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Digestive System Diseases - Top 30 Publications

Occupational Animal Exposure Among Persons with Campylobacteriosis and Cryptosporidiosis - Nebraska, 2005-2015.

Campylobacter and Cryptosporidium are two common causes of gastroenteritis in the United States. National incidence rates measured for these pathogens in 2015 were 17.7 and 3.0 per 100,000 population, respectively; Nebraska was among the states with the highest incidence for both campylobacteriosis (26.6) and cryptosporidiosis (≥6.01) (1). Although campylobacteriosis and cryptosporidiosis are primarily transmitted via consumption of contaminated food or water, they can also be acquired through contact with live animals or animal products, including through occupational exposure (2). This exposure route is of particular interest in Nebraska, where animal agriculture and associated industries are an important part of the state's economy. To estimate the percentage of disease that might be related to occupational animal exposure in Nebraska, the Nebraska Department of Health and Human Services (NDHHS) and CDC reviewed deidentified investigation reports from 2005 to 2015 of cases of campylobacteriosis and cryptosporidiosis among Nebraska residents aged ≥14 years. Case investigation notes were searched for evidence of occupational animal exposures, which were classified into discrete categories based on industry, animal/meat, and specific work activity/exposure. Occupational animal exposure was identified in 16.6% of 3,352 campylobacteriosis and 8.7% of 1,070 cryptosporidiosis cases, among which animal production (e.g., farming or ranching) was the most commonly mentioned industry type (68.2% and 78.5%, respectively), followed by employment in animal slaughter and processing facilities (16.3% and 5.4%, respectively). Among animal/meat occupational exposures, cattle/beef was most commonly mentioned, with exposure to feedlots (concentrated animal feeding operations in which animals are fed on stored feeds) reported in 29.9% of campylobacteriosis and 7.9% of cryptosporidiosis cases. Close contact with animals and manure in feedlots and other farm settings might place workers in these areas at increased risk for infection. It is important to educate workers with occupational animal exposure about the symptoms of enteric diseases and prevention measures. Targeting prevention strategies to high-risk workplaces and activities could help reduce disease.

Updated Dosing Instructions for Immune Globulin (Human) GamaSTAN S/D for Hepatitis A Virus Prophylaxis.

GamaSTAN S/D (Grifols Therapeutics, Inc., Research Triangle Park, North Carolina) is a sterile, preservative-free solution of immune globulin (IG) for intramuscular administration and is used for prophylaxis against disease caused by infection with hepatitis A, measles, varicella, and rubella viruses (1). GamaSTAN S/D is the only IG product approved by the Food and Drug Administration for hepatitis A virus (HAV) prophylaxis. In July 2017, GamaSTAN S/D prescribing information was updated with changes to the dosing instructions for hepatitis A preexposure and postexposure prophylaxis indications. These changes were made because of concerns about decreased HAV immunoglobulin G antibody (anti-HAV IgG) potency, likely resulting from decreasing prevalence of previous HAV infection among plasma donors, leading to declining anti-HAV antibody levels in donor plasma (2). No changes in dosing instructions were made for measles, varicella, or rubella preexposure or postexposure prophylaxis.

Transplanting HCV-Infected Kidneys into Uninfected Recipients.

Transplanting HCV-Infected Kidneys into Uninfected Recipients.

Transplanting HCV-Infected Kidneys into Uninfected Recipients.

Predictive factors to diagnosis undifferentiated early gastric cancer after endoscopic submucosal dissection.

