Brunner's gland hyperplasia: A rare cause of gastrointestinal bleeding.

Brunner's gland hyperplasia (BGH) is an unusual entity that presents with large duodenal polyp or mass and rarely causes gastrointestinal bleeding. It is usually asymptomatic and often an incidental finding during the esophagoduodenoscopy (EGD). However, most of the cases are benign. We encounter a 40 years old man who presented in Emergency Room with melena. EGD revealed solitary, large duodenal polyp in second part of duodenum and later histopathological findings were consistent with BGH.

Increased main pulmonary artery diameter and main pulmonary artery to ascending aortic diameter ratio in smokers undergoing lung cancer screening.

OBJECTIVES: Pulmonary hypertension (PH) is a progressive, potentially fatal disease, difficult to diagnose early due to non-specific nature of symptoms. PH is associated with increased morbidity and death in many respiratory and cardiac disorders, and with all-cause mortality, independent of age and cardiopulmonary disease. The main pulmonary artery diameter (MPA), and ratio of MPA to adjacent ascending aorta (AA), MPA:AA, on Chest CT are strong indicators of suspected PH. Our goal was to determine the prevalence of abnormally high values of these indicators of PH in asymptomatic low-dose CT (LDCT) screening participants at risk of lung cancer, and determine the associated risk factors. METHODS: We reviewed consecutive baseline LDCT scans of 1949 smokers in an IRB-approved study. We measured the MPA and AA diameter and calculated MPA:AA ratio. We defined abnormally high values as being more than two standard deviations above the average (MPA ≥ 34 mm and MPA:AA ≥ 1.0). Regression analyses were used to identify risk factors and CT findings of participants associated with high values. RESULTS: The prevalence of MPA ≥ 34 mm and MPA:AA ≥ 1.0 was 4.2% and 6.9%, respectively. Multivariable regression demonstrated that BMI was a significant risk factor, both for MPA ≥ 34 mm (OR = 1.07, p < 0.0001) and MPA:AA ≥ 1.0 (OR = 1.04, p = 0.003). Emphysema was significant in the univariate but not in the multivariate analysis. CONCLUSIONS: We determined that the possible prevalence of PH as defined by abnormally high values of MPA and of MPA:AA was greater than previously described in the general population and that pulmonary consultation be recommended for these participants, in view of the significance of PH.

Current Management of Alcohol-Associated Liver Disease.

Alcohol consumption is a major risk factor for various diseases worldwide and is one of the most common causes of chronic liver disease. Alcohol use has risen over the past 30 years and is forecast to continue to rise. Concurrently, there has been an increased incidence of alcohol-associated liver disease (ALD). Alcohol use, regardless of the amount, leads to years of health loss across populations when considering the strong association between alcohol consumption and overall disease burden. Given the rising incidence of ALD and associated mortality, it is imperative to study the underlying factors driving these trends. This article summarizes the diagnosis and management of ALD, with a focus on various screening and prognostic tools and treatments for alcohol-associated hepatitis.

Safety of computed tomography in patients with cardiac rhythm management devices: assessment of the U.S. Food and Drug Administration advisory in clinical practice.

OBJECTIVES: To assess the safety of computed tomography (CT) imaging in patients with cardiac rhythm management (CRM) devices, which was subject to an advisory from the U.S. Food and Drug Administration (FDA) in 2008. BACKGROUND: The FDA warned about potential interference of CT imaging with CRM devices and made recommendations for clinical practice despite only limited evidence. METHODS: All 516 CT scans that involved direct radiation exposure of CRM devices (332 defibrillators, 184 pacemakers) at 2 large-volume centers between July 2000 and May 2010 were included. The primary outcome was a composite endpoint of death, bradycardia or tachycardia requiring termination of the scan or an immediate intervention, unplanned hospital admission, reprogramming of the device, inappropriate defibrillator shocks, or device replacement/revision thought to be due to CT imaging. Significant changes in device parameters were sought as a secondary outcome (control group 4:1 ratio). RESULTS: The main finding was that none of the CTs were associated with the primary outcome. With serial device interrogations, there were no differences in changes in battery voltage or lead parameters between devices exposed to radiation and their controls. Potentially significant changes in device parameters were observed in a small group of devices (both the CT group and control group), but no definitive link to CT was confirmed, and there were no associated clinical consequences. CONCLUSIONS: The findings suggest that the presence of CRM devices should not delay or result in cancellation of clinically indicated CT imaging procedures, and provide evidence that would be helpful when the FDA advisory is re-evaluated.

Adenosine-induced pulmonary vein ectopy as a predictor of recurrent atrial fibrillation after pulmonary vein isolation.

