Ebtesam Islam

Left ventricular assist devices and gastrointestinal bleeding: a narrative review of case reports and case series.

The use of left ventricular assist devices (LVADs) has become a state‐of‐the‐art therapy for advanced cardiac heart failure; however, multiple reports in the literature describe an increased risk for gastrointestinal (GI) bleeding in these patients. We characterized this association by reviewing recent studies on this topic.

The Frequency of Frailty in Ambulatory Patients With Chronic Lung Diseases

Objectives: To determine the prevalence of frailty in patients with chronic lung diseases. Methods: We studied 120 patients with chronic lung disease using Fried’s criteria (gait speed, weight loss, exhaustion, grip strength, and physical activity). Results: The study population (56% women) had a mean age of 64 ± 13 years, mean body mass index of 31± 9 kg/m2, and a mean FEV1 (forced expiratory volume in 1 second) of 60% ± 25% of predicted. The average gait speed was 52.1 ± 14.3 m/min; 18% were frail, 64% prefrail, and 18% robust. Gait speed correlated with frailty status and decreased as frailty worsened (57 m/min in robust subjects and 41 m/min in frail subjects). Slow gait speeds (<60 m/min) had a 95% sensitivity and 34% specificity to predict frailty. Conclusions: Patients with chronic lung disease frequently meet Fried’s criteria for frailty. Gait speed can be used to screen these patients to determine if a more detailed evaluation is needed.

Endoscopic removal of multiple duodenum foreign bodies: An unusual occurrence

Deliberate single foreign body ingestion is a scenario that many gastroenterologists commonly see in psychiatric units and prisons. However, multiple foreign body ingestions, especially located in the duodenum, provide the endoscopist with unique challenges for management and treatment. Although most foreign objects pass spontaneously, one should have a low threshold of intervention for multiple objects, especially those that are wide, sharp and at risk of perforation. Diagnosis is typically made when there is a history of ingestion coupled with corresponding radiographic verification. The symptoms tend to be non-specific although some patients are able to delineate where the discomfort level is, correlating with the site of impaction. Most foreign bodies pass spontaneously; however when multiple sharp objects are ingested, the gastroenterologist should perform endoscopic procedures to minimize the risks of bowel perforation. We describe here a successful case of multiple ingested foreign bodies retrieved across the C-loop of the duodenum and the pharynges-esophageal curve via endoscopy and review the literature of multiple foreign body ingestion.

Sigmoid plasmacytoma mimicking colon cancer in a patient with multiple myeloma: case report and review of literature

Congenital duodenal occlusion presenting as a neonatal emergency may be caused by a diaphragm or a complete obliteration of the duodenal lumen. Complete obliteration may result from vascular occlusion in utero. A diaphragm may represent incomplete vacuolation of the proliferating epithelial lining of the duodenum between the sixth and eighth weeks of gestation. 1 If the occlusion caused by the diaphragm is complete, symptoms appear from birth. In some cases, a lumen persists in the diaphragm, and presentation is delayed. The lumen is rarely wide enough to avoid symptoms or for symptomstobedelayeduntiladultlife.Thehistoryinadults isusuallyoneofpersistent vomitingandweightloss.Twenty adult patients with duodenal web were reported in a large series of congenital duodenal anomalies from one center in the United States. 3 The onset of symptoms in adult life seems to be the effect of progressive decompensation of the peristaltic force of the stomach and proximal duodenum.

The association between glucose levels and hospital outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND: Corticosteroids used for chronic obstructive pulmonary disease (COPD) exacerbations can cause hyperglycemia in hospitalized patients, and hyperglycemia may be associated with increased mortality, length of stay (LOS), and re-admissions in these patients. MATERIALS AND METHODS: We did three retrospective studies using charts from July 2008 through June 2009, January 2006 through December 2010, and October 2010 through March 2011. We collected demographic and clinical information, laboratory results, radiographic results, and information on LOS, mortality, and re-admission. RESULTS: Glucose levels did not predict outcomes in any of the studied cohorts, after adjustment for covariates in multivariable analysis. The first database included 30 patients admitted to non-intensive care unit (ICU) hospital beds. Six of 20 non-diabetic patients had peak glucoses above 200 mg/dl. Nine of the ten diabetic patients had peak glucoses above 200 mg/dl. The maximum daily corticosteroid dose had no apparent effect on the glucose levels. The second database included 217 patients admitted to ICUs. The initial blood glucose was higher in patients who died than those who survived using bivariate analysis (P = 0.015; odds ratio, OR, 1.01) but not in multivariable analysis. Multivariable logistic regression analysis also demonstrated that glucose levels did not affect LOS. The third database analyzing COPD re-admission rates included 81 patients; the peak glucose levels were not associated with re-admission. CONCLUSIONS: Our data demonstrate that COPD patients treated with corticosteroids developed significant hyperglycemia, but the increase in blood glucose levels did not correlate with the maximum dose of corticosteroids. Blood glucose levels were not associated with mortality, LOS, or re-admission rates.