It is difficult to predict precisely whether the lesion corresponds to endoscopic resection indication. Furthermore, discrepancy may occur between endoscopic forceps biopsy (EFB) and finally resected specimen, which may be diagnosed as undifferentiated cancer and additional surgery may be required. Our study aimed to evaluate predictive factors to diagnose undifferentiated cancer after endoscopic submucosal dissection (ESD).Among the 532 patients diagnosed by ESD between January 2009 and December 2015, 557 early gastric cancer (EGC) cases were studied. Factors predicting diagnosis of undifferentiated cancer and clinical outcomes of the lesions were retrospectively analyzed.Among the 557 cases with EGC, 535 (96.1%) were diagnosed as differentiated cancer and 22 (3.9%) as the undifferentiated type with ESD. Tumor size was larger (mean size 20.67 vs 13.59 mm, P < .001) and age was lower (60.24 vs 64.50 years, P < .001) in the group with undifferentiated cancer. En bloc resection rate was similar (95.5% vs 95.9%, P = .886), but the complete resection rate was lower (72.7% vs 92.4%, P < .001) in the group with undifferentiated cancer. On multivariate analysis, tumor size ≥10 mm (OR = 11.340, P = .032), age <55 years (OR = 5.972, P = .004), surface redness (OR = 11.562, P = .024), and whitish discoloration (OR = 35.368, P < .001) were predominantly associated with undifferentiated cancer.Young age (<55 years), large tumor size (≥10 mm), surface redness, and whitish discoloration are predictors of undifferentiated cancer, and lesions with these features detected need to be treated cautiously.

Acute vanishing bile duct syndrome after therapy with cephalosporin, metronidazole, and clotrimazole: A case report.

Vanishing bile duct syndrome (VBDS) consists of a series of diseases characterized by the loss of >50% bile duct in portal areas. Many factors are associated with VBDS including infections, neoplasms, and drugs. Antibiotic is one of the most frequently reported causes of VBDS.

Therapeutic efficacy of neuromuscular electrical stimulation and electromyographic biofeedback on Alzheimer's disease patients with dysphagia.

To study the therapeutic effect of neuromuscular electrical stimulation and electromyographic biofeedback (EMG-biofeedback) therapy in improving swallowing function of Alzheimer's disease patients with dysphagia.A series of 103 Alzheimer's disease patients with dysphagia were divided into 2 groups, among which the control group (n = 50) received swallowing function training and the treatment group (n = 53) received neuromuscular electrical stimulation plus EMG-biofeedback therapy. The mini-mental state scale score was performed in all patients along the treatment period. Twelve weeks after the treatment, the swallowing function was assessed by the water swallow test. The nutritional status was evaluated by Mini Nutritional Assessment (MNA) as well as the levels of hemoglobin and serum albumin. The frequency and course of aspiration pneumonia were also recorded.No significant difference on mini-mental state scale score was noted between 2 groups. More improvement of swallowing function, better nutritional status, and less frequency and shorter course of aspiration pneumonia were presented in treatment group when compared with the control group.Neuromuscular electrical stimulation and EMG-biofeedback treatment can improve swallowing function in patients with Alzheimer's disease and significantly reduce the incidence of adverse outcomes. Thus, they should be promoted in clinical practice.

Endoscopic submucosal dissection for large colorectal epithelial neoplasms: A single center experience in north China.

Colorectal endoscopic submucosal dissection (ESD) is a technically difficult procedure with a higher risk of complications, especially for large colorectal epithelial neoplasms. This study aimed to report our experience and clinical outcomes, and to estimate the factors associated with incomplete resection and complications.One hundred forty one colorectal epithelial neoplasms in 130 consecutive patients treated by ESD at the endoscopy center of Tianjin Medical University General Hospital from January 2013 to January 2016 were included. Factors associated with the incomplete resection and perforation were evaluated.The mean colorectal epithelial neoplasm size was 26.5 ± 9.5 (15.0-60.0) mm, the mean procedure time of colorectal ESD was 76.1 ± 48.7 (36.5-195.0) minutes. The en bloc resection rate, the en bloc R0 resection rate, and the curative resection rate, were 93.6% (132/141), 91.5% (129/141), and 88.7% (125/141), respectively. Perforation during colorectal ESD occurred in 7 patients (4.9%), postoperative bleeding occurred in 4 patients (2.8%). There was no recurrence occurred in all patients during follow periods of 13.2 ± 8.6 (6.0-36.0) month. Submucosal fibrosis was the only independent factor related to both incomplete resection (odds ratio [OR] 12.425; 95% confidence interval [CI] 2.501-61.734; P = .002) and perforation (OR 10.646; 95%CI 1.188-95.421; P = .035) of colorectal ESD.Colorectal ESD is a safe and effective technique for en bloc resection of large colorectal epithelial neoplasms. Submucosal fibrosis was independently related to incomplete resection and perforation.

