Dina Ahmad

Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases.

Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm3 (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm3 (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm3 (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.

Miralax With Gatorade for Bowel Preparation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES:Polyethylene glycol (PEG) is a very popular bowel preparation for colonoscopy. However, its large volume may reduce patient compliance, resulting in suboptimal preparation. Recently, a combination of Miralax and Gatorade has been studied in various randomized controlled trials (RCTs) as a lower volume and more palatable bowel preparation. However, results have varied. Therefore, we conducted a meta-analysis assessing the use of Miralax–Gatorade (M–G) vs. PEG for bowel preparation before colonoscopy.METHODS:Multiple databases were searched (January 2014). RCTs on adults comparing M–G (238–255 g in 1.9 l that is 64 fl oz) vs. PEG (3.8–4 l) for bowel preparation before colonoscopy were included. The effects were analyzed by calculating pooled estimates of quality of bowel preparation (satisfactory, unsatisfactory, excellent), patient tolerance (nausea, cramping, bloating), and polyp detection by using odds ratio (OR) with fixed- and random-effects models.RESULTS:Five studies met inclusion criteria (N=1,418), with mean age ranging from 53.8 to 61.3 years. M–G demonstrated statistically significantly fewer satisfactory bowel preparations as compared with PEG (OR 0.65; 95% confidence interval (CI): 0.43–0.98, P=0.04) but more willingness to repeat preparation (OR 7.32; 95% CI: 4.88–10.98, P<0.01). Furthermore, no statistically significant differences in polyp detection (P=0.65) or side effects were apparent between the two preparations for nausea (P=0.71), cramping (P=0.84), or bloating (P=0.50). Subgroup analysis revealed similar results for split-dose M–G vs. split-dose PEG.CONCLUSIONS:M–G for bowel preparation before colonoscopy was inferior to PEG in bowel preparation quality while demonstrating no significant improvements in adverse effects or polyp detection. Therefore, PEG appears superior to M–G for bowel preparation before colonoscopy.

The effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis.

Objectives Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). Methods A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. Results Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34–0.71; P < 0.01), mild PEP (OR, 0.52; 95% CI, 0.32–0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24–0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. Conclusions Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP.

Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient

Summary Background: Multiloculated pleural effusion is a life-threatening condition that needs early recognition. Drainage by chest tube might be difficult which necessitates a surgical intervention. While x-ray typically does not show loculations, CT scan might not also identify the loculations. Ultrasound has a high sensitivity in detecting pleural diseases including multiloculated pleural effusion. Case Report: A 55-year-old female presented with dyspnea, cough and yellowish sputum for 3 days. Her heart rate was 136 bpm ,O2 saturation 88%, and WBC 21,000/mcL. Chest x-ray showed complete opacification of right lung. A chest tube insertion was unsuccessful. CT scan of the chest showed large pleural effusion occupying the right hemithorax with collapse of the right lung. Bedside ultra-sound showed a multiloculated pleural effusion with septations of different thickness. The patient subsequently underwent thoracotomy which showed multiple, fluid-filled loculations with significant adhesions. The loculations were dissected along with decortications of thick a pleural rind. Blood and pleural fluid cultures grew Streptococcus pneumoniae and the patient was treated successfully with Penicillin G. Conclusions: We advocate bedside ultrasound in patients with complete or near complete opacification of a hemithorax on chest x-ray. CT scan is less likely to show septations within pleural effusions compared to ultrasounnd. Therefore, CT scan and ultrasound are complementary for the diagnosis of empyema and multiloculated pleural effusion.

Malnutrition secondary to non-compliance with vitamin and mineral supplements after gastric bypass surgery: What can we do about it?

Summary Background: Nutritional deficiency due to loss of follow up and non-compliance with routine mineral and multivitamin supplements is not uncommonly encountered following bariatric surgery. In this report, and utilizing a case study, we will address issues related to loss of long term medical follow up and the measures that can be taken to prevent it in this patient population. Case Report: The case of a 38-year-old female patient who was recently managed for severe vitamin deficiency and iron deficiency anemia following bariatric surgery is presented. Non-compliance with routine vitamin and mineral supplements was believed to be the main culprit of her condition. Articles published in English addressing issues related to non-compliance with supplementations and regular follow up after bariatric surgery were accessed from PubMed and are discussed. Conclusions: Multiple factors affecting long term follow up and compliance have been studied including age, financial costs, distance from the clinic and psychiatric comorbidities. Preventive measures have also been tested and some of them have shown significant benefit. More research is needed to identify other modifiable factors and preventive measures influencing compliance and long term follow up following bariatric surgery.

