Edward Feller

Circulating Immune Complexes and Complement Activation in Primary Biliary Cirrhosis

We evaluated 20 patients with primary biliary cirrhosis and seven controls with extrahepatic biliary obstruction for presence of circulating immune complexes, having found serologic evidence of alternate complement-pathway activation in eight of the 20. Immune complexes were isolated by cryoprecipitation from serum and measured directly by the sensitive Raji-cell radioimmunoassay. Cryoproteins, found in high concentrations in 90 per cent of the patients with cirrhosis but undetectable in the controls, were composed of IgM (60 per cent), IgG-IgM (25 per cent) and IgA-IgM (5 per cent) and were capable of activating the complement system in vitro. Immune complexes detected by the Raji assay were found in 95 per cent of the patients with cirrhosis and circulated in exceedingly high concentrations (474 microgram per milliliter; range, 16.2 to 2192) but were absent in the controls. Furthermore, the alternate complement pathway was activated in eight cirrhotic patients. These complement-fixing immune complexes differ from immune complexes isolated from other types of liver diseases and may be important in the pathogenesis of primary biliary cirrhosis.

Treatment outcomes with pegylated interferon and ribavirin for male prisoners with chronic hepatitis C.

Goals To report our experience with pegylated interferon and ribavirin treatment of hepatitis C virus (HCV) RNA-positive inmates at the Rhode Island Department of Corrections. Background An estimated 1 out of 3 HCV-infected individuals will spend time in a jail or prison within a 1-year period, making prisons a unique setting for management of chronic HCV. Study Chart review of all inmates identified as having initiated HCV treatment between October 2000 and April 2004. HCV-infected individuals were identified by HCV antibody screening at intake for known risk factors, elevated aminotransferase levels, or per individual request. Treatment followed standard guidelines with weight-based dosing of pegylated interferon-α2b and ribavirin. End points were completion of therapy plus 6 months for sustained virologic response (SVR), therapy discontinuation, and loss to follow-up. Results The cohort included 71 male patients, was mostly white (80%), and genotype 1 (65%). All 9 African Americans (AA) had genotype 1. Of 59 patients having liver biopsy, 41 had early stage disease. Overall SVR was 28%. Response rate was lower for genotype 1 compared with genotypes 2 and 3 (SVR 18% vs. 60% and 50%). Of inmates with genotype 1, no difference existed in treatment response by race (SVR 22% AA vs. 18% white). Thirty-three patients completed treatment, 26 stopped for side effects, and 5 for initial nonresponse. Eleven were lost to follow-up. Conclusions Acceptable HCV treatment outcomes can be achieved in prisons. Our small study indicates no difference in treatment response by AA versus white race for genotype 1.

Acculturation and Cardiovascular Behaviors Among Latinos in California by Country/Region of Origin

Despite generally lower socioeconomic status and worse access to healthcare, Latinos have better overall health outcomes and longer life expectancy than non-Latino Whites. This “Latino Health Paradox” has been partially attributed to healthier cardiovascular (CV) behaviors among Latinos. However, as Latinos become more acculturated, differences in some CV behaviors disappear. This study aimed to explore how associations between acculturation and CV behaviors among Latinos vary by country of origin. Combined weighted data from the 2005 and 2007 California Health Interview Survey (CHIS) were used to investigate associations between acculturation level and CV behaviors among Latinos by country of origin. Among all Latinos, increased acculturation was associated with more smoking, increased leisure-time physical activity, and greater consumption of fast foods, but no change in fruit/vegetable and less soda intake. These trends varied, however, by Latino sub-groups from different countries of origin. Country of origin appears to impact associations between acculturation and CV behaviors among Latinos in complex ways.

Severe colonic complications of pancreatic disease

Introduction Colonic involvement in pancreatic disorders is rare but potentially fatal. Extension of contiguous inflammation or neoplasm, autodigestive effects of enzymes, or dissection of a pseudocyst or abscess may involve the colon producing obstruction, perforation, hemorrhage, or abdominal pain. Results Nine patients with pancreatic disease requiring colonic resection were identified. Cases included pancreatic abscess producing colonic necrosis (2), pancreatic carcinoma invading the colon (3), extension of pancreatitis producing a colonic stricture (3), and pseudocyst eroding into the splenic flexure (1). Presentation was varied, including rectal bleeding (2), clinical deterioration during severe pancreatitis (4), and large bowel obstruction (3). The 3 cases due to malignancy, 1 of which was recurrent, presented with primary large bowel symptoms suggesting intestinal obstruction rather than pancreatic disease. Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. Conclusions Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Colonoscopy, contrast x-rays, or CT scan may be vital in selected cases to detect underlying pathology. Clinicians should be aware that acute or chronic pancreatitis or pancreatic carcinoma may compress, erode, or inflame the large bowel, resulting in life-threatening colonic necrosis, bleeding, obstruction, or perforation.

