Differences in gastroenterologists' self-reported race affect fear levels during endoscopic procedures: Results from a us national survey

Introduction: Racial disparities continue to exist during the COVID-19 pandemic. A systematic review found that Black and Hispanic patients experience disproportionate COVID-19 hospitalizations and higher morbidity and mortality. Low level evidence in that review suggested that Asians' outcomes are similar to those of non-Hispanic whites. As most practicing gastroenterologists are White, and as endoscopies are aerosolizing procedures risking viral transmission, this study evaluates differences in fear levels among gastroenterologists from different racial backgrounds. Methods: This IRB-approved multi-center cross-sectional study used a snowball sampling approach to disseminate a 42-question survey, pilot-tested for reliability and validity, to gastroenterologists across different geographic locations in the US. Fear levels during endoscopic procedures on suspected/confirmed COVID-19 patients were assessed using a 1-10 Likert scale, with 10 being the greatest fear. Fear was assessed at three points for upper and lower endoscopies: first procedure, subsequent before the COVID-19 vaccine, and subsequent after the vaccine. Data was analyzed using Pearson's chi-squared, Mann-Whitney U, and Wilcoxon rank tests and significance was determined at p<0.05 Results: We analyzed 69 responses from gastroenterologists at 30 sites. Of the respondents, 39 selfidentified as white, 3 as Black, 6 as Latinx, 4 as Middle Eastern, and 17 as Asian. Due to the small sample size, non-White racial groups were combined to evaluate the impact of race on reported fear level reported by gastroenterologists who performed endoscopies during the COVID-19 pandemic. Fear levels at the six assessed points were not significantly different when comparing Asians to Whites, and when comparing Blacks and Latinx to Whites. However, Asians, Blacks, and Latinx had a higher fear level post vaccine when performing lower endoscopies compared to Whites (mean (m) 53.59, standard deviation (SD)=2.83 vs m=1.94, SD=1.083, respectively;P=0.045). Conclusion: While results can be due to chance due to the small sample size and survey response bias, our study suggests that after receiving the COVID-19 vaccine, minority endoscopists experienced greater fear than White endoscopists while performing lower endoscopies. It is possible that the disproportionate COVID-19 disease burden in Black and Hispanic communities negates the decrease in fear levels that was experienced by White endoscopists even after receiving the COVID-19 vaccine..

A rare care of pancreatic neuroendocrine tumor and hyperammonemic encephalopathy

Introduction: Hyperammonemic encephalopathy infrequently occurs as the presenting manifestation of a pancreatic neuroendocrine tumor (PNET) without associated hepatic failure. We present a rare case of a patient with neurologic decline requiring hospitalization who was diagnosed with a PNET and hyperammonemic encephalopathy without liver failure. Case Description/Methods: A 59-year-old male attorney with hypertension presented to his primary care physician with a bilateral intention tremor and 2 weeks later developed progressively worsening cognition. His medical history was otherwise unremarkable. Upon hospitalization, vital signs were normal. A neurologic exam showed 1/4 recall and impaired attention. Labs revealed an elevated ammonia (219 mg/dL) and total bilirubin of 5.9 mg/dL (indirect 4.1 mg/dL). His CBC, CMP, AST/ALT/Alkaline phosphatase, coagulation panel, heavy metal screen, B1, B6, B12, folate, HIV, TSH, RPR, Lyme, infectious evaluation (including COVID), and lumbar puncture were normal. A brain MRI showed nonspecific bilateral basal ganglia changes. A RUQ ultrasound showed a pancreatic mass. His mental status improved after 2 days of lactulose titrated to 3-4 soft bowel movements daily. A chest / abdominal / pelvic CT scan revealed an 11.3 cm heterogeneous pancreatic mass encasing the splenic artery and abutting greater than 50% of the superior mesenteric vein, without evidence of pulmonary or hepatic metastases. CA 19-9 was 13 U/mL. Ultrasound-guided biopsy revealed a well-differentiated neuroendocrine tumor (WHO Grade 2) positive for synaptophysin, Cam 5.2, Chromogranin A, Ki67 5%, and mitotic count < 2/5 mm 2. The patient underwent an open distal pancreatectomy and splenectomy;a liver nodule, positive for well-differentiated neuroendocrine cells, was found. 5/65 lymph nodes were positive for metastatic disease. Pathologic stage was T3N1M1a. A PET scan, done approximately a month after surgery, showed mild metabolic activity in the pancreatic body and multiple liver metastases not seen on CT scan. Currently, the patient is being followed by oncology and is receiving Lanreotide. Discussion: This case is unusual because the patient presented with encephalopathy without evidence of hepatic failure. It is postulated that the encephalopathy was the result of microvascular portosystemic shunting due to unrecognized hepatic metastases. This case study emphasizes the potential need for advanced imaging in patients with PNET and encephalopathy when initial studies suggest no evidence of hepatic failure.

Campylobacter and E. Coli in a COVID Patient With Diarrhea: A Complicated Scenario

INTRODUCTION: Multiple studies have attempted to characterize the signs and symptoms of infection with SARS-CoV-2 (COVID-19). While fever and respiratory symptoms remain the most common manifestations, gastrointestinal issues including abdominal pain, nausea, vomiting, and diarrhea have been increasingly reported. The etiology of diarrhea in SARS-CoV-2 has not been fully elucidated, but it may be multifactorial. This is a rare case of a COVID-infected patient with diarrhea and multiple gastrointestinal organisms. CASE DESCRIPTION/METHODS: A 59 year old male nursing home resident presented to the hospital with dyspnea, cough, fever, nausea and diarrhea. On arrival, he was febrile (T 38.1 C), mildly tachycardic with an oxygen saturation of 96% breathing room air. His abdomen was soft with diffuse, mild tenderness. Labs showed a normal white blood cell count, but lymphopenia. His chemistry panel and liver enzymes were normal. D-dimer was elevated . 2. He was SARS-CoV-2 positive. Supportive care and therapeutic anticoagulation was initiated. The next day, the patient continued to have frequent diarrhea with streaking of bright red blood. Stool PCR testing revealed Campylobacter and enteropathogenic E.coli. He was started on azithromycin, his anticoagulation was held, and his hematochezia and diarrhea slowly improved. DISCUSSION: The regular use of antibiotics in acute diarrheal illness is generally not recommended unless the risk of complications from diarrheal illness outweigh the risks associated with antibiotic use. Additionally, in diarrhea associated with Shiga-toxin producing E. Coli strains, antibiotic use is associated with higher rates of hemolytic uremic syndrome. In this patient, it was determined that his symptoms were severe enough to warrant antibiotics. Azithromycin was chosen due to its activity against Campylobacter and the potential benefit in COVID-19 infection due to inherent antiinflammatory properties. Intestinal inflammation and diarrhea in SARS-CoV-2 has been hypothesized to result from viral damage to ACE-2 receptors. However, the severity of diarrhea in this patient with potentially infectious enteric bacteria prompted antibiotic administration. The presence of multiple gastrointestinal organisms has rarely been reported in COVID patients. It is difficult to determine which enteric organisms are pathogenic and which may be colonizers. Clinicians must carefully evaluate the potential risks and benefits of initiating antimicrobials for diarrhea in patients with SARS-CoV-2.