Faculty Bibliography

Kwashiorkor syndrome is a form of severe protein-energy malnutrition characterized by protein deficiency and bilateral extremity swelling. Worldwide, most affected regions include Southeast Asia, South Africa and Central America; it is rare in developed countries such as the USA. We report a case of profound kwashiorkor in a 38-year-old male with an underlying psychiatric disorder and restricted diet who presented with extensive abdominal distention and systemic findings indicative of protein malnutrition.

This report describes what we believe is the first reported case of clinically significant cholestasis and acute liver injury within three days of meropenem therapy. An 83-year-old Hispanic female was admitted for sepsis of unknown origin and was started on intravenous meropenem. Three days following initiation of the antibiotic, the patient developed mixed hepatocellular and cholestatic liver injury with jaundice and pruritus. Possible causes of cholestasis were excluded after extensive investigations. A drug-induced liver injury was suspected and meropenem was discontinued. Following discontinuation of meropenem, the patient demonstrated symptomatic and laboratory improvements, and her liver enzymes and bilirubin levels were normalized.

BACKGROUND The novel COVID-19 disease caused by the SARS-CoV-2 virus is a highly infectious disease that originated in Wuhan, China, and has rapidly spread throughout the world. In addition to respiratory complications, the virus has also been implicated in damage to other organ systems as well as coagulopathy. The present report describes the first presumptive case of COVID-19-associated acute superior mesenteric artery thrombosis and acute intestinal ischemia. CASE REPORT A 55-year old man presented to the emergency department with nausea, generalized abdominal pain and diarrhea; he denied having a fever or any respiratory symptoms. Computed tomography (CT) of the abdomen and pelvis revealed bilateral pulmonary ground-glass opacities. He tested positive for SARS-CoV-2, and was treated with hydroxychloroquine, azithromycin and ceftriaxone, and was discharged home after five days of inpatient treatment. One week later, the patient returned with recurrent nausea, vomiting and worsening diffuse abdominal pain. A CT scan of the abdomen showed a 1.6-cm clot, causing high grade narrowing of the proximal superior mesenteric artery and bowel ischemia. The patient emergently underwent exploratory laparotomy, thromboembolectomy and resection of the ischemic small bowel. A post-operative complete hypercoagulable workup was unrevealing. CONCLUSIONS Despite the absence of respiratory symptoms, patients infected with SARS-CoV-2 may show atypical presentations, such as gastrointestinal symptoms. Clinicians managing patients with suspected or confirmed SARS-CoV-2 infection during the COVID-19 pandemic should monitor these patients for potential complications that may arise from this disease.

BACKGROUND:Quality of bowel preparation and patient knowledge remains a major barrier for completing colorectal cancer screening. Few studies have tested unique ways to impact patient understanding centering on interactive computer programs, pictures, and brochures. Two studies explored instructional videos but focused on patient compliance and anxiety as endpoints. Furthermore, excessive video length and content may limit their impact on a broad patient population. No study so far has studied a video's impact on preparation quality and patient understanding of the colonoscopy procedure. METHODS:We conducted a single blinded prospective study of inner city patients presenting for a first time screening colonoscopy. During their initial visit patients were randomized to watch an instructional colonoscopy video or a video discussing gastroesophageal reflux disease (GERD). All patients watched a 6 minutes long video with the same spokesperson, completed a demographic questionnaire (Supplemental Digital Content 1, http://links.lww.com/JCG/A352) and were enrolled only if screened within 30 days of their visit. On the day of the colonoscopy, patients completed a 14 question quiz of their knowledge. Blinded endoscopist graded patient preparations based on the Ottawa scale. All authors had access to the study data and reviewed and approved the final manuscript. RESULTS:Among the 104 subjects enrolled in the study, 56 were in the colonoscopy video group, 48 were in GERD video group, and 12 were excluded. Overall, 48% were male and 52% female; 90% of patients had less than a high school education, 76% were African American, and 67% used a 4 L split-dose preparation. There were no differences between either video group with regard to any of the above categories. Comparisons between the 2 groups revealed that the colonoscopy video group had significantly better Ottawa bowel preparation score (4.77 vs. 6.85; P=0.01) than the GERD video group. The colonoscopy video group also had less-inadequate repeat bowel preparations versus the GERD video group (9% vs. 23%; P<0.01). The overall score on the knowledge questionnaire (Supplemental Digital Content 1, http://links.lww.com/JCG/A352) was significantly higher in the colonoscopy video group as compared with the GERD video group (12.77 vs. 11.08; P<0.001. In all patients the overall quiz score positively correlated with preparation quality (odds ratio, 2.31; confidence interval, 1.35-3.94; P<0.001). CONCLUSIONS:Our unique population represented an overwhelmingly under-educated (85% had a high school education or less) and minority group (76% African American). They are one of the most at risk of having multiple barriers such as comprehension and reading difficulties resulting in poor preparation examinations and no shows to procedures. Our instructional video proved to be high yield in this population. The patients assigned to watch the colonoscopy video showed a significant increase in "excellent" grade adequate bowel preparation quality by >23% and a significant decrease in "inadequate" bowel preparations by almost 50%. Our study proves that an educational video can improve both comprehension with regard to all aspects of colonoscopy. ClinicalTrials.gov number, NCT02906969.

Drug-induced liver injury (DILI) is an important and often elusive cause of iatrogenic hepatic injury which complicates its recognition and treatment. We describe a rare case of severe liver injury in a previously healthy individual associated with a commonly used and reportedly safe soy protein powder supplement. Discontinuation of the supplements and initiation of ursodeoxycholic acid provided symptomatic relief, decreased pruritus, and resulted in a resolution of hepatic panel labs.