Donevan Westerveld

A Detailed Characterization of the Dysfunctional Immunity and Abnormal Myelopoiesis Induced by Severe Shock and Trauma in the Aged

The elderly are particularly susceptible to trauma, and their outcomes are frequently dismal. Such patients often have complicated clinical courses and ultimately die of infection and sepsis. Recent research has revealed that although elderly subjects have increased baseline inflammation as compared with their younger counterparts, the elderly do not respond to severe infection or injury with an exaggerated inflammatory response. Initial retrospective analysis of clinical data from the Glue Grant trauma database demonstrated that despite a similar frequency, elderly trauma patients have worse outcomes to pneumonia than younger subjects do. Subsequent analysis with a murine trauma model also demonstrated that elderly mice had increased mortality after posttrauma Pseudomonas pneumonia. Blood, bone marrow, and bronchoalveolar lavage sample analyses from juvenile and 20–24-mo-old mice showed that increased mortality to trauma combined with secondary infection in the aged are not due to an exaggerated inflammatory response. Rather, they are due to a failure of bone marrow progenitors, blood neutrophils, and bronchoalveolar lavage cells to initiate and complete an emergency myelopoietic response, engendering myeloid cells that fail to clear secondary infection. In addition, elderly people appeared unable to resolve their inflammatory response to severe injury effectively.

Through Thick and Thin: Identifying Barriers to Bariatric Surgery, Weight Loss Maintenance, and Tailoring Obesity Treatment for the Future

More than one-third of the adults in the United States are obese. This complex metabolic disorder is associated with multiple comorbidities and increased all-cause mortality. Bariatric surgery has been shown to be more effective than medical therapy and has been associated with weight loss maintenance and decreased mortality. In spite of these well-established benefits, less than 1% of candidates undergo surgery due to multiple factors, such as patient and physician perceptions and attitudes, patient-physician interaction, lack of resources, and cost burden. Furthermore, even in patients who do undergo bariatric surgery and/or alternate weight loss interventions, long-term weight control is associated with high-risk failure and weight regain. In this review, we highlight some of the current barriers to bariatric surgery and long-term weight loss maintenance and underscore the importance of an individualized multidisciplinary longitudinal strategy for the treatment of obesity.

A Rare Case of Raoultella planticola Pneumonia: An Emerging Pathogen

Raoultella planticola (R. planticola), considered an environmental organism, is a gram negative, motile, bacillus with phenotypic similarities to the genus Klebsiella. The organism remains a rare cause of human infection with a few cases reported in the literature. However, since its description in 1981 there have been increasing rates of infections caused by R. planticola with reports of conjunctivitis, liver abscess, cholangitis, pancreatitis, and necrotizing fasciitis. More concerning are reports of carbapenemase-producing isolates which have led to the only 2 mortalities associated with R. planticola infections. To our knowledge, we report the third case of R. planticola pneumonia in an immunocompromised patient with no known direct exposure to the reported risk factors.

Cutaneous metastasis: a rare herald of a silent cancer

A 59-year-old previously healthy man with a 50-pack-year smoking history presented with rib pain 1 month after a mechanical fall. Physical examination revealed a 1.5 cm right cervical lymph node and a 0.9×0.9 cm scalp nodule. The patient had only noticed the scalp lesion a month prior to presentation. Chest X-ray revealed a 5.8×5.0 cm left infrahilar mass. CT angiography demonstrated extensive metastatic mediastinal and right hilar adenopathy as well as hepatic, right adrenal and brain lesions. Pathology from fine-needle aspiration of cervical lymph nodes and punch biopsy of the scalp lesion were consistent with non-small cell lung cancer (NSCLC) metastasis. The patient underwent brain stereotactic radiosurgery and palliative radiation therapy. Unfortunately, he passed away 4 months after diagnosis. Malignancy (primary or secondary) should be considered by clinicians in the work up of patients with new skin lesions, particularly in those at high risk of cancer.

