Daniel Cornett

Comparison of hepatitis C virus treatment between incarcerated and community patients

The prevalence of chronic hepatitis C virus (HCV) infection among incarcerated individuals in the United States is estimated to be between 12% and 31%. HCV treatment during incarceration is an attractive option because of improved access to health care and directly observed therapy. We compared incarcerated and nonincarcerated HCV‐infected patients evaluated for treatment at a single academic center between January 1, 2002 and December 31, 2007. During this period, 521 nonincarcerated and 388 incarcerated patients were evaluated for HCV treatment. Three hundred and nineteen (61.2%) nonincarcerated patients and 234 (60.3%) incarcerated patients underwent treatment with pegylated interferon and ribavirin. Incarcerated patients were more likely to be male, African‐American race, and have a history of alcohol or intravenous drug use. Treated incarcerated patients were less likely to have genotype 1 virus and were less likely to have undergone previous treatment. There was a similar prevalence of coinfection with human immunodeficiency virus (HIV) in both groups. A sustained viral response (SVR) was achieved in 97 (42.9%) incarcerated patients, compared to 115 (38.0%) nonincarcerated patients (P = 0.304). Both groups had a similar proportion of patients that completed a full treatment course. Stepwise logistic regression was conducted, and the final model included full treatment course, non‐genotype 1 virus, younger age at treatment start, and negative HIV status. Incarceration status was not a significant predictor when added to this model (P = 0.075). Conclusion: In a cohort of HCV‐infected patients managed in an academic medical center ambulatory clinic, incarcerated patients were as likely to be treated for HCV and as likely to achieve an SVR as nonincarcerated patients. (HEPATOLOGY 2012)

Findings on Optical Colonoscopy After Positive CT Colonography Exam

BACKGROUND & AIMS: The aim of this study is to evaluate the findings on optical colonoscopy (OC) after a positive CT colonography (CTC) exam and characterize the type of polyps seen on OC but not reported by CTC.METHODS:Over an 18-month period a total of 159 asymptomatic adults had polyps seen on computed tomography colonography examination and subsequently underwent planned therapeutic optical colonoscopy. The colonoscopists were aware of the findings on CT colonography prior to further evaluation of the colon. Characteristics of polyps and adenomas seen on subsequent optical colonoscopy but not seen or reported on CT colonography were examined.RESULTS:The adenoma miss rate for CT colonography overall was 18.9% (25/132) including 6.2% (4/65) for polyps >9 mm and 18.2% (8/44) for polyps 6–9 mm. Three of the adenomas >9 mm not seen on CTC were sessile, and two were found in patients with technically difficult CT colonography studies due to poor colonic distention. No adenomas with advanced pathology <6 mm were found on optical colonoscopy but not reported on CT colonography. False-positive CTC referral where no polyp was seen on colonoscopy was 5.0%.CONCLUSIONS:CT colonography has adenoma miss rates similar to miss rates historically found with optical colonoscopy, with most missed adenomas being <10 mm and sessile in shape.

Screening colonoscopy and detection of neoplasia in asymptomatic, average-risk, solid organ transplant recipients: case-control study.

The aim of this study was to evaluate the detection of colonic neoplasia in an average‐risk population of SOT recipients. Studies regarding colonic neoplasia in solid organ transplantation (SOT) recipients have demonstrated mixed results due to the inclusion of above average‐risk patients. We performed a case–control study of 102 average‐risk SOT recipients who underwent screening colonoscopy, compared with an average‐risk, age and sex‐matched control group (n = 287). Cancer rates were compared with an age‐matched cohort from the National Cancer Institute’s Survival, Epidemiology, and End Results (SEER) database. There was no difference in number of patients with adenomas (P = 1.00). There was no difference in polyps per patient (P = 0.31). Although the number of advanced lesions (excluding adenocarcinoma) between groups did not differ (P = 0.25), there were two adenocarcinomas identified in the SOT group and none in the control group (P = 0.068). Detection of colorectal cancer was an unexpected finding in the SOT cohort and was more likely when compared to age‐matched cancer incidence generated by the SEER database. These results suggest no increased adenoma detection in SOT recipients, but with more cases of colorectal cancer than anticipated. Given previous, larger, transplant database studies demonstrating increased colorectal cancer rates, more frequent screening may be justified.

Utility of colonoscopy in the evaluation of diarrhea in solid organ transplant recipients.