Improved Postoperative Survival for Intraductal-Growth Subtype of Intrahepatic Cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is classified according to the following subtypes: massforming (MF), periductal infiltrating (PI), and intraductal growth (IG). The aim of this study is to measure the association between ICC subtypes and patient survival after surgical resection. Data were abstracted on all patients treated with definitive resections of ICC at a single institution between 2000 and 2011 with at least three years follow-up. Survival estimates were quantified using Kaplan-Meier curves and compared using the log-rank test. There were 37 patients with ICC treated with definitive partial hepatectomies with a median survival of 33.5 months. Tumor stage (P < 0.0001), satellitosis (P < 0.001), lymphovascular space invasion (P = 0.003), and macroscopic subtype (P = 0.003) were predictive of postoperative survival. Disease-free survivals for MF, PI, and IG subtypes, respectively, were 30 per cent, 0 per cent, and 57 per cent (P = 0.017). Overall survivals among ICC macroscopic subtypes were as follows: MF 37 per cent, PI 0 per cent, and IG 71 per cent (P = 0.003). Although limited by the small sample size of this rare cancer, this study demonstrates significant differences among macroscopic subtypes of ICC in both disease-free survivals and overall survivals after definitive partial hepatectomy.

Limited Resection of the Duodenum for Nonampullary Duodenal Tumors, with Review of the Literature.

The surgical management of duodenal pathology is challenging because of its retroperitoneal position and shared blood supply with the pancreas. We present three types of limited resection of the duodenum for the removal of superficial or small nonampullary duodenal (NADL) lesions, and also a review of the English literature regarding management, such as endoscopic resection and limited duodenal resection. Ten cases underwent limited resections of the duodenum for superficial or small NADL lesions from 2011 to 2015. Pancreas-preserving segmental duodenectomy was performed in three cases, local full-thickness resection was performed in three and transduodenal submucosal dissection was performed in four. One patient experienced pancreatic fistula as a postoperative complication. Postoperative pathological diagnosis were adenoma (n = 2), mucosal adenocarcinomas (n = 5), and neuroendocrine tumor (n = 3). Surgical margin was negative in all cases, and no patient has experienced postoperative recurrence or metastasis. Limited resections of the duodenum were feasible and safe procedures for patients with superficial or small NADL lesions. Laparoscopic surgery may be considered in treatment for these tumors. However, the optimal surgical management for superficial or small nonampullary duodenal lesions remains controversial.

Mixed Hepatocellular Carcinoma, Neuroendocrine Carcinoma of the Liver.

We present the case of a 76-year-old male found to have a large tumor involving the left lateral lobe of the liver, presumed to be hepatocellular carcinoma (HCC). After resection, pathologic features demonstrated both high-grade HCC and high-grade neuroendocrine carcinoma (NEC). Areas of NEC stained strongly for synaptophysin, which was not present in HCC component. The HCC component stained strongly for Hep-Par 1, which was not present in the NEC component. The patient underwent genetic analysis for biomarkers common to both tumor cell types. Both tumor components contained gene mutations in CTNNB1 gene (S33F located in exon 3). They also shared mutations in PD-1, PGP, and SMO. Mixed HCC/NEC tumors have been rarely reported in the literature with generally poor outcomes. This patient has been referred for adjuvant platinum-based chemotherapy; genetic biomarker analysis may provide some insight to guide targeted chemotherapy.

Spontaneous Hepatic Hemorrhage: A Single Institution's 16-Year Experience.

