Neil Vyas

Association between serum vitamin D levels and gastric cancer: A retrospective chart analysis.

AIM To determine whether there is an increased risk of gastric adenocarcinoma associated with vitamin D deficiency (VDd). METHODS A retrospective case control study was performed of all patients diagnosed with gastric adenocarcinoma between 2005 and 2015. After we excluded the patients without a documented vitamin D level, 49 patients were included in our study. RESULTS The average age of patients with gastric adenocarcinoma and documented vitamin D level was 64 years old (95%CI: 27-86) and average vitamin D level was 20.8 mg/dL (95%CI: 4-44). Compared to a matched control group, the prevalence of VDd/insufficiency in patients with gastric adenocarcinoma was significantly higher than normal vitamin D levels (83.7% vs 16.3%). Forty-one patients (83.7%) with adenocarcinoma showed VDd/insufficiency compared to 18 (37%) patients with normal vitamin D level without gastric cancer (OR: 8.8, 95%CI: 5-22, P value < 0.0001). The average age of males with gastric adenocarcinoma diagnosis was 60 years old vs 68 years old for females (P = 0.01). Stage II gastric adenocarcinoma was the most prevalent in our study (37%). CONCLUSION We reported a positive relationship between VDd and gastric adenocarcinoma, that is to say, patients with decreased VDd levels have an increased propensity for gastric adenocarcinoma.

Morbidity and mortality of infective endocarditis in a hospital system in New York City serving a diverse urban population

Infective endocarditis (IE) is a severe illness associated with significant morbidity and mortality. The primary purpose of this study was to evaluate morbidity and mortality of IE in a hospital serving the most diverse area in New York City. An analysis of 209 patients admitted to the hospital from 2000 to 2012 who were found to have IE based on modified Duke criteria. Among the 209 patients with IE, 188 (88.8%) had native heart valves and 21 (11.2%) had prosthetic valves. Of the patients with native heart valves, 3.7% had coronary artery bypass graft, 4.3% were active drug users, 6.3% had permanent pacemakers, 12.2% had a history of IE, 25.7% were diabetic, 17% had end-stage renal disease (ESRD), 9% had congestive heart failure, 8% had abnormal heart valves, and 13.8% had an unknown etiology. Mortality rates of the patients with prosthetic heart valves were 27.7% compared to 8.11% in patients with native heart valves (OR 3, p<0.0001). Since we identified diabetes mellitus and ESRD to be significant risk factors in our population, we isolated and compared characteristics of patients with and without IE. IE among patients with diabetes mellitus was 23% compared with 13.8% in the control group (p=0.016). Cases of IE in patients with ESRD were 15.3%, compared with 4% in the control group (p<0.0001). We identified an overall mortality rate of 20.1% in patients with IE, a readmission rate within 30 days of discharge of 21.5%, and an average age of 59 years. Among 209 patients, 107 were males and 102 females. The most common organisms identified were Staphylococcus aureus (43.7%), viridans streptococci (17%) followed by Enterococcus (14.7%). Despite appropriate treatment, high rates of morbidity and mortality remained, with a higher impact in patients greater than 50 years of age. Such discoveries raise the importance of controlling and monitoring risk factors for IE.

Serum vitamin D levels correlate to coronary artery disease severity: a retrospective chart analysis

ABSTRACT Background: The pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. We further emphasized and evaluated the severity of coronary artery disease (CAD) with varying levels of vitamin D in relation to age, gender, ethnicity and baseline confounders. Methods: A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed levels of 25(OH)D and extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Results: Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis of the extent of coronary disease, we identified 20% of patients having normal coronaries, 55% having obstructive CAD and 25% having non-obstructive CAD. Baseline clinical risk factors and co-morbidities did not differ between the groups. Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2 – 9.5, p < 0.0001). Comparing patients with normal 25(OH)D levels, patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 62% were found to have obstructive CAD (n = 624, OR: 2.9, 95% CI: 2.3-3.7, p < 0.0001) and 25% had non-obstructive CAD (n = 249, OR: 1.5, 95% CI: 1.1-2, p = 0.02). Conclusion: Normal coronaries and CAD were shown to correlate with normal and low levels of 25(OH)D, respectively. There is an inverse relationship between the percentage of coronary artery occlusion and serum 25(OH)D concentrations. Vitamin D may provide benefits in risk stratification of patients with CAD and serve as a possible risk factor.

Video capsule endoscopy: is bowel preparation necessary?

