Current status of intestinal and multivisceral transplantation.

Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure (IF). Traditionally, patients with IF have been relegated to lifelong parenteral nutrition (PN) once surgical and medical rehabilitation attempts at intestinal adaptation have failed. Over the past two decades, however, outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation. This has become possible through relentless efforts in the standardization of surgical techniques, advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care. Four types of intestinal transplants include isolated small bowel transplant, liver-small bowel transplant, multivisceral transplant and modified multivisceral transplant. Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections. From an experimental stage to the currently established therapeutic modality for patients with advanced IF, outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s. Studies have shown that intestinal transplant is cost-effective within 1-3 years of graft survival compared with PN. Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation. Future research should focus on detecting biomarkers of early rejection, enhanced immunosuppression protocols, improved postoperative care and early referral to transplant centers.

Malnutrition: laboratory markers vs nutritional assessment.

Malnutrition is an independent risk factor for patient morbidity and mortality and is associated with increased healthcare-related costs. However, a major dilemma exists due to lack of a unified definition for the term. Furthermore, there are no standard methods for screening and diagnosing patients with malnutrition, leading to confusion and varying practices among physicians across the world. The role of inflammation as a risk factor for malnutrition has also been recently recognized. Historically, serum proteins such as albumin and prealbumin (PAB) have been widely used by physicians to determine patient nutritional status. However, recent focus has been on an appropriate nutrition-focused physical examination (NFPE) for diagnosing malnutrition. The current consensus is that laboratory markers are not reliable by themselves but could be used as a complement to a thorough physical examination. Future studies are needed to identify serum biomarkers in order to diagnose malnutrition unaffected by inflammatory states and have the advantage of being noninvasive and relatively cost-effective. However, a thorough NFPE has an unprecedented role in diagnosing malnutrition.

Cutis laxa presenting as recurrent ileus.

Cutis laxa (CL) is a rare connective tissue disorder characterized by phenotypic appearance of loose and redundant skin. CL can be congenital or acquired. Congenital forms include autosomal dominant, autosomal recessive and X-linked recessive. Apart from cutaneous abnormalities, CL can present with visceral involvement. In this article, we report a case of CL presenting as recurrent ileus.

Adenoma detection rate in high-risk patients differs from that in average-risk patients.

BACKGROUND: Adenoma detection rates (ADRs) are established as quality targets in average-risk (AR) individuals undergoing colorectal cancer (CRC) screening colonoscopy. Little is known about the ADR in high-risk (HR) individuals undergoing index or surveillance colonoscopy. OBJECTIVE: To determine and compare ADR in HR versus AR individuals undergoing colonoscopy. DESIGN AND SETTING: Retrospective study, tertiary care center. PATIENTS AND INTERVENTION: We reviewed records of 7357 patients who underwent colonoscopy by 66 multispecialty endoscopists at our institution during the period 2008 to 2009. Both screening and surveillance colonoscopies in AR and HR patients for CRC were studied. HR patients were further divided into 3 subgroups: those with a (1) personal history of polyps (PHP), (2) family history of polyps (FHP), and (3) family history of CRC (FHCRC). Multivariable logistic regression analysis was performed to evaluate differences in ADR between the groups after adjusting for possible confounders. MAIN OUTCOME MEASUREMENTS: ADR in HR patients. RESULTS: The study included 4141 patients, of whom 2170 were AR and 1971 were HR. Patients in the HR group were older (64.5 ± 9.1 years vs 59.1 ± 7.9 years, P < .001). HR patients were more likely to have adenomas (30.7% vs 25.6%, P < .001). Adenomas were detected more often in the proximal colon than in the distal colon (29.3% vs 21.0%, P < .001 and 22.8% vs 15.8%, P < .001, respectively). Patients with a PHP had the highest ADR (33.1%, P < .001). However, after adjusting for confounders, HR status was not found to be associated with ADR (odds ratio [OR] 1.2; 95% confidence interval [CI], 0.93-1.6; P = .15 for females and 0.93; 95% CI, 0.70-1.2; P = .61 for males). HR females were found to have a 40% greater likelihood of having proximal adenomas than AR females (1.4; 95% CI, 1.01-2; P = .04). LIMITATIONS: Retrospective design, single tertiary center. CONCLUSIONS: Patients with a PHP have a significantly higher ADR compared with AR patients. Defining a minimum target ADR for individuals with a PHP undergoing surveillance colonoscopy is important.

Perspectives of physicians regarding screening patients at risk of hepatocellular carcinoma.

BACKGROUND AND AIMS: Screening patients at risk for hepatocellular carcinoma (HCC) facilitates early detection of disease, with improved outcome. The most common causes of HCC include chronic viral hepatitis infection-namely hepatitis B, hepatitis C, and cirrhosis. The aim of this study was to assess the awareness of screening among physicians involved in the management of patients at risk for HCC. METHODS: Three hundred physicians from three academic centers were invited to participate in a mailed survey questionnaire. The main outcome measure was physicians' knowledge of the current HCC screening guidelines. Demographic and clinical variables were obtained from the survey questionnaire. RESULTS: A total of 177 (59.0%) out of the 300 invited physicians responded to the survey questionnaire, including faculty members (n = 129), residents (n = 46), and fellows (n = 2). The specialty areas of the responding physicians were internal medicine (62.1%), family medicine (16.4%), gastroenterology (15.3%), oncology (3.4%) and others (2.8%). The number of physicians who performed HCC screening in patients with cirrhosis secondary to chronic hepatitis B and chronic hepatitis C infection were 163 (92.1%) and 167 (94.4%), respectively; 35.0% of them used alpha-fetoprotein (AFP) every 6 months, while 22.0% used imaging modalities every 6 months to screen for HCC. Further, 22 physicians (12.4%) did not check for serum AFP levels and 33 (18.6%) never used imaging to screen for HCC. CONCLUSION: The majority of the participating physicians screen high-risk patients for HCC. However, the most appropriate modality of screening (i.e. imaging) is not employed by most physicians and there is greater reliance on AFP levels.