Spontaneous hemorrhage from hepatic tumors is an uncommon but serious complication. Recently, interventional radiologic (IR) techniques are being used increasingly in the management of these patients. We report our 16-year experience in managing spontaneous hemorrhage from liver tumors. Twenty-six consecutive patients were diagnosed with spontaneous liver hemorrhage between 1995 and 2011. Initial management was operative in eight, IR in six, and supportive in 12 patients. Of those managed operatively, five were segmentectomies; one hemihepatectomy; one wedge resection; and one packing who later died from coagulopathy. In the IR patients, seven had an angiographic embolization; two required reembolization; one underwent resection of a hepatic adenoma 21 days after angiographic embolization. The malignant lesions included hepatocellular carcinoma (n = 6), angiosarcoma (n = 1), metastatic squamous cell carcinoma (n = 1), metastatic leiomyosarcoma (n = 1), nonsquamous cell carcinoma (n = 1), or metastatic angiosarcoma (n = 1). Benign diseases included hepatic adenoma (n = 5), end-stage liver disease (n = 1), and polycystic liver (n = 1). Spontaneous hemorrhage from the liver occurs evenly from benign or malignant causes, one-third of which are primary liver disease. If the patients presents emergently, angiographic embolization may control the bleeding and allow for elective resection once the sequelae of bleeding have resolved.

Resection of Gastrointestinal Metastases in Stage IV Melanoma: Correlation with Outcomes.

The prognosis of patients with gastrointestinal (GI) melanoma metastases is poor. Surgery renders select patients disease free and/or palliates symptoms. We reviewed our single-institution experience of resection with GI melanoma metastases. A retrospective review was performed on patients who underwent surgery for GI melanoma metastases from 2007 to 2013. Fifty-four patients were identified and separated based on completeness of resection into curative 13 (24%) and palliative 41 (75.9%) groups. Thiry-six (63.2%) were symptomatic preoperatively with bleeding and/or obstruction/pain with 91.7 per cent achieving objective symptom relief. Thirty-day operative mortality was 0 per cent. The most common complication was wound infection (n = 5); major complications like anastomotic leak (n = 1) were uncommon. With a median follow-up of 9.5 months (range 0.2-75.8), median overall survival was not reached (curative) versus 9.53 months (palliative group). Median recurrence-free and progression-free survival after resection were 18.89 and 1.97 months in the curative versus palliative groups, respectively. On multivariate analysis, resection to no clinical evidence of disease (P = 0.012) and presence of single metastases (P = 0.031) were associated with improved overall survival. Surgery for GI metastases from melanoma provides symptomatic relief without major morbidity. Fewer metastases and curative resection were associated with improved survival.

The Ferguson Operating Anoscope for Resection of T1 Rectal Cancer.

The Ferguson Operating Anoscope (FOA) is a surgical instrument, which can facilitate transanal excision of appropriate rectal tumors within 15 cm of the anal verge. Previous work showed low recurrence (4.3%) for favorable T1 tumors (no lymphovascular invasion, well/moderate differentiation, negative margins). This follow-up study evaluates outcomes in rectal cancer excised with FOA at a tertiary care center. T1 rectal cancer patients were identified in a prospectively maintained database. Tumor pathology and patient characteristics were reviewed. Primary outcomes include tumor recurrence and patient and disease-free survival. Secondary outcomes are quality of excision (intact specimen). Twenty-eight patients had pathologic stage T1 rectal cancer (average 8 ± 2.6 cm from the anal verge). Final path demonstrated 14 per cent to be well differentiated, 82 per cent moderately differentiated, and 93 per cent without angiolymphatic invasion. All specimens removed were intact. One patient had a true local recurrence and underwent a salvage operation 24 months after her index operation. Patient survival was 96.4 per cent (n = one death from primary lung cancer) at median follow-up 64 ± 35 months. With appropriate tumor selection and quality of initial resection, FOA has demonstrated utility in achieving optimal oncologic resection of T1 rectal tumors.

Independent Preoperative Predictors of Prolonged Length of Stay after Laparoscopic Appendectomy in Patients Over 30 Years of Age: Experience from a Single Institution.

