Fadi Antaki

OGILVIE SYNDROME AND HERPES ZOSTER: CASE REPORT AND REVIEW OF THE LITERATURE

BACKGROUND The very unusual association between herpes zoster and Ogilvie syndrome has received scant attention in the published literature. OBJECTIVES This review discusses the published experience since 1950 and attempts to increase clinical awareness about the co-existence of both conditions. CASE REPORT An 84-year-old male patient affected by herpes zoster presented with advanced acute colonic pseudo-obstruction and was successfully treated with colonic diversion. DISCUSSION Twenty published studies (1950-2008) of 28 patients in whom the two conditions co-existed are reviewed. The review included 22 male and 7 female patients (24%) aged 32-87 years (mean, 61 years). Significant co-morbidities were present in 45% of the patients. The majority of patients were observed and treated conservatively (83%). Two patients died (7%), both suffering from respiratory complications and malignancy. CONCLUSION Recognition of the combined syndrome may help to avoid unnecessary surgery. Laparotomy should be reserved as a last resort for when the obstruction cannot be successfully managed by endoscopy. A diverting colostomy can be used to monitor the blood supply and thus provide early warning for an impending abdominal catastrophe.

Efficacy of interferon plus ribavirin in the treatment of hepatitis C virus genotype 5

Summary.  Hepatitis C virus (HCV) genotype 5 has only been reported in a few countries and treatment response has not been well characterized. Our aim is to present the treatment outcome for HCV genotype 5 patients evaluated at three medical centres in Syria between January 2004 and June 2007. Medical records were reviewed retrospectively. Treatment consisted of ribavirin 1 000–1 200 mg daily plus interferon α‐2a, 3 MU × 3/week or pegylated‐interferon α‐2a, 180 μg/week. Patients were treated for 24 or 48 weeks. Sustained viral response (SVR) was assessed at the end of a 6‐month follow‐up period. Twenty‐six treatment‐naïve patients with HCV genotype 5 have completed the course of anti‐HCV therapy and a 6‐month follow‐up. An SVR was achieved in 54% (47% with standard interferon and 67% with pegylated interferon, P = 0.43). A trend towards better results was observed for younger patients, low viremia and mild fibrosis. SVR was similar for treatment course of 24 or 48 weeks. In summary, treatment of HCV genotype 5 with combination therapy resulted in SVR in 54% of patients. Twenty‐four weeks of treatment might be adequate. Further research should evaluate the ideal duration of treatment.

Multi-center colonoscopy quality measurement utilizing natural language processing

Background:An accurate system for tracking of colonoscopy quality and surveillance intervals could improve the effectiveness and cost-effectiveness of colorectal cancer (CRC) screening and surveillance. The purpose of this study was to create and test such a system across multiple institutions utilizing natural language processing (NLP).Methods:From 42,569 colonoscopies with pathology records from 13 centers, we randomly sampled 750 paired reports. We trained (n=250) and tested (n=500) an NLP-based program with 19 measurements that encompass colonoscopy quality measures and surveillance interval determination, using blinded, paired, annotated expert manual review as the reference standard. The remaining 41,819 nonannotated documents were processed through the NLP system without manual review to assess performance consistency. The primary outcome was system accuracy across the 19 measures.Results:A total of 176 (23.5%) documents with 252 (1.8%) discrepant content points resulted from paired annotation. Error rate within the 500 test documents was 31.2% for NLP and 25.4% for the paired annotators (P=0.001). At the content point level within the test set, the error rate was 3.5% for NLP and 1.9% for the paired annotators (P=0.04). When eight vaguely worded documents were removed, 125 of 492 (25.4%) were incorrect by NLP and 104 of 492 (21.1%) by the initial annotator (P=0.07). Rates of pathologic findings calculated from NLP were similar to those calculated by annotation for the majority of measurements. Test set accuracy was 99.6% for CRC, 95% for advanced adenoma, 94.6% for nonadvanced adenoma, 99.8% for advanced sessile serrated polyps, 99.2% for nonadvanced sessile serrated polyps, 96.8% for large hyperplastic polyps, and 96.0% for small hyperplastic polyps. Lesion location showed high accuracy (87.0–99.8%). Accuracy for number of adenomas was 92%.Conclusions:NLP can accurately report adenoma detection rate and the components for determining guideline-adherent colonoscopy surveillance intervals across multiple sites that utilize different methods for reporting colonoscopy findings.

Role of cancer stem cells in racial disparity in colorectal cancer.