Aortic stenosis and angiodysplastic gastrointestinal bleeding: Heyde's disease.

Obscure gastrointestinal (GI) bleeding can be a perplexing and difficult problem in elderly patients, especially if they are hemodynamically unstable. If aortic stenosis is also present, the cause of the GI bleeding may be explained. We present a 66-year-old man with a medical history of coronary artery disease who presented with acute GI bleeding. During his hospital course, the patient had a colonoscopy showing diffuse angiodysplasia and an echocardiogram showing severe aortic stenosis. This combination of angiodysplasia and aortic stenosis is known as Heydes syndrome. It has been hypothesized that the aortic stenosis causes an acquired von Willebrand factor deficiency that leads to GI bleeding. Aortic valve replacement, when possible, can prevent recurrent GI bleeding in these cases, but medical decisions in these cases are complex and difficult.

Anti-N-methyl-D-aspartate receptor encephalitis.

Abstract:A case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis with an atypical finding of transient increased intracranial pressure is reported. Anti-NMDAR encephalitis is an underrecognized, novel and treatable form of encephalitis being increasingly identified as an explanation of encephalitis in young adults. Management of these patients requires a multidisciplinary approach involving neurologists, internists, nursing and rehabilitation staff. It is important for internists to recognize this condition and consider it in the differential diagnosis of encephalopathy. Internists also need to be familiar with the clinical manifestations and the treatment of the disease as they have an important role in the care of these patients during their prolonged stay in the hospital. Increased intracranial pressure is an atypical and underrecognized finding that has been only noted in a previous review on this disorder. It may present a diagnostic or management challenge in patients with anti-NMDAR encephalitis.

Pulmonary valve stenosis causing massive pulmonary artery aneurysm: a conservative approach.

To the Editor Pulmonary artery aneurysms are a rare clinical entity, and their clinical management guidelines are not well established, especially for older patients. We present the case of a 70-year-old woman with a significant pulmonary artery aneurysm treated conservatively with medical management. The aim of this report is to draw attention to possible conservative management and treatment options for elderly patients with pulmonary artery aneurysms.

Congenital hypertrophy retinal pigment epithelium as a manifestation of colon cancer.

REFERENCES 1 . Clark M , Colombel JF , Feagan BC et al. American Gastroenterological Association consensus development conference on the use of biologics in the treatment of infl ammatory bowel disease . Gastroenterology 2007 ; 133 : 312 – 39 . 2 . Gisbert JP , Panes J . Loss of response and requirement of infl iximab dose intensifi cation in Crohn’s disease: a review . Am J Gastroenterol 2009 ; 104 : 760 – 7 . 3 . Regueiro M , Siemanowski B , Kip K et al. Infl i ximab dose intensifi cation in Crohn’s disease . Infl amm Bowel Dis 2007 ; 13 : 1093 – 9 . 4 . Rahier JF , Ben-Horin S , Chowers Y et al. European evidence based consensus on the prevention, diagnosis and management of opportunistic infections in infl ammatory bowel disease . J Crohn’s Colitis 2009 ; 3 : 47 – 91 .

Comparison of dexmedetomidine and propofol in mechanically ventilated patients with sepsis: A pilot study

Objective: To compare the effects of a propofol-based versus dexmedetomidine-based sedation regimen for mechanically ventilated patients with sepsis. Methods: Single-center, randomized, open-label interventional study of critically ill patients admitted to the intensive care unit with sepsis and respiratory failure requiring mechanical ventilation. Patients were sedated with either propofol or dexmedetomidine. Results: Thirty-six patients with sepsis and respiratory failure requiring mechanical ventilation were randomly assigned to receive sedation with either dexmedetomidine or propofol. Fentanyl was used for analgesia in both groups. The primary end point was duration of mechanical ventilation, and secondary end points included 28-day mortality, the duration of ICU stay, and the duration of vasopressor support. There was a non-statistically significant trend toward decreased duration of mechanical ventilation in the dexmedetomidine group (p = 0.107), and multivariable analysis demonstrated a small to moderate effect size in the sample. There were no significant differences in 28-day mortality, duration of ICU stay, or duration of vasopressor requirement. No patients required discontinuation of study drug due to adverse effects. Conclusions: Although underpowered for statistical significance, there was a trend toward decreased duration of mechanical ventilation with dexmedetomidine. More studies with higher patient enrollment are needed to determine whether the duration of mechanical ventilation in patients with sepsis who receive sedation with dexmedetomidine is reduced when compared to propofol.