Prompt discharge after laparoscopic appendectomy (LA) is a marker of quality of care, fiscally desirable and feasible in select patients. Patients over 30 comprise a more heterogeneous cohort known to experience worse outcomes after LA. We aimed to identify easily available preoperative risk factors portending a postoperative length of stay ≥2 days among patients above age 30. In this investigation, 296 included patients from a single institution who underwent LA for acute appendicitis from 2010 to 2014 were retrospectively reviewed for preoperative demographics, laboratory studies, comorbidities, presentation characteristics, radiographic finding, and other rationally selected factors for association with postoperative length of stay ≥2 days. Bivariate and multivariate analysis was conducted to determine independent risk factors, which were subsequently modeled via receiver-operating characteristic curve generation and Kaplan-Meier analysis. "Classic" presentation [odds ratio (OR) = 0.5, P = .02], elevated red cell distribution width (RDW; OR = 1.5/% increase, P = 0.004) as well as evidence of rupture on CT (OR = 6.9, P < 0.001) were independently associated with postoperative length of stay ≥ 2 days. Modeling length of stay using these factors generated an area under the curve of 0.713 ± 0.037. Kaplan-Meier analysis of "classic" presentation, elevated RDW, and evidence of rupture on CT through the fifth postoperative day generated log-rank P values of 0.02, 0.05, and ≤ 0.001, respectively. In summary, lack of "classic" presentation, elevated RDW, and CT evidence of rupture are novel risk factors for prolonged postoperative length of stay in LA patients over 30. These findings may help target patients most appropriate for prompt discharge.

National Disparities in Surgical Approach to T1 Rectal Cancer and Impact on Outcomes.

This study investigated disparities between patients who had local excision versus radical resection for T1 rectal cancer. A retrospective analysis was performed using the National Cancer Data Base, 2004 to 2011. Inclusion criteria consisted of patients with T1, N0 rectal adenocarcinoma that were <3 cm, well or moderately differentiated without perineural invasion. Patients were stratified based on local excision and radical surgery. The primary outcome was overall survival (OS). Secondary outcomes included 30-day mortality, unplanned readmission rates, and postoperative length of stay. A total of 2235 patients were identified; 1335 (59.7%) underwent local excision and 900 (40.3%) had radical surgery. Overall, radical surgery was associated with an improved 5-year OS rate compared to local excision (0.86 vs 0.78, P = 0.009), increased unplanned readmission (6.5% vs 2.7%, P < 0.001), and longer postoperative length of stay (6.9 days vs 3.1 days, P < 0.001). For patients who had local excision, insurance status was an independent predictor of OS. Compared to patients with private insurance, those with government plans or no insurance had poorer OS (hazard ratio = 1.77 and 17.45, respectively, P = 0.006). Further study is warranted to understand the reasons accounting for this disparity in surgical approach to T1 rectal cancer.

Disparities in Mangement of Patients with Benign Colorectal Disease: Impact of Urbanization and Specialized Care.

Disparities in the management of patients with various medical conditions are well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with noncancerous benign colorectal diseases. We hypothesized that there is no difference among rural versus urban centers (UC) in the surgical management for noncancerous benign colorectal diseases. The national estimates of surgical procedures for benign colorectal diseases from the National Inpatient Sample database 2011 representing 20 per cent of all in-patient admissions were abstracted. Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer and those who underwent emergency surgery were excluded. The population was divided into two groups: urban and rural, based on the location of treatment. Outcome measures were in-hospital complications, mortality, and hospital costs. Subanalysis of UC was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed. A total of 20,617 patients who underwent surgical intervention for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. Of the UC, 38.3 per cent centers had colorectal surgeons. Patients managed in UC had lower complication rate (7.6% vs 10.2%, P < 0.001), shorter hospital length of stay (4.7 ± 3.1 vs 5.9 ± 3.6 days, P < 0.001), and higher hospital costs ($56,820 ± $27,691 vs $49,341 ± $2,598, P < 0.001) compared with rural centers. On subanalysis, patients managed in UC with colorectal surgeons had 11 per cent lower incidence of in-hospital complications [odds ratio: 0.89 (95% confidence interval: 0.76-0.94)] and a shorter hospital length of stay [Beta: -0.72 (95% confidence interval: -0.81 to -0.65)] when compared with patients managed in UC without colorectal specialization. Disparities exit in outcomes of the patients with noncancerous benign colorectal diseases managed surgically in urban versus rural centers. Specialized care with colorectal surgeons at UC helps reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost-effective manner across rural as well as UC are warranted.