Although African‐Americans (AAs) have a higher incidence of colorectal cancer (CRC) than White people, the underlying biochemical mechanisms for this increase are poorly understood. The current investigation was undertaken to examine whether differences in self‐renewing cancer stem/stem‐like cells (CSCs) in the colonic mucosa, whose stemness is regulated by certain microRNAs (miRs), could partly be responsible for the racial disparity in CRC. The study contains 53 AAs and 47 White people. We found the number of adenomas and the proportion of CD44+CD166− CSC phenotype in the colon to be significantly higher in AAs than White people. MicroRNAs profile in CSC‐enriched colonic mucosal cells, expressed as ratio of high‐risk (≥3 adenomas) to low‐risk (no adenoma) CRC patients revealed an 8‐fold increase in miR‐1207‐5p in AAs, compared to a 1.2‐fold increase of the same in White people. This increase in AA was associated with a marked rise in lncRNA PVT1 (plasmacytoma variant translocation 1), a host gene of miR‐1207‐5p. Forced expression of miR‐1207‐5p in normal human colonic epithelial cells HCoEpiC and CCD841 produced an increase in stemness, as evidenced by morphologically elongated epithelial mesenchymal transition( EMT) phenotype and significant increases in CSC markers (CD44, CD166, and CD133) as well as TGF‐β, CTNNB1, MMP2, Slug, Snail, and Vimentin, and reduction in Twist and N‐Cadherin. Our findings suggest that an increase in CSCs, specifically the CD44+CD166− phenotype in the colon could be a predisposing factor for the increased incidence of CRC among AAs. MicroRNA 1207‐5p appears to play a crucial role in regulating stemness in colonic epithelial cells in AAs.

The model for end-stage liver disease (MELD) predicts survival of liver cirrhosis patients after discharge to hospice.

Aim To assess if the Model for End-stage Liver Disease (MELD) score correlates with survival of liver cirrhosis patients after discharge to hospice. Methods Patients who were discharged to a hospice program for decompensated liver cirrhosis during a 7-year period were identified. MELD score was calculated for all patients. Medical records and the Social Security Death Index (SSDI) were used to determine the exact date of death and survival after discharge. Results Fifty patients were identified. Average MELD score was 26.4. Exact date of death was available for 42 of these patients. Average survival after discharge to hospice was 36.83 days. There was a moderate correlation (r=−0.61, P<0.0001) between MELD scores and survival after hospice discharge. The area under the receiver operating characteristic curve for MELD score predicting 30-day mortality was 0.84. MELD score ≥25 predicted 30-day mortality with a sensitivity of 74.19%, a specificity of 90.91%, and an accuracy of 78.58%. The positive predictive value was 95.83% and the negative predictive value 55.56%. Conclusions Patients with cirrhosis who are not candidates for liver transplantation are referred to hospice care at a late stage with an average survival of 1 month. The MELD score correlates with survival of cirrhosis patients enrolled in hospice and can be used to estimate 30-day mortality. Further, research is needed to determine a MELD score that predicts a survival of 6 months or less, an important determinant of appropriate hospice referrals.

HBsAg titers in the different phases of hepatitis B infection in Syrian patients

BACKGROUND AND OBJECTIVES Little is known about hepatitis B surface antigen (HBsAg) level during the natural course of hepatitis B virus (HBV) infection. The aims of this study were to determine the HBsAg titer in the different phases of HBV infection and to evaluate for the presence of a correlation between HBsAg titers and HBV DNA levels. STUDY DESIGN 272 HBV patients were analyzed in a cross-sectional study. The patients were classified into 4 categories: immune tolerant phase (IT, n=9), immune clearance phase (IC, n=26), low-replicative phase (LR, n=131), and HBeAg-negative hepatitis (ENH, n=106). RESULTS Median HBsAg titers were different between each phase of CHB (p<0.001): IT (4.31log(10)IU/ml), IC (4.42log(10)IU/ml), LR (3.32log(10)IU/ml) and ENH (3.71log(10)IU/ml). Correlation of HBsAg and HBV DNA was strong in IT patients (r=0.74) and the whole group (r=0.83), moderate in the ENH phase (r=0.44) and poor in the IC (r=0.14) and the LR phases (r=0.080). CONCLUSIONS This large study demonstrates that in HBV patients, HBsAg levels are significantly different in the different stages of the disease. A correlation between serum HBV DNA and HBsAg titers does not exist except in the IT and ENH phases. Three other studies have addressed the same issue on different genotypes and we notice that there is no concordance between the 4 studies. This leads to conclude that measurement of HBsAg level, for the time being, will not replace the serum HBV DNA as a marker of replication.

