Gaurav Kistangari

Immune thrombocytopenia in adults: an update.

Immune thrombocytopenia (ITP) in adults is a chronic disease resulting from increased platelet destruction and impaired platelet production. Splenectomy remains the most effective and durable treatment in cases that are refractory to first-line therapy, but its use has declined because of the availability of alternate medical therapy, the associated risk of infection, and concern for surgeryrelated complications. Rituximab (Rituxan) may be an effective alternative but carries the risk of immunosuppression. Management has changed in the last decade, with new drugs and with increased awareness of treatment side effects.

A Clinical Review of Small-Cell Carcinoma of the Urinary Bladder

Small-cell carcinoma of the urinary bladder is a rare and aggressive type of bladder cancer that has a poor prognosis. The incidence has been gradually increasing because of the aging population. Owing to its rarity there are no available treatment guidelines. Several retrospective studies and 1 prospective study have provided some insight into therapy for this disease. A multimodal approach that includes chemotherapy, local radiation therapy, and definitive surgery in resectable cases appears to be an optimal management approach.

Mean platelet volume as a marker of increased cardiovascular risk in patients with nonalcoholic steatohepatitis

Nonalcoholic Fatty Liver Disease (NAFLD); Nonalcoholic Steatohepatitis (NASH); Mean plateletvolume (MPV); Inflammation; Steatosis; Ballooning; Fibrosis; Cardiovascular RiskNonalcoholic fatty liver disease (NAFLD) has emerged as the most common cause ofchronic liver disease in western countries (1). NAFLD is frequently associated with obesity,diabetes, metabolic syndrome, and increased cardiovascular risk. Moreover, patients withthe aggressive form of NAFLD, nonalcoholic steatohepatitis or NASH, may be at higher riskof atherosclerosis than patients with simple steatosis due to increased oxidative stress andsystemic inflammation (2–4). Mean platelet volume (MPV) is a marker of platelet activationand a validated predictor of cardiovascular risk (5). Larger platelets are enzymatically moreactive than small platelets, produce more thromboxane A2, and have an increased propensityto thrombosis (6).The aim of this study was two-fold: first to assess MPV levels in patients with biopsyproven NAFLD, and second to determine the relation between histological features ofNASH and MPV. Our cohort consisted of 100 consecutive patients undergoing liver biopsyfor clinical suspicion of NAFLD. Patients were divided into 3 groups: NASH (n=52), simplesteatosis (n=25), and normal biopsy (n=21). We measured MPV in blood samples collectedat the time of liver biopsy. The mean age was 49.8(± 10.6) years and the mean body massindex was 31.4 (± 4.8) kg/m

Frequency and Risk Factors of Clostridium difficile Infection in Hospitalized Patients With Pouchitis: A Population-based Study

Background: Clostridium difficile infection (CDI) in patients with the ileal pouch after proctocolectomy has been increasingly recognized. We sought to evaluate the frequency and risk factors of CDI in patients with the primary or secondary discharge diagnosis of pouchitis in the United States. Methods: We reviewed the National Inpatient Sample of the Healthcare Cost and Utilization Project and identified patients admitted for pouchitis with underlying inflammatory bowel disease (IBD) or familial adenomatous polyposis (FAP), between 2010 and 2012. Cases with CDI were identified based on a concomitant primary or secondary discharge diagnosis for CDI. The frequency of CDI was estimated in patients with underlying IBD and FAP. Multivariable analysis was conducted to study the risk factors associated with CDI in those with pouchitis with underlying IBD. Results: A total of 3566 eligible patients with pouchitis were identified during the study period. Eighty-nine patients (2.5%) had CDI as a concomitant primary or secondary discharge diagnosis. CDI was identified in 2.6% (99.9% confidence interval [CI], 1.3–3.8) of pouchitis patients with underling IBD. None of the patients with pouchitis with underlying FAP were found to have CDI during the study period. Among pouchitis patients with underlying IBD, the presence of nonalcoholic fatty liver disease (odds ratio = 5.4; 95% CI, 1.5–19.9), obesity (odds ratio = 5.5; 95% CI, 1.4–21.4), or obstructive sleep apnea (odds ratio = 10.3; CI, 2.0–53.7) was associated with an increased risk of CDI. Conclusions: It seems that CDI was limited to pouchitis with underlying IBD and rare in those with underlying FAP. Patients with nonalcoholic fatty liver disease, obesity, and obstructive sleep apnea are at an increased risk of C. difficile pouchitis among patients with IBD.

Electrocardiographic changes in amitriptyline overdose.

A 49-year-old woman was unresponsive after taking an unknown quantity of amitriptyline.

Teriparatide Induced Delayed Persistent Hypercalcemia

Teriparatide, a recombinant PTH, is an anabolic treatment for osteoporosis that increases bone density. Transient hypercalcemia is a reported side effect of teriparatide that is seen few hours following administration of teriparatide and resolves usually within 16 hours of drug administration. Persistent hypercalcemia, although not observed in clinical trials, is rarely reported. The current case describes a rare complication of teriparatide induced delayed persistent hypercalcemia.

Utility of Mycoplasma IgM Serology in Hospitalized Patients

Sidra Khalid* Amrita Bath Alia Poore Gaurav Kistangari and Anil Kumar Changarath Vijayan Fairview Hospital, Cleveland Clinic, Cleveland, OH C A T IO N , R E S E A R C H , A N D Q U A L IT Y IM P R O V E M E N PURPOSE: Mycoplasma IgM serology is frequently ordered for hospitalized patients with pneumonia. This study aims to understand the impact of positive Mycoplasma IgM serology on the use of antibiotics that cover atypical organisms in such patients.

Clinical significance and management of Barrett’s esophagus with epithelial changes indefinite for dysplasia

Barretts esophagus (BE) is defined as the extension of salmon-colored mucosa into the tubular esophagus ≥ 1 cm proximal to the gastroesophageal junction with biopsy confirmation of intestinal metaplasia. Patients with BE are at increased risk of esophageal adenocarcinoma (EAC), and undergo endoscopic surveillance biopsies to detect dysplasia or early EAC. Dysplasia in BE is classified as no dysplasia, indefinite for dysplasia (IND), low grade dysplasia (LGD) or high grade dysplasia (HGD). Biopsies are diagnosed as IND when the epithelial abnormalities are not sufficient to diagnose dysplasia or the nature of the epithelial abnormalities is uncertain due to inflammation or technical issues. Specific diagnostic criteria for IND are not well established and its clinical significance and management has not been well studied. Previous studies have focused on HGD in BE and led to changes and improvement in the management of BE with HGD and early EAC. Only recently, IND and LGD in BE have become focus of intense study. This review summarizes the definition, neoplastic risk and clinical management of BE IND.

Fluctuating Risk Factors and Epidemiology

Barrett’s esophagus (BE) is an acquired condition associated with severe gastroesophageal reflux disease (GERD) and has a malignant predisposition. The overall prevalence of BE in general population varies between 1.6% and 6.8% in western countries. BE is a multifactorial disease with GERD being the most important contributing factor. Other risk factors include older age, male gender, Caucasian race, and family history of BE or esophageal adenocarcinoma. The modifiable risk factors include visceral obesity, smoking, diet rich in processed foods and poor in fruits and vegetables. There is emerging evidence about aspirin, nonsteroidal anti-inflammatory drugs, diabetes, and sleep apnea. There is growing interest in the field of biomarkers to detect BE and development of risk prediction models.