Vikas Khullar

Emergence of new classes of recreational drugs-synthetic cannabinoids and cathinones.

ABSTRACTDesigner drugs represent an increasingly popular form of recreational substance abuse, especially amongst young adults. The two classes of designer drugs that have recently risen to prominence are the synthetic cannabinoids and synthetic cathinones. These substances are not detected by conventional drug screening methods and can often be associated with serious health consequences, including seizures, renal failure and death. Thus, clinicians should be familiar with the signs, symptoms, and toxicities associated with the use of these substances, and maintain a high level of suspicion for synthetic drugs as an alternative means of “getting high.” We present a case of a 20-year-old college student who presented to the emergency department with altered mental status and severe agitation who later admitted to using bath salts. The goal of this article is to raise awareness about these new designer drugs, their clinical presentation, and management of their intoxication.

Rare cause of acute hepatitis: a common energy drink

A previously healthy man aged 50 years presented with malaise, anorexia, abdominal pain, nausea, vomiting, generalised jaundice, scleral icterus and dark urine. He was not on any prescription or over-the-counter medications, but reported drinking 4–5 energy drinks daily for 3 weeks prior to presentation. Physical examination revealed jaundice and right upper quadrant abdominal tenderness. Laboratory studies were remarkable for transaminitis and evidence of chronic hepatitis C infection. Ultrasound scan demonstrated an echogenic liver and diffuse gallbladder wall thickening. Liver biopsy showed severe acute hepatitis with bridging necrosis and marked cholestasis. The patient was treated supportively with complete resolution of his symptoms and marked improvement in his laboratory abnormalities. The development of acute hepatitis in this patient was likely secondary to excessive energy drink consumption. Energy drinks as well as other herbal/over-the-counter supplements should be considered by clinicians in the workup of patients with acute hepatitis, particularly once other aetiologies have been excluded.

Once Versus Twice-Daily Oral Proton Pump Inhibitor Therapy for Prevention of Peptic Ulcer Rebleeding: A Propensity Score-Matched Analysis

Background After inpatient management of upper gastrointestinal bleeding (GIB) due to peptic ulcer disease (PUD), oral proton pump inhibitor (PPI) therapy is recommended at discharge to decrease rebleeding risk and improve ulcer healing. Our aim is to determine whether once-daily oral PPI dosing at hospital discharge is associated with inferior 30-day rebleeding outcomes as compared to twice-daily dosing. Methods We retrospectively identified 233 patients admitted with signs and symptoms of upper GIB found to be due to PUD on upper endoscopy. After inpatient management, patients discharged on once-daily oral PPI were compared to those discharged on twice-daily therapy. We utilized propensity score matching based on Rockall scores to ensure the two groups were closely matched in terms of their baseline rebleeding risk. Primary outcome was the incidence of rebleeding within 30 days. Secondary outcomes were all-cause mortality, blood transfusion requirement, requirement for interventional radiology or surgery. Results Overall, 49 patients were discharged on once-daily and 184 on twice-daily PPI. Recurrent bleeding occurred in 18 patients (7.7%) within 30 days. There was no statistically significant difference in recurrent bleeding rates between once-daily (n = 7, 14.3%) as compared to twice-daily PPI (n = 11, 6%) (P = 0.053). In a 1:1 propensity score matched analysis, there was no statistically significant difference in 30-day recurrent bleeding rate between groups (14% once-daily vs. 4% twice-daily, P = 0.159). There were no differences in secondary outcomes. Conclusions Once-daily oral PPI dosing at hospital discharge was not associated with inferior outcomes compared to twice-daily dosing in patients hospitalized for upper GIB due to PUD.

Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus: a retrospective analysis

Background  Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). Methods  This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. Results  In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 – 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 – 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 – 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 – 29 months) than the recommended interval. Conclusion  Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Hematochezia: An Uncommon Presentation of Colonic Tuberculosis

Abdominal tuberculosis (TB) is an uncommon entity in the United States. Colonic TB is reported in 2-3% of patients with abdominal TB. It is frequently misdiagnosed as Crohns disease or carcinoma of the colon due to their shared clinical, radiographic, and endoscopic presentations. We present a case of a 72-year-old male with colonic tuberculosis presenting as hematochezia. Our patient presented with shortness of breath and weight loss. Chest X-ray demonstrated ill-defined bilateral parenchymal opacities in the perihilar, mid, and lower lung zones. The patient was diagnosed and treated for community acquired pneumonia, with no improvement. Hematochezia complicated by symptomatic hypotension developed later in the course of admission. Colonoscopy revealed multiple ulcers at the anus and transverse and ascending colon as well as the cecum with stigmata of bleeding. Biopsy of a sigmoid ulcer was consistent with colonic tuberculosis. Antitubercular therapy was initiated, but the patient passed away secondary to multiorgan failure 29 days into admission.

Duodenal perforation following esophagogastroduodenoscopy (EGD) with cautery and epinephrine injection for peptic ulcer disease: An interesting case of nonoperative management in the medical intensive care unit (MICU)

Highlights • One dreaded complication of EGD that has attributed to substantial morbidity and mortality is duodenal perforation.• Due to its relative infrequency, significant ambiguity exists surrounding the optimal management of duodenal perforations following EGD.• We describe a case of nonoperative treatment for duodenal perforation following EGD that ended in mortality.• The case we present here is novel and unique in that it describes the medical management of an uncommon and devastating complication of a procedure that is frequently performed.• Outcomes for duodenal perforation following EGD appear to be improved when select patients with duodenal free wall perforation leading to peritonitis and hemodynamic instability are taken for laparotomy and surgical repair.

Mo1039 Safety Profile of Sorafenib in Hepatocellular Carcinoma, Could Certain Adverse Events Predict Better Survival?

up CT imaging and the microscopic examination showed intraarterial degradation of gelfoam and microsphere. The blood tests demonstrated insignificant changes of liver and renal functions. Conclusion: Our microspheres, with the characteristics of calibrated, radiopaque, and biodegradable, can be used for TAE with effects equivalent to or better than gelfoam and embosphere in pigs. Currently used drug-eluting beads can only be bound by positive charged drugs. As our microsphere was made of pharmaceutical excipients, it will not be limited to the electric charge of drugs and has a potential to combinewith different chemotoxic agents for TACE. Hemodynamic Changes of Liver Before and After Embolization

Spontaneous occlusion of the circle of Willis in a young woman with epilepsy: epileptic-type moyamoya disease

The authors report a case of a 31-year-old woman from India with history of seizure disorder who presented with sudden onset right hemiparesis and right-sided upper motor neuron type facial palsy. No identifiable risk factors were noted on admission and all laboratory investigations were negative. MR angiography helped in arriving at the diagnosis of moyamoya disease as the aetiology of her symptoms.