Rare occurrence of gastric pseudomelanosis

We greatly appreciate Dr Antaki’s interest in our case. Pseudomelanosis of the GI tract is a rare, potentially reversible benign condition that produces no symptoms and incidentally manifests itself on endoscopy as discrete, flat, small, brownish-black spots in the mucosa. This case of gastric pseudomelanosis is very unusual. The usual form of melanosis ilei is exogenous, that is, it stems from atmospheric dust and/or ingested materials. These ingested materials eventually form pigments through largely unknown mechanisms. Regardless of their chemical composition, deposits are typically found within macrophages in the lamina propria of normal villi. The function of these macrophages may be somewhat altered, producing an accumulation of ferrous sulfide. Although some correlate certain systemic diseases or a variety of drugs with pseudomelanosis, no definite etiology or mechanism has been traced. A prospective study evaluating these associations, together with chemical analysis, such as electron probe radiograph analysis, may be desirable. This lesion is very rare and will be difficult to study.

Acceptance of split-dose bowel preparation regimen for colonoscopy by patients and providers.

Background: Split-dose bowel preparation (split prep) for colonoscopy has been shown to be superior to conventional dosing (entire dose taken on the evening preceding colonoscopy) and has been endorsed by recent guidelines. A potential limitation is the requirement for patients to wake up early to drink the second half. Methods: A group of colonoscopy patients, scheduled for morning procedures were surveyed regarding their opinion about a split prep regimen. The survey specifically asked if they would be willing to wake up at 4:00 AM to drink the second half of the preparation. Primary care providers (PCPs) were given a similar survey asking for their opinion about the willingness of their patients to take a split prep regimen. Results: Among the 149 patients surveyed, 95 patients (64%) were willing to wake up early to complete a split prep, whereas 54 (36%) were not. The majority, 65 of 95 (68%) patients, preferred an early morning appointment. Only 3 of 95 (3%) patients preferred an afternoon one. There were no statistically significant differences between patients in favor of a split or conventional preparation, in respect to demographics, family history of colorectal cancer, or prior experience with colonoscopy. A total of 25 of 34 PCPs (74%) answered the survey. Only 14 PCPs (56%) thought their patients would be willing to wake up at 4:00 AM to complete the preparation. Conclusions: Despite a high level of apprehension among PCPs, the majority of colonoscopy patients seem willing to comply with a split prep. Therefore, split prep should be used whenever possible for colonoscopy.

Tu1047 Assessing Key Barriers to Treatment of Chronic Hepatitis C Virus (HCV) With Next Generation Agents in a Veteran Population

variability was noted in the responses, with some waiting as long as 5 years to repeat screening in the presence of a high-risk adenoma with IBP. Awareness of MSTF recommendations or adherence to these guidelines still remains weak among GI physicians and physician-extenders. Publicity of guidelines and further data to support their recommendations are warranted. REFERENCES 1.Lebwohl B, et al. Gastrointest Endosc 2011;73(6):1207-1214. 2.Neerincx M, et al. Endoscopy 2010;42(9):730-735. 3.Lieberman DA, et al. Gastroenterology 2012;143(3):844-57.

Approach to Presenting a Clinical Journal Club

It can be a daunting assignment thatmost traineeswill face at some point in their careers: Selecting, appraising, and presenting an article for a clinical journal club. Thoughts of where to begin looking for an article arise, which is often followed by apprecase-control studies, and meta-analyses can occasionally be chosen. Case reports and review articles are not appropriate for this purpose and should be avoided. Although past landmark articles can be considered because they often represent the foundation of current clinical practice, we recommend choosing an article that has been published recently, preferably within the last 3–6 months, and has received attention at major GI conferences and through the lay press. This way, a “cutting-edge” topic can be presented, which your audience should hopefully already be familiar with, leading to a more productive discussion. The American College of Physicians Journal Club can be an excellent resource, as it incorporates the McMaster Online Rating of hension about interpreting statistical tests and critically analyzing the article. Finally comes the task of presenting the article and leading a focused group discussion. Despite the unease that can accompany these tasks, honing the skills necessary for article appraisal and succinct presentation are important. They are essential not only for an effective journal club presentation in residency and fellowship, but also for development into an astute, evidence-based clinician. Clinical journal clubs also provide an excellent opportunity to discuss new innovations in gastroenterology that shape our clinical practice. Here we present an approach (Table 1) that walks the reader through the steps necessary for preparation and successful presentation of a clinical article at journal club.