Prevalence and predictors of vitamin D deficiency and response to oral supplementation in patients receiving long-term home parenteral nutrition.

UNLABELLED: Previous studies have suggested a high prevalence of vitamin D deficiency in patients receiving long-term home parenteral nutrition (HPN). The aim of this study was to determine the prevalence and predictors of vitamin D deficiency in long-term HPN patients. METHODS: A retrospective, institutional review board-approved study was performed on all adult patients followed by the Cleveland Clinic HPN program receiving HPN therapy >6 months between 1989 and 2013 with a 25-(OH) D3 level reported. Patients were categorized by serum vitamin D status as follows: sufficient, insufficient, and deficient with respective 25-(OH) D3 levels of ≥30 ng/mL, 20-30 ng/mL, and <20 ng/mL. RESULTS: Seventy-nine patients were categorized based on serum vitamin D status as follows: 35 (44.3%) deficient, 24 (30.4%) insufficient, and 20 (25.3%) sufficient. The mean age of the cohort at the initiation of HPN was 52.0 ± 12.7 years, and 26 (32.9%) were male. The median HPN duration was 39 months, and the most common indication was inflammatory bowel disease (36.7%). Most (82.3%) patients had at least 1 prescription of oral vitamin D supplement (50,000 International Units) during this time. History of jejunal resection (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.9-15.1; P = .002) and lack of oral vitamin D supplementation (OR, 0.7; 95% CI, 0.52-0.93; P = .038) were the strongest predictors of vitamin D deficiency. CONCLUSION: Vitamin D deficiency is common among patients receiving long-term HPN despite oral supplementation.

Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist.

BACKGROUND & AIMS: The adenoma detection rate (ADR) is an important measure of the quality of colonoscopy; it is associated with interval colorectal cancer and varies among sexes and locations. Recommended indicators of competence for colonoscopy include minimal ADRs >25% for average-risk men and >15% for women. These ADRs are rigorous, so polypectomy detection rate (PR) has been suggested as a surrogate. Colonoscopy is less effective in the proximal colon, where interval cancers are more likely to occur. We compared ADRs and PRs in different segments of colon and between sexes. METHODS: We performed a cross-sectional review of findings from 2167 screening colonoscopies performed by 65 endoscopists on average-risk outpatients at the Cleveland Clinic, 2008-2009. We reviewed colonoscopy and pathology reports of randomly selected procedures (mean, 33 ± 16 procedures per endoscopist). We calculated PRs, ADRs, and correlation between PR and ADR for each colon segment and sex. RESULTS: The mean overall PR was 42% ± 16.7%, and ADR was 25% ± 3.3%. The correlation between overall ADR and PR was strong (r = 0.80). PR of 40% in men and 30% in women correlated with the established minimum benchmark ADRs of 25% and 15% for men and women, respectively. PR was more strongly correlated with ADR in the proximal colon (r = 0.92) than the distal colon (r = 0.58). The correlation was stronger in men than in women, as well as in the entire colon (r = 0.88 vs 0.75), the proximal colon (r = 0.91 vs 0.87), and the distal colon (r = 0.75 vs 0.55). The advanced ADR was 4% and did not correlate with PR (r = 0.32). CONCLUSIONS: On the basis of a review of findings from screening colonoscopies, overall PR correlates with ADR for the entire colon, but PR and ADR correlate most strongly for the proximal colon, where many adenomas can be missed and interval cancers develop. The correlation between PR and ADR is weaker for women than men and for distal colon. If PR is used as a surrogate for ADR, colon location and patient sex should be considered.

Relationship between type-2 diabetes and use of metformin with risk of colorectal adenoma in an American population receiving colonoscopy.

The aim of this study is to explore the relationship between type-2 diabetes, its treatments (Use of metformin) and the development of colorectal adenoma. Colonoscopy reports from a total of 66 endoscopists in one big hospital in midwest during 2008-2009 were reviewed. Colonoscopy findings including quality of preparation, polyp size, location, morphology, pathology and history of diabetes and metformin treatment were retrieved. Of the 7382 colonoscopy reports were reviewed, 3465 average risk patients were included in our final analysis. The pathologically proven Adenoma detection rate (ADR) in total population was 24.6 % (30.2% in Men and 19.2% in Women). Old age and male sex were significantly associated with increasing risk of colorectal adenoma. Type-2 diabetes was associated increased risk of colorectal adenoma (OD 1.35, 95% confidence interval 1.08-1.70, p=0.009). A total of 426 subjects (12.29%) had diabetes and 405 of these subjects (11.7%) had type-2 diabetes. Within diabetic patient group, people who were taking metformin have significantly lower risk of colorectal adenoma (OD 0.55, 95% confidence interval 0.34-0.87, p=0.011). Diabetic subjects have increased risk of developing colorectal adenoma. Our study also supports the beneficial effect of metformin in development of colorectal adenoma.