There is no standardized protocol for bowel preparation prior to video capsule endoscopy, although one is strongly recommended. The purpose of our study was to see if there was a statistical significance between small bowel mucosal visualization rates for those who received bowel preparation and those who did not. We retrospectively analyzed all patients who had a video capsule endoscopy from August 2014 to January 2016 at a tertiary care center. All patients fasted prior to the procedure. Bowel preparation when used consisted of polyethylene glycol. A long fast consisted of 12 or more hours. The grading system used to assess the small bowel was adapted from a previously validated system from Esaki et al. Statistical analyses were performed using Fishers exact test or Welchs 2-sample t-test and statistical significance was present if the p value was ≤0.05. 76 patients were carried forward for analysis. Small bowel mucosal visualization rates were similar between those who received bowel preparation and those who did not (92.5% vs 88.9%, p=0.44). Small bowel mucosal visualization rates were significantly better in those patients who had a long fast compared with those who had a short fast (97.7% vs 81.3%, p=0.019). Our study demonstrates that the addition of bowel preparation prior to video capsule endoscopy does not significantly improve small bowel mucosal visualization rates and, in addition, there is a statistically significant relationship between increased fasting time and improved small bowel mucosal visualization. A prolonged fast without bowel preparation might be satisfactory for an adequate small bowel visualization but further randomized, prospective studies are necessary to confirm these findings.

Acute hepatitis E presenting with clinical feature of autoimmune hepatitis

A 32-year-old immigrant man presented with new onset jaundice. His past medical history was significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. His initial laboratory finding and liver biopsy were suggestive of autoimmune hepatitis (AIH). The plan was to start steroids pending negative results for viral serology, but it came back positive for hepatitis E virus. The patients liver function test and clinical condition improved significantly on conservative management over a period of 1 month. Therefore, we suggest testing for hepatitis E especially in immigrants or recent travelers to endemic areas who presents with clinical features suggestive of AIH.

Risk factors for coronary artery disease and acute coronary syndrome in patients ≤40 years old

OBJECTIVE In this study, we assessed the risk factor profile in premature coronary artery disease (CAD) and acute coronary syndrome for adults ≤40 years old. METHODS A retrospective chart analysis of 397 patients ≤40 years old admitted from 2005 to 2014 for chest pain and who underwent coronary arteriography. RESULTS Of 397 patients that had undergone coronary arteriography, 54% had CAD while 46% had normal coronary arteries. When compared with patients with normal coronary arteries, patients with CAD were more likely to smoke tobacco, have dyslipidemia, be diabetic, have BMI >30 kg/m(2), have a family history of premature CAD and be male in gender. CONCLUSION Healthcare intervention in the general population through screening, counseling and education regarding the risk factors is warranted to reduce premature CAD.

Primary squamous cell carcinoma of the rectum: a case report and literature review.

Squamous cell carcinoma (SCC) of the rectum is a rare occurrence with an incidence rate of 0.1–0.25% per 1,000 cases. Herein, we report a case of a 52-year-old female who presented with a 2-month history of diffuse lower abdominal pain and hematochezia. Abdominal CT scan revealed a 7-cm irregular rectal mass, and the biopsy showed SCC.

Isolated supra-cardiac partial anomalous pulmonary venous connection causing right heart failure

Right heart failure (RHF) has been overlooked as left heart failure has predominated. One of the many causes of RHF is partial anomalous pulmonary venous connection (PAPVC), an extremely rare entity in nature. Physicians should consider the unusual causes of RHF after ruling out the common causes.

Coronary artery disease in patients with body mass index ≥30 kg/m 2 : a retrospective chart analysis

Objective In this study, we evaluated obesity as a single risk factor for coronary artery disease (CAD), along with the synergistic effect of obesity and other risk factors. Methods A retrospective study of 7,567 patients admitted to hospital for chest pain from 2005 to 2014 and underwent cardiac catheterization. Patients were divided into two groups: obese and normal with body mass index (BMI) calculated as ≥30 kg/m2 and <25, respectively. We assessed the modifiable and non-modifiable risk factors in obese patients and the degree of CAD. Results Of the 7,567 patients who underwent cardiac catheterization, 414 (5.5%) had a BMI ≥30. Of 414 obese patients, 332 (80%) had evidence of CAD. Obese patients displayed evidence of CAD at the age of 57 versus 63.3 in non-obese patients (p<0.001). Of the 332 patients with CAD and obesity, 55.4% had obstructive CAD versus 44.6% with non-obstructive CAD. In obese patients with CAD, male gender and history of smoking were major risk factors for development of obstructive CAD (p=0.001 and 0.01, respectively) while dyslipidemia was a major risk factor for non-obstructive CAD (p=0.01). Additionally, obese patients with more than one risk factor developed obstructive CAD compared to non-obstructive CAD (p=0.003). Conclusion Having a BMI ≥30 appears to be a risk factor for early development of CAD. Severity of CAD in obese patients is depicted on non-modifiable and modifiable risk factors such as the male gender and smoking or greater than one risk factor, respectively.

Transient global amnesia: Minor inconvenience or early warning sign?

Transient global amnesia (TGA) is a clinical diagnosis and is often a diagnosis of exclusion. However, despite the benign nature of this condition, it has been associated with underlying life-threatening medical conditions (e.g., myocardial infarction, dissecting aortic aneurysm, arrhythmias). Our case report highlights the importance of early recognition of those with cardiovascular risk factors who present with acute onset altered mental status to look for underlying medical comorbidities.