BACKGROUND: Adenosine can unmask dormant pulmonary vein (PV) conduction after PV isolation. Adenosine can also induce ectopy in electrically silent PVs after isolation, possibly via activation of autonomic triggers. We sought to identify the implications of adenosine-induced PV ectopy for atrial fibrillation (AF) recurrence after PV isolation. METHODS AND RESULTS: A total of 152 patients (age, 60±11 years; 63% paroxysmal AF) undergoing PV isolation for AF were studied. After each PV was isolated, adenosine was administered and the presence of adenosine-induced PV reconnection and PV ectopy were recorded. Dormant conduction was targeted with additional ablation. Adenosine-induced PV ectopy was seen in 45 (30%) patients, and dormant conduction was seen in 44 (29%) patients. After a median follow-up of 374 days, 48 (32%) patients had recurrent AF after a single ablation procedure. Rates of freedom from AF among patients with adenosine-induced PV ectopy were significantly lower than patients without adenosine-induced PV ectopy (63% versus 76% at 1 year; log rank, 0.014). Rates of freedom from AF among patients with dormant conduction were also lower than patients without dormant conduction (64% versus 76% at 1 year; log rank, 0.062). With multivariate analysis, adenosine-induced PV ectopy was found to be the only independent predictor of AF after PV isolation (hazard ratio, 1.90; 95% confidence interval, 1.06-3.40; P=0.032). CONCLUSIONS: Adenosine-induced PV ectopy is a predictor of recurrent AF after PV isolation and may be a marker of increased susceptibility to autonomic triggers of AF.

Mechanisms, predictors, and trends of electrical failure of Riata leads.

BACKGROUND: Riata and Riata ST implantable cardioverter-defibrillator leads have been shown to be prone to structural and electrical failure. OBJECTIVE: To determine predictors, mechanisms, and temporal patterns of Riata/ST lead electrical failure. METHODS: All 314 patients who underwent Riata/ST lead implantation at our institution with greater than or equal to 90 days of follow-up were studied. The Kaplan-Meier analysis of lead survival was performed. Results from the returned product analysis of explanted leads with electrical lead failure were recorded. RESULTS: During a median follow-up of 4.1 years, the Riata lead electrical failure rate was 6.6%. The rate of externalized conductors among failed leads was 57%. The engineering analysis of 10 explanted leads revealed 5 (50%) leads with electrical failure owing to breach of ethylene tetrafluoroethylene conductor coating. Female gender (hazard ratio 2.7; 95% confidence interval 1.1-6.7; P = .04) and age (hazard ratio 0.95; 95% confidence interval 0.92-0.97; P < .001) were multivariate predictors of lead failure. By using log-log analysis, we noted that the rate of Riata lead failure initially increased exponentially with a power of 2.1 but leads surviving past 4 years had a linear pattern of lead failure with a power of 1.0. CONCLUSIONS: Younger age and female gender are independent predictors of Riata lead failure. Loss of integrity of conductor cables with ethylene tetrafluoroethylene coating is an important mode of electrical failure of the Riata lead. Further study of Riata lead failure trends is warranted to guide lead management.

Repeated attempts using different strategies are important for timely contact with study participants.

OBJECTIVE: To study the effect of different mail- and phone-based strategies, along with patient- and research-related factors, on the time to contact with research participants. STUDY DESIGN AND SETTING: A prospective evaluation of a 12-week standardized protocol (embedded with two randomized trials of mail- and phone-based strategies) for contacting existing research participants for recruitment into a related study. RESULTS: Of 146 participants, 87 were eligible for contact via the standardized protocol, and 63 (72%) of these were successfully contacted within 12 weeks after multiple mail- and phone-based efforts. Using Cox proportional hazards regression analysis, the different mail and phone strategies showed no significant difference in the time to contact with participants. Of 34 patient- and research-related factors evaluated, only two were independently associated with time to contact among all 146 participants: (1) participants having their last visit conducted outside of the research clinic because of patient illness/condition had a longer time to contact and (2) those with a self-reported chronic fatigue history had a shorter time to contact. CONCLUSION: Few patient characteristics and research-related factors accurately predict time to contact. Repeated attempts using different strategies are important for successful and timely contact with study participants.

International classification of diseases and current procedural terminology codes underestimated thrombolytic use for ischemic stroke.

BACKGROUND AND OBJECTIVE: To determine the accuracy of recently introduced International Classification of Diseases Ninth Revision (ICD-9) procedure and Current Procedural Terminology (CPT) codes designed for injection or infusion of thrombolytic agents. MATERIALS AND METHODS: We determined the accuracy of ICD-9 procedure code 99.10 and CPT codes 37201, 37202 for use of thrombolysis in ischemic stroke by comparing procedure codes of University Hospital discharge data with a concurrent prospective registry. RESULTS: Of the 369 ischemic stroke patients, 49 (13.3%) received either intravenous and/or intraarterial thrombolysis. The sensitivity and specificity for ICD-9 procedure code 99.10 was 55% and 98% and CPT procedure code 37201 and 37202 was 49% and 99%. Identification by either ICD-9 codes or CPT codes yielded a high sensitivity and specificity of 82% and 98%. CONCLUSIONS: The use of ICD-9 and CPT codes alone may underestimate the use of thrombolytics using national and regional database. Best results are achieved when a combination of ICD-9 and CPT codes are used to identify the use of thrombolytics.