Assessment of liver fibrosis with acoustic radiation force impulse in patients with chronic hepatitis C.

Coeliac disease: further evidence that biopsy is not always necessary for diagnosis.

Avoiding biopsy for initial diagnosis for celiac disease: are we there yet?

Editorial: Widening the Use of the Functional Lumen Imaging Probe to Kids With Eosinophilic Esophagitis: Esophageal Narrowing is not Just an Adult Problem.

The functional lumen imaging probe (FLIP) provides objective measurement of esophageal distensibility, thus offering a unique and potentially valuable assessment in eosinophilic esophagitis (EoE). Menard-Katcher and colleagues report the first study evaluating use of FLIP in pediatric patients that demonstrated a reduction in esophageal distensibility in patients with EoE compared to patients without EoE. An increase in esophageal distensibility was observed with age among pediatric patients without EoE, but not among those with EoE. While this study further supports the promise of esophageal distensibility assessment in EoE, future work remains needed to optimize FLIP utilization in both research and clinical settings.

Editorial: Severe Acute Liver Injury: Cause Connects to Outcome.

Severe acute liver injury (ALI) is a common condition with little objective study of its natural history and outcomes. In this paper by Koch et al. and the Acute Liver Failure (ALF) Study Group, the authors utilize a consensus definition of ALI requiring newly elevated bilirubin, alanine aminotransferase (ALT), and international normalized ration (INR) without evidence of hepatic encephalopathy (HE), with HE as the key differentiator of ALI from ALF. They show significantly higher rates of progression to ALF, liver transplantation, or death in non-acetaminophen etiologies of ALI. This study's findings provide guidance in supporting careful allocation of scarce critical care and liver transplant resources for ALI patients.

Editorial: Direct Antiviral Agents Eliminate the Age Barrier to Treatment of Chronic Hepatitis C.

Interferon-based therapy for chronic hepatitis C in elderly patients, who are at greatest risk for advanced disease, resulted in low sustained virologic response rates, poor tolerability, a significant frequency of adverse events leading to treatment discontinuation, and the occasional precipitation of hepatic decompensation. In contrast, in the era of direct-acting antiviral therapy, age is no longer a predictor of response rates in those with or without cirrhosis and adverse events are much less frequent. The benefits of treatment of the elderly appear to outweigh potential risks but long-term follow-up is necessary, particularly in those with advanced disease.

Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening Completion: A Randomized Clinical Trial.

Mailed fecal immunochemical test (FIT) outreach is more effective than colonoscopy outreach for increasing 1-time colorectal cancer (CRC) screening, but long-term effectiveness may need repeat testing and timely follow-up for abnormal results.

Effect of Physician Notification Regarding Nonadherence to Colorectal Cancer Screening on Patient Participation in Fecal Immunochemical Test Cancer Screening: A Randomized Clinical Trial.

Increasing participation in fecal screening tests is a major challenge in countries that have implemented colorectal cancer (CRC) screening programs.

Efficacy of Additional Surgical Resection After Endoscopic Submucosal Dissection for Superficial Esophageal Cancer.

This study aimed to investigate the efficacy of additional surgical resection (ASR) after endoscopic submucosal dissection (ESD) for superficial esophageal cancer (SEC).

Surgical Strategy for T1 Duodenal or Ampullary Carcinoma According to the Depth of Tumor Invasion.

To investigate the utility of local resection (LR) for T1 duodenal carcinoma and T1 ampullary carcinoma.

Incidence and Oncological Implications of Previously Undetected Tumor Multicentricity Following Pancreaticoduodenectomy for Pancreatic Adenocarcinoma in Patients Undergoing Salvage Pancreatectomy.

The risk for multicentricity of pancreatic adenocarcinoma remains unclear and the question whether pancreaticoduodenectomy represents sufficient oncological treatment for patients with ductal adenocarcinoma of the head of the pancreas needs further investigation.

Targeted Delivery of Cordycepin to Liver Cancer Cells Using Transferrin-conjugated Liposomes.

Cordycepin is an endogenous nucleoside with significant anticancer biological activity. The objective of this study was to develop targeted liposomes to improve solubility and biological activity of cordycepin.