Christopher Ashley

Management of complications in patients receiving home parenteral nutrition

Patients receiving long-term home parenteral nutrition tend to fall under the care of adult and pediatric gastroenterologists. This article reviews the management of potential infectious, mechanical and metabolic complications and describes common psychosocial issues related to the therapy. The point at which to refer the patient to an intestinal failure program offering autologous bowel reconstruction and small bowel transplantation is discussed.

Autopsy Tissue Trace Elements in 8 Long-Term Parenteral Nutrition Patients Who Received the Current U.S. Food and Drug Administration Formulation

Iron, zinc, copper, manganese, chromium, and selenium levels were measured in autopsy tissues of 8 people with short bowel syndrome who received home parenteral nutrition (HPN) and the U.S. Food and Drug Administration (FDA)-approved trace element formulation for an average duration of 14 years (range, 2-21). Iron, zinc, copper, manganese and selenium were measured by inductively coupled plasma methods; chromium, by graphite furnace atomic absorption spectrometry. The levels in the 4 tissues studied, heart, skeletal muscle, liver, and kidney, were compared with levels in 45 controls who died without chronic gastrointestinal disorders. Results showed normal HPN patient values for iron and selenium, mild elevation of zinc, and major elevations of copper, manganese, and chromium. The implications of these results for trace-element supplements in long-term PN adult patients are discussed, and the need for reformulation of commercially available multi-trace element products in the United States is stressed.

Multi-center colonoscopy quality measurement utilizing natural language processing

Background:An accurate system for tracking of colonoscopy quality and surveillance intervals could improve the effectiveness and cost-effectiveness of colorectal cancer (CRC) screening and surveillance. The purpose of this study was to create and test such a system across multiple institutions utilizing natural language processing (NLP).Methods:From 42,569 colonoscopies with pathology records from 13 centers, we randomly sampled 750 paired reports. We trained (n=250) and tested (n=500) an NLP-based program with 19 measurements that encompass colonoscopy quality measures and surveillance interval determination, using blinded, paired, annotated expert manual review as the reference standard. The remaining 41,819 nonannotated documents were processed through the NLP system without manual review to assess performance consistency. The primary outcome was system accuracy across the 19 measures.Results:A total of 176 (23.5%) documents with 252 (1.8%) discrepant content points resulted from paired annotation. Error rate within the 500 test documents was 31.2% for NLP and 25.4% for the paired annotators (P=0.001). At the content point level within the test set, the error rate was 3.5% for NLP and 1.9% for the paired annotators (P=0.04). When eight vaguely worded documents were removed, 125 of 492 (25.4%) were incorrect by NLP and 104 of 492 (21.1%) by the initial annotator (P=0.07). Rates of pathologic findings calculated from NLP were similar to those calculated by annotation for the majority of measurements. Test set accuracy was 99.6% for CRC, 95% for advanced adenoma, 94.6% for nonadvanced adenoma, 99.8% for advanced sessile serrated polyps, 99.2% for nonadvanced sessile serrated polyps, 96.8% for large hyperplastic polyps, and 96.0% for small hyperplastic polyps. Lesion location showed high accuracy (87.0–99.8%). Accuracy for number of adenomas was 92%.Conclusions:NLP can accurately report adenoma detection rate and the components for determining guideline-adherent colonoscopy surveillance intervals across multiple sites that utilize different methods for reporting colonoscopy findings.

Neutrophilic myositis as a manifestation of celiac disease: a case report

A 42-year-old white man presented with recurrent attacks of muscle pain and swelling. Clinically, he looked like he had severe pyogenic infection. He failed to respond to multiple courses of wide-spectrum antibiotics. Repeated cultures from muscle lesions and from the blood were negative. Hospital course was very hectic and life threatening at times. Upon further questioning, the patient gave a history of frequent loose-bowel movements for many years. A duodenal biopsy with villous blunting and positive antiglidin antibodies confirmed the diagnosis of celiac disease. The patient had complete recovery and remained in remission on a gluten-free diet.