Background. Diarrhea is common in solid organ transplant recipients. Colonoscopy with random biopsies is performed frequently in the diagnostic evaluation of the posttransplant population with diarrhea. The purpose of this study was to determine the sensitivity of colonoscopy with random biopsy in determining a specific diagnosis and changing management in solid organ transplant recipients with diarrhea. Methods. From October 1996 to June 2008, 88 patients were identified who had undergone solid organ transplantation and subsequently underwent colonoscopy for an indication of “diarrhea.” These patient’s electronic medical records were reviewed to determine patient demographics, laboratory results, findings on colonoscopy and histopathology, and any subsequent diagnoses made and management changes in relation to the diarrhea. Results. Eighty-eight patients (mean age 54 years, 65% male) underwent colonoscopy a mean of 69 months after transplantation. Abnormal colonoscopic findings were seen in 16 (18.2%) patients. Histopathology was abnormal in 17/80 (21.3%). However, only eight (9.1%) had findings on colonoscopy or pathologic condition that led to specific diagnosis being made. In addition, only nine (10.2%) patients had a change in medical management as a direct result of colonoscopy with biopsy. Conclusion. Although colonoscopic or histopathologic abnormalities are common in the solid organ transplant recipient with diarrhea, the findings rarely lead to a specific diagnosis or management change. Colonoscopy with biopsy should be performed only after noninvasive testing for infectious diarrhea and a thorough review and adjustment of medications. In many patients, a trial of antidiarrheal medication is warranted before colonoscopy.

Metastatic Pancreatic Small-Cell Carcinoma Presenting As Acute Pancreatitis

A 77-year-old woman presented with nausea and acute onset of severe epigastric pain with radiation to her back. Physical examination revealed epigastric tenderness without rebound or guarding. Laboratory analysis showed lipase at 1,970 U/L (reference range, 23 to 300 U/L) and amylase at 220 U/L (reference range, 30 to 110 U/L) with normal liver chemistries, including bilirubin at 0.3 mg/dL (reference range, 0.2 to 1.3 mg/dL), alkaline phosphatase at 100 U/L (reference range, 38 to 136 U/L), ALT at 22 U/L (reference range, 9 to 72 U/L), and AST at 35 U/L (reference range, 14 to 59 U/L). She was diagnosed with acute pancreatitis, and gastroenterology consultation was obtained for further evaluation and management. A right upper quadrant ultrasound demonstrated a 2.3 cm 1.9 cm area of hypoechogenicity in the pancreatic head suggestive of a primary pancreatic neoplasm. An abdominal computed tomography (CT) scan confirmed an ill-defined 2.2-cm low-attenuation mass in the pancreatic head. Also seen were bilateral adrenal masses measuring up to 5 cm in size. Her cancer antigen 19-9 (CA 19-9) was 26 U/L (reference range, 37 U/L). The liver appeared normal without evidence of metastatic disease. An endoscopic ultrasound with fine-needle aspiration of the pancreatic head (Fig 1) and adrenal (Fig 2) masses revealed small-cell carcinoma (Fig 3). Immunohistochemistry was performed, and thyroid transcription factor 1, synaptophysin, and chromogranin were positive, confirming the diagnosis. The patient did not have any respiratory complaints but was a long-time smoker with a 55-pack-year history. A chest CT demonstrated enlarged axillary, mediastinal, and hilar lymph nodes as well as a solitary 8-mm sclerotic lesion in the midthoracic spine but was notably negative for pulmonary nodules or masses. Further staging work-up included a brain CT scan that showed several small enhancing masses consistent with diffuse brain metastasis. Given the extent of her disease she elected not to undergo chemotherapy or radiation treatment and succumbed to her disease within 2 months of her initial diagnosis. Small-cell carcinoma of the pancreas (SCCP) is a rare and aggressive tumor with a high metastasis rate. Only 1% of all primary pancreatic neoplasms are small-cell carcinomas and 4% of all small-cell carcinomas have an extrapulmonary origin. In a review of all published cases of SCCP, 91% were metastatic at the time of initial diagnosis. The most common sites for metastases are peripancreatic lymph nodes, liver, lungs, bone marrow, bone, colon, and adrenal gland. Bilateral adrenal metastases from a primary small-cell carcinoma of the pancreas, as described in our patient, is exceedingly rare

Metastatic Kaposi's Sarcoma with Perirectal Involvement Diagnosed with Endoscopic Ultrasound-Guided EchoBrush Cytology Sampling.

AIDS-related Kaposi’s sarcoma (KS) is a low-grade vascular tumor that occurs in association with human herpesvirus 8 infection. Here we report the case of a 21-year-old male with recently diagnosed cutaneous KS who presented with rectal bleeding and anal pruritus. Initial endoscopic evaluation was nondiagnostic. CT imaging showed diffuse lymphadenopathy including perirectal involvement which was suspicious for metastatic KS. Echoendoscopy with needle biopsies and EchoBrush sampling of the lymph nodes revealed spindle cells confirming metastatic KS. Treatment was initiated with liposomal doxorubicin resulting in rapid improvement of the skin lesions. After treatment completion, repeat CT imaging showed improved lymphadenopathy. No further rectal bleeding or perianal pruritus was reported. Although the EchoBrush has previously been used to aid in the diagnosis of pancreatic lesions, this report describes a novel use of EchoBrush to diagnose KS from perirectal lymph nodes.