Faculty Bibliography

BACKGROUND:Hidradenitis suppurativa patients often seek non-prescription therapies. OBJECTIVE:To determine the prevalence of alternative medicine use and characterize the differences between patients who report using alternative medications versus those who do not. METHODS:We surveyed 67 patients with hidradenitis suppurativa regarding demographics, alternative medicine use, disease severity, and quality of life. RESULTS:25 (37.2%) of the HS subjects reported alternative medicine use. Alternative medicine users tended to be younger (36.7 vs 40.8 years), have a shorter time since diagnosis (12.6 vs14.6 years), and reported worse quality of life (14.1 vs 11.0) than non-users. These differences were not statistically significant. LIMITATIONS/CONCLUSIONS:Limitations included a small sample size. CONCLUSION/CONCLUSIONS:Alternative medicine use among patients with hidradenitis is common regardless of disease severity; even mild disease may drive patients to seek alternative treatment. J Drugs Dermatol. 2021;20(10):1072-1074. doi:10.36849/JDD.6046.

Introduction: A transcatheter aortic valve replacement (TAVR) carries a 2% risk of postoperative upper gastrointestinal bleeding. It presents as extensive bleeding resulting in hemorrhagic shock or respiratory failure. In this case, an early clot with sentinel bleeding prevented the widening of a full thickness aortoesophageal fistula formed from the TAVR placement, was symptomatic enough to prompt an earlier esophagogastroduodenoscopy (EGD) and prevented a probable fatality. Case Description/Methods: An 85-year-old male with a past medical history of AAA repair, GERD, HLD, TIA, aortic dissection s/p coronary bypass graft, AS with TAVR 5 months prior presented with hematemesis after initiating colonoscopy bowel prep. He also had unintentional 30-lb weight loss over 3 months, fecal incontinence, and melena. Medications include a daily aspirin. Abdominal CT demonstrated an 8cm aortic arch aneurysm, a 5cm descending thoracic aortic aneurysm, and a 5.8 x 4 cm collection posterolateral to the aorta with proximal dilation of the esophagus. EGD demonstrated a partially obstructing protruding mass in the esophagus 20 cm from the incisors with sentinel bleeding from an adherent clot. The mass was determined to be extrinsic compression from the aortic arch aneurysm with the TAVR seen through the aortoesophageal fistula (Image 1A-1B). The stomach and duodenum were unremarkable. Patient was transferred to vascular surgery where a 1cm compressed Amplatzer Vascular Plug II embolization and reinforcement of the endoleak was done. Patient remained hemodynamically stable and discharged home with a vascular follow up.
Discussion(s): Aorto-esophageal fistula following TAVR is a rare complication with a wide etiology ranging from infections, antithrombotic use, pressure necrosis, angiodysplasia, underlying PUD, or uncontrolled comorbidities such as HTN. Our patient's risk factors were his elderly age, comorbidities, use of daily aspirin, and contribution from the pressure or ischemic necrosis of the aortic aneurysm compressing on the esophagus. Presentation involves hemoptysis, chest pain, hemorrhagic shock, respiratory failure and frank bleeding. CTA is considered the initial test of diagnosis as endoscopy, though sensitive, could rupture the clot and unleash massive bleeding. In this case, sentinel bleeding and visualization of the TAVR through the fistula was enough to diagnose and retreat to be treated appropriately with embolization and reinforcement

Introduction: Gastrointestinal follicular lymphoma (FL) is a rare, but distinct extra-nodal variant of non-Hodgkin's lymphoma. Its incidence has grown outside of known genetic inheritance, due to epigenetic mutations from increased toxic exposure to benzene and pesticides, expanded life spans, and widespread standardized screening efforts. Diagnosis is by colonoscopy-obtained tissue staining and can be missed if alternative CRC screening methods are used in lieu. Case Description/Methods: A 54-year-old Ukranian male with a past medical history of HTN and GERD came in for an asymptomatic screening colonoscopy. One 8 mm polyp in the transverse colon was positive for FL. IHC staining demonstrated atypical small B-lymphocytes, positive for CD451, CD201, PAX51, CD101, and BCL-21. Bloodwork, including LDH, beta-2-microglobulin, were normal. A staging PET scan was negative indicating an isolated disease within the colonic polyp. As the patient was asymptomatic, no further treatment was indicated and the patient was scheduled for regular follow-up.
Discussion(s): GI FL is a B-cell lymphoma with an incidence slightly higher in women and a median age of 65. Occurrence outside of the bone marrow, spleen, or liver is uncommon. Descending incidence within the GI tract is the duodenum, ileum, stomach, and rarely colon. Within the colon, it presents asymptomatically. Definitive diagnosis is by a colonoscopy-obtained tissue staining. Colonoscopy adherence is generally high after the age of 65, given the median age of colorectal cancer incidence is 67 and the availability of Medicare coverage. However, if alternatively approved screening modalities are utilized such as the gFOBT, FIT, FIT-DNA, or flexible sigmoidoscopy, then the diagnosis of a FL might be missed until either mass or metastatic effects become apparent. Diagnostic work-up includes IHC staining for CD-20, CD-36, a follicular cell pattern, increase in B cells, bcl-2, bcl-6, and a 14:18 translocation by FISH or PCR (85% of cases). Investigation into a primary NHL, leukemia, or MDS includes flow cytometry, bone marrow biopsy, and cytogenetics. Increased LDH indicates rapid progression with staging done by PET or pan CTs. Colonic FL have a 10-year survival rate of 80% and an indolent course, so treatment is only indicated if the patient is symptomatic. Treatment for stage 1 is radiation, stages 2-4 is CHO P-R chemotherapy. Adjuvant or refractory treatments include anti-CD20 monoclonal antibodies, such as rituximab or obinutuzumab.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is present in 36-70% of women with polycystic ovary syndrome (PCOS). Both are highly prevalent in subjects with obesity. Androgen overproduction in PCOS promotes a pro-apoptotic environment and may contribute to NAFLD. Our objective was to examine the association between PCOS and NAFLD diagnosis and if PCOS is an independent predictor of advanced fibrosis in patients with NAFLD.
Method(s): In a single-center retrospective analysis of electronic medical records, 625 adult patients ( .18 years old) with a diagnosis of NAFLD from 2018-2019 were divided into 3 cohorts: a female study group with PCOS, female control group without PCOS, and a male control cohort, age-matched to the study group. PCOS diagnosis was based on established PCOS society criteria. Our primary outcome was to assess the stage of liver fibrosis, as defined by histology, Fibroscan, MR elastography, NAFLD fibrosis score (NFS), by the age of initial diagnosis. Additionally, demographic, laboratory and clinical parameters were analyzed to compare the three cohorts. Demographics were analyzed using ANOVA, Pearson's chi-squared, and Kruskal-Wallis methods. Linear regression modeling NAFLD score as a function of age of diagnosis was performed.
Result(s): A total of 625 subjects with NAFLD were seen. Of these, 21 met criteria for the female NAFLD/PCOS study group, 525 in the female NAFLD only control group, and 79 age-matched male subjects with NAFLD. The NAFLD/PCOS females study group were significantly younger than the other two cohorts at time of diagnosis of NAFLD, had the highest BMI of 38.4, highest AST/ALT ratio of 0.92, lowest albumin value of 4.03, highest percentage of patients with physical signs of the male cohort was associated with a 0.7 reduction in NFS compared to women with NAFLD only. Females with NAFLD demonstrate significant difference in the mean NFS and mean age of diagnosis compared to the other 2 groups, while females with both versus males with NAFLD did not (Image 1).
Conclusion(s): Females with PCOS significantly demonstrated NAFLD at an earlier age supported by positive physical and radiological signs, and worse NFS vs. males at the time of initial NAFLD diagnosis.