Upper gastrointestinal tract metastasis from lung cancer.

A 62 year-old female with a history of smoking presented ith abdominal pain, melena, and cough for one month. She was ypotensive and tachycardic. Her haemoglobin was 9 g/dl. Esophgogastroduodenoscopy showed multiple odd-looking lesions in he mid-gastric body measuring 1.5 cm with heaped up edges and entral ulceration (Fig. 1). Similar lesions were noted throughout he duodenum. One of the lesions in proximal D2 had a large cenral ulceration and a prominent vessel in the base. Biopsy of the astric lesion showed poorly differentiated large cell carcinoma Fig. 2). Helicobacter pylori was not detected. Computed Tomogaphy/Positron Emission Tomography scan showed avid uptake in he left hilum, adrenal glands and numerous osseous and soft tisue lesions. The overall condition was consistent with lung cancer ith metastasis to the upper gastrointestinal tract. A similar picure might be seen with gastrointestinal stromal tumours which

Endoscopic Surveillance for Gastric Ulcers

Objective Gastric ulcers (GUs) can be caused by a malignancy, and endoscopists are challenged with the question of how to rule out underlying malignancy. Although routine endoscopic surveillance is not advised, it is still overused. The purpose of this study was to explore the practice in our tertiary referral center during the last 3 years. Methods We retrospectively reviewed all inpatient and outpatient esophagogastroduodenoscopies (EGDs) that were performed between November 2009 and November 2012 for GUs. Patients with GUs who normally would not undergo biopsy, such as patients who present with bleeding or had stigmata of high-risk bleeding, were excluded. Results A total of 165 patients were diagnosed between November 2009 and November 2012 as having GUs on EGD. Fifty-two patients were excluded because they presented with bleeding or had GUs that had stigmata of high-risk bleeding. We reviewed the charts of 113 patients and endoscopic surveillance was recommended for 96 (85%). Of those 96 patients, 72 (64%) underwent repeat EGD. In those 72 patients, GU was still present in 9 patients and was completely healed or healing in 63 patients. Only 25 (22%) GUs were biopsied at initial EGD, 23 of which were benign and 2 were adenocarcinomas. No additional malignancy was found on surveillance EGD. Conclusions EGD surveillance for GUs is a common practice, although the guidelines discourage such a practice. Our rate of endoscopic surveillance was significantly higher than reported previously (64% vs 25%). In our experience, such a high rate of surveillance did not reveal any additional gastric malignancy. Alternatively, the rate of biopsy of GUs at initial EGD is low (22%), which also reflects endoscopists’ preference for endoscopic surveillance.

Gastrointestinal: Penile prosthesis reservoir appearing as a cecal submucosal mass

A 49-year-old male with history of prostate cancer who has had radical prostatectomy was being evaluated for a new-onset anemia. As part of his work-up, colonoscopy was performed to rule out colorectal cancer. It showed a small sessile ascending colon polyp in addition to a large submucosal lesion in the cecal base adjacent to the appendiceal orifice (Fig. 1). The mass measured 3 cm and was firm on probing with forceps. Tunneled biopsies were obtained. The biopsy came back negative. Computed tomography (CT) scan of the abdomen and pelvis was done to evaluate for external compression. CT scan revealed a penile prosthesis with a reservoir in the right lower quadrant causing the external compression (Figs 2–4). Penile prostheses have been used for the treatment of erectile dysfunction since the 1950s. They vary in their design and number of pieces. Our patient had a three-piece implant that consists of penile cylinders, a scrotal pump, and retropubic reservoir. Erection is achieved by repeatedly squeezing the pump; each compression transfers fluid from the reservoir to the intracorporeal cylinders until adequate rigidity is achieved. The reservoir is placed preperitoneally behind the rectus muscle, either through the external inguinal ring or via a separate lower abdominal incision. Apparently, the reservoir could cause bulging into the cecum, which might be mistaken for a submucosal mass on colonoscopy. Knowledge about these prostheses is crucial for endoscopists to avoid unnecessary biopsies and imaging.