What is the optimal therapy for severe ulcerative colitis

INITIAL OVERALL ASSESSMENT OF THE SEVERE ULCERATIVE COLITIS PATIENT It is important to initially perform an overall assessment of the severe ulcerative colitis (UC) patient. Several questions need to be asked. First, does the patient have chronic severe (moderate to severe) or acute severe (fulminant) UC? Second, does the patient have significant blood work abnormalities or findings consistent with toxic (fulminant) disease on abdominal imaging studies? Third, have all other possible causes of bloody diarrhea been ruled out? Fourth, is the current extent and severity of the UC known and documented? Fifth, has the patient lost significant amounts of weight and/or is the patient malnourished? Sixth, are there any extraintestinal manifestations or complications that might also warrant therapy? Finally, does the patient understand UC, the therapeutic options available, and the potential side effects of possible treatments? After each of these questions has been addressed, therapeutic approaches can be undertaken. In patients with severe UC it is important to make certain that the bloody diarrhea is not due to: Clostridium difficile, hemorrhagic E. coli 0157:H7, Salmonella, Shigella, Campylobacter, cytomegalovirus (CMV), amebiasis, NSAIDS, Crohn’s colitis, ischemia, or radiation colitis. In addition to stool cultures, an unprepped sigmoidoscopy or limited colonoscopy with biopsies can often provide critically important data on whether or not there is another entity (such as C. difficile, CMV, Crohn’s colitis, or ischemic colitis) which could explain the severe bloody diarrhea. Long-term treatment should be based on the documented severity and extent of the disease, which requires a colonoscopy for optimal assessment. Symptoms, physical exam, laboratory studies, and abdominal imaging studies also will be of great importance in determining treatment approaches.

Erratum: Multi-center colonoscopy quality measurement utilizing natural language processing (American Journal of Gastroenterology (2015) 110 (543-552) DOI: 10.1038/ajg.2015.51

Timothy D. Imler, MD, MS 1,2,3 , Justin Morea, DO 2,3 , Charles Kahi, MD 1,2,4 , Eric A. Sherer, PhD 4,5 , Jon Cardwell, MS 4 , Cynthia S. Johnson, MS 6 , Huiping Xu, PhD 6 , Dennis Ahnen, MD 7 , Fadi Antaki, MD 8 , Christopher Ashley, MD 9 , Gyorgy Baff y, MD 10 , Ilseung Cho, MD 11 , Jason Dominitz, MD 12 , Jason Hou, MD 13 , Mark Korsten, MD 14 , Anil Nagar, MD 15 , Kittichai Promrat, MD 16 , Douglas Robertson, MD 17 , Sameer Saini, MD 18 , Amandeep Shergill, MD 19 , Walter Smalley, MD 20 and Th omas F. Imperiale, MD 1,2,4,21

Erratum: Corrigendum: Multi-Center Colonoscopy Quality Measurement Utilizing Natural Language Processing

Timothy D. Imler, MD, MS 1,2,3 , Justin Morea, DO 2,3 , Charles Kahi, MD 1,2,4 , Eric A. Sherer, PhD 4,5 , Jon Cardwell, MS 4 , Cynthia S. Johnson, MS 6 , Huiping Xu, PhD 6 , Dennis Ahnen, MD 7 , Fadi Antaki, MD 8 , Christopher Ashley, MD 9 , Gyorgy Baff y, MD 10 , Ilseung Cho, MD 11 , Jason Dominitz, MD 12 , Jason Hou, MD 13 , Mark Korsten, MD 14 , Anil Nagar, MD 15 , Kittichai Promrat, MD 16 , Douglas Robertson, MD 17 , Sameer Saini, MD 18 , Amandeep Shergill, MD 19 , Walter Smalley, MD 20 and Th omas F. Imperiale, MD 1,2,4,21

Corrigendum: Multi-Center Colonoscopy Quality Measurement Utilizing Natural Language Processing.

Timothy D. Imler, MD, MS 1,2,3 , Justin Morea, DO 2,3 , Charles Kahi, MD 1,2,4 , Eric A. Sherer, PhD 4,5 , Jon Cardwell, MS 4 , Cynthia S. Johnson, MS 6 , Huiping Xu, PhD 6 , Dennis Ahnen, MD 7 , Fadi Antaki, MD 8 , Christopher Ashley, MD 9 , Gyorgy Baff y, MD 10 , Ilseung Cho, MD 11 , Jason Dominitz, MD 12 , Jason Hou, MD 13 , Mark Korsten, MD 14 , Anil Nagar, MD 15 , Kittichai Promrat, MD 16 , Douglas Robertson, MD 17 , Sameer Saini, MD 18 , Amandeep Shergill, MD 19 , Walter Smalley, MD 20 and Th omas F. Imperiale, MD 1,2,4,21