BACKGROUND:The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE:To examine the effects of LSG on GERD symptoms. METHODS:One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS:respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION/CONCLUSIONS:These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

The dermatology application process is grueling, that is tough to navigate without the proper guidance. This commentary is meant to shed light on the factors that can help applicants stand out in order to be successful in the match. It includes observations from successful applicants from the most recent match process.

In recent years, intragastric balloons (IGBs) have emerged as an efficacious, nonsurgical modality to treat obesity. We present a case in which an IGB caused a gastric ulcer, only unearthed after the novel technique of deflation and early retrieval.

Background and study aims  Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) can be used in patients with unresectable pancreatic ductal adenocarcinoma (PDAC). We performed a systematic review and meta-analysis to evaluate the efficacy of EUS-RFA in treatment of locally advanced unresectable PDAC and other pancreatic tumors. Patients and methods  A comprehensive search was done of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of EUS-RFA for pancreatic lesions. The primary outcome was to evaluate technical and clinical success of the procedure. The secondary outcome was to study overall adverse events (AEs). Results  Thirteen studies reporting 165 EUS-RFA procedures on 134 patients were included. Of 134 patients, 27.94 % (38) had unresectable locally advanced PDAC, 40 % (53) had PNETs, 3 % (4) had metastasis to the pancreas and 30 % (41) had other lesions. The pooled technical success rate calculated out of the total number of procedures was 100 % (95 % CI [99.18 - 100], I2 = 0 %). The pooled clinical success rate calculated out of the total number of patients was 91.58 % (95 % CI [82.5 - 98.08], I2 = 21.5 %). The pooled overall AE rates were 14.67 % (95 % CI [4.77 - 27.46], I2 = 56.19 %) out of which abdominal pain was the most common with 9.82 % (95 % CI [3.34 - 18.24], I2 = 23.76 %). Low to moderate heterogeneity was noted. Conclusion  EUS-RFA has high technical (100 %) and clinical success (91.5 %) rates. Further multicenter trials are needed to further validate our findings.

INTRODUCTION: Timing of certain proton pump inhibitors (PPIs) administration plays an important role in their efficacy. Delayed release capsules of omeprazole and lansoprazole should be taken 30 minutes before breakfast. Studies have demonstrated increased efficacy of PPIs when administered 30-60 minutes before breakfast.
METHOD(S): We performed a retrospective chart review of the patients admitted in the hospital in December 2018. All adult patients in the hospital who were on any PPI were included. Patients on twice daily PPI dosing were excluded. Data was collected on timing of PPI administration. An EHR intervention was implemented where the default frequency for PPI administration was changed from ?daily? to ?before breakfast? which meant it would be given at least 30 minutes before breakfast. After the intervention, chart review was done to collect the data for patients admitted in March 2019.
RESULT(S): Out of 100 patients reviewed before the intervention, none received PPI 30 minutes before breakfast due to EHR order of ?daily? dosing which meant PPI was administration at 10 AM. After the EHR intervention, data of 100 patients on PPI was reviewed. All patients received PPI 30 minutes before the breakfast. This was a 100% improvement from pre-intervention.
CONCLUSION(S): PPIs were not being administered at the optimal time before the intervention. While only some PPIs must be administered 30 minutes before meals, it was decided that all will be administered this way as to simplify discharge instruction for patients (not knowing exactly which PPI the primary team would be discharging them with). A simple EHR intervention was implemented that resulted in 100% compliance with appropriate timing of PPI administration