urban medical center. Information regarding ethnic background, disease classification (UC versus CD), IBD related hospitalizations (using chief complaint of diarrhea, abdominal pain, or IBD flare) and CDI positivity was collected from the years 2006–2013. RESULTS: Two hundred forty-one IBD-related hospitalizations were identified, of which CDI testing was performed in 110. Of these 110 hospitalizations, 11 (10%) proved positive for CDI. Comparing to the number of IBD patients with diarrhea tested for CDI, 3/58 (5.2%) of UC patients were CDI+, 7/42 (16.7%) of CD patients were CDI +, and 1/10 (10%) of indeterminate colitis patients were CDI+. CONCLUSIONS: In our cohort of Afro-Caribbean patients with previously diagnosed IBD, Crohns disease carried a higher than previously reported rate (16.7%) of contracting clinically significant Clostridium difficile infection. Rate of CDI amongst UC patients (5.2%) remained in line with other studies. This study emphasizes the role of C. difficile infection in IBD flares, particularly amongst Crohns disease flares in an Afro-Caribbean population.