Once Versus Twice-Daily Oral Proton Pump Inhibitor Therapy for Prevention of Peptic Ulcer Rebleeding: A Propensity Score-Matched Analysis

Background After inpatient management of upper gastrointestinal bleeding (GIB) due to peptic ulcer disease (PUD), oral proton pump inhibitor (PPI) therapy is recommended at discharge to decrease rebleeding risk and improve ulcer healing. Our aim is to determine whether once-daily oral PPI dosing at hospital discharge is associated with inferior 30-day rebleeding outcomes as compared to twice-daily dosing. Methods We retrospectively identified 233 patients admitted with signs and symptoms of upper GIB found to be due to PUD on upper endoscopy. After inpatient management, patients discharged on once-daily oral PPI were compared to those discharged on twice-daily therapy. We utilized propensity score matching based on Rockall scores to ensure the two groups were closely matched in terms of their baseline rebleeding risk. Primary outcome was the incidence of rebleeding within 30 days. Secondary outcomes were all-cause mortality, blood transfusion requirement, requirement for interventional radiology or surgery. Results Overall, 49 patients were discharged on once-daily and 184 on twice-daily PPI. Recurrent bleeding occurred in 18 patients (7.7%) within 30 days. There was no statistically significant difference in recurrent bleeding rates between once-daily (n = 7, 14.3%) as compared to twice-daily PPI (n = 11, 6%) (P = 0.053). In a 1:1 propensity score matched analysis, there was no statistically significant difference in 30-day recurrent bleeding rate between groups (14% once-daily vs. 4% twice-daily, P = 0.159). There were no differences in secondary outcomes. Conclusions Once-daily oral PPI dosing at hospital discharge was not associated with inferior outcomes compared to twice-daily dosing in patients hospitalized for upper GIB due to PUD.

Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus: a retrospective analysis

Background  Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). Methods  This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. Results  In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 – 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 – 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 – 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 – 29 months) than the recommended interval. Conclusion  Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Diffuse alveolar haemorrhage and Libman-Sacks endocarditis: a rare presentation of antiphospholipid syndrome

A 26-year-old woman with a history of idiopathic thrombocytopaenic purpura and a 1-year history of blood-streaked sputum presented after a severe episode of haemoptysis with dyspnoea. Chest imaging revealed diffuse ground glass and bronchovascular nodules. Bronchoscopy revealed bilateral diffuse alveolar haemorrhage (DAH). Sputum and bronchoalveolar lavage studies were negative for infectious aetiologies. A transthoracic echocardiogram revealed Libman-Sacks endocarditis with severe mitral regurgitation and physical examination revealed retinal artery occlusion and Osler’s nodes. The patient had an increased anticardiolipin Immunoglobulin IgG and anti-B2 glycoprotein IgG, suggesting antiphospholipid syndrome (APLS). The patient was then started on high-dose methylprednisolone and had an improvement in her dyspnoea and haemoptysis. She was also started on anticoagulation as treatment for Libman-Sacks endocarditis. APLS should be considered as a possible underlying aetiology for unusual presentations of DAH with concurrent Libman-Sacks endocarditis in non-intravenous drug users with existing autoimmune disorders.

The use of a lumen-apposing metal stent for a short malignant duodenal stricture in a patient with a coexisting metal biliary stent

re 1. A, Endoscopic view of malignant gastric outlet obstruction. B, C, Endoscopic balloon dilation of duodenal stricture under endoscopic (B) and oscopic (C) guidance. D, Endoscopic placement of uncovered self-expandable metal stent across the malignant distal biliary stricture. E, F, Endoic (E) and fluoroscopic (F) images of lumen-apposing stent (arrows) immediately proximal to the distal end of the newly placed biliary stent.

Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

Background and study aim  Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds. Methods  Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach. Results  A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P  < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P  < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ. Conclusion  There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.

Oesophageal mastocytosis: eosinophilic oesophagitis without eosinophils?

A 59-year-old male with a history of lifelong asthma, allergic rhinitis and hypercholesterolaemia presented to the emergency department for management of severe substernal chest pain with radiating pain to his left arm, nausea and diaphoresis. Physical examination was unrevealing and a cardiac workup including cardiac enzymes, ECG, chest radiographs were negative for an underlying ischaemic event. A subsequent gastrointestinal workup including oesophageal manometry and oesophagogastroduodenoscopy revealed elevated lower oesophageal pressures and histopathology suggestive of mast cell proliferation, respectively. These findings were suggestive of oesophageal mastocytosis. Treatment with omeprazole-sodium bicarbonate, cetirizine, montelukast and oral budesonide promptly ameliorated his symptoms which have not recurred.