The Identifying and Counseling of Breastfeeding Women by Pharmacists

OBJECTIVE Concerns about medications influence breastfeeding decisions. Mothers may stop breastfeeding when they take medications. After the distribution of Thomas Hales Medications and Mothers Milk (MMM) (Hale Publishing, Amarillo, TX, 2006) by the Rhode Island Department of Health (Providence, RI) in November 2006 to Rhode Island pharmacies, we investigated, during the summer of 2007, what strategies and resources pharmacists were using to identify breastfeeding women and guide medication recommendations. METHODS Copies of MMM were sent to 47 pharmacies in Rhode Island. Subsequently, one pharmacist at each site completed a confidential, 10-question written survey. RESULTS The survey response rate was 92%. More than half (58%) of the pharmacists surveyed never asked women if they were breastfeeding. Most (85%) of pharmacists reported feeling somewhat or very comfortable giving advice to breastfeeding women. All but one pharmacist who had received MMM reported using the reference at least monthly. More than half (52%) of the pharmacists reported using the Physicians Desk Reference (Thomson PDR, Montvale, NJ). DISCUSSION Pharmacists need a consistent approach to identify breastfeeding women and access to reliable, continuously updated resources to guide their advice about medication use to breastfeeding women. Physicians and pharmacists should collaborate to prevent medication use from being a barrier to breastfeeding.

Clostridium septicum Sepsis and Colon Carcinoma: Report of 4 Cases

An association exists between colon carcinoma and Clostridium septicum infection, especially bacteremia. We reviewed retrospectively all positive blood cultures for this organism at a 300-bed general hospital over 4 years. Four of 15 cases were associated with concurrent colon carcinoma. C. septicum infection was the presenting feature of previously undiagnosed large bowel malignancy in three patients. We report this small case series to alert clinicians to the diverse spectrum and diagnostic difficulties of this rare, potentially catastrophic association. Although commonly associated with necrotizing skin or soft tissue infections, this bacterium can present with nonspecific or atypical symptoms. All patients with positive blood cultures for C. septicum, even without clinical suspicion of large bowel malignancy, should undergo colonoscopy to evaluate for colon carcinoma.

Corticosteroid‐associated avascular necrosis: dose relationships and early diagnosis

Corticosteroids are the most common etiological factor in nontraumatic avascular necrosis (AVN) of bone, accounting for about 10% of arthroplasties performed annually in the United States. Evidence is conflicting on the relative importance of peak dose, daily dose, or cumulative dose, and most likely all three represent “high dose” corticosteroid administration and play a role in AVN. The etiology may be multifactorial with corticosteroids superimposed on genetic or pathological predispositions. Joint preservation depends upon early diagnosis and treatment before fracture of the subchondral trabeculae and joint incongruity. Early intervention depends upon identifying at‐risk patients and quantifying their risk by understanding clinical and pathophysiological contributions to that risk. Our data and that of others suggest that a screening MRI of at‐risk populations will permit detection of AVN at a prefracture stage when preservation of the joint is possible.

Examining Internet resources on gender differences in ACL injuries: what patients are reading.

BACKGROUND The Internet is a popular and powerful resource used by both clinicians and patients. However, medical information on the Internet is often unregulated, biased, and of poor quality. Given the frequency of ACL injuries in young women, this topic was used as a case study to examine the information available to patients on the Internet. METHODS An Internet search was performed using the top three general search engines for four different search phrases related to ACL injuries in females. The top ten sites from each search were analyzed on the basis of both website interface and a specific content scoring guide. RESULTS A total of 35 unique websites were analyzed. The majority of websites were authored by a layperson or had an unidentified author. Readability data indicated that many sites were written at literacy levels that were too difficult for the average reader. Finally, the average content analysis score for all sites was 41.6 out of a possible 100 points (range 10-87.5); only one-third of the websites cited references for the information provided. CONCLUSIONS We found the Internet information on ACL injuries in women to be largely unsupported, outdated and too difficult for the average reader to comprehend. The average site covered less than half of the topics that we considered relevant to ACL injuries in females indicating that information available on the Internet is largely incomplete. CLINICAL RELEVANCE Clinicians should be aware of the deficiencies in Internet information in order to appropriately address these issues with patients.

Diverse Presentation of Secondary Aortoenteric Fistulae

Secondary aortoenteric fistula, due to mechanical erosion or infection of a prosthetic graft, is a very rare cause of gastrointestinal bleeding and an uncommon complication of abdominal aortic aneurysm repair. A retrospective chart review conducted at our institution revealed 5 cases of secondary AEF occurring between 2006 and 2010. Presentations were diverse, including hematemesis, coffee-ground emesis, and unexplained sepsis. Delay in diagnosis was common. In reporting these cases, we seek to highlight the diverse clinical spectrum and potentially misleading features of this condition. Clinicians must retain a high index of suspicion to avoid potentially catastrophic outcomes.

Endoscopic visualization of nodular lymphoid hyperplasia

One can expect to encounter upper gastrointestinal hemorrhage from aortoenteric fistulas more often as vascular reconstructive surgery becomes more common. The complication is lethal if not recognized and treated promptly. Upper gastrointestinal fiberoptic endoscopy can be used to make an early diagnosis, at the same time excluding other sources of hemorrhage. Endoscopy is a rapid, safe diagnostic tool that can be used in the seriously ill patient while supportive measures are being instituted.