Successful use of amoxicillin-clavulanate acid in a patient with severe wound infection with wound communication secondary to Actinomyces.

INTRODUCTION: Actinomyces is a common genus of bacteria that is typically found in the oral cavity, gastrointestinal tract, and genitourinary tract, as well as on the skin. Gleimia europaea (formerly A europaeus) is a facultative anaerobic gram-positive rod that has been well associated with abscesses of the groin, axilla, and breast, as well as with decubitus ulcer. Infection with this species usually involves multiple abscesses communicating through sinus tracts. Treatment typically requires a prolonged course of penicillin or amoxicillin (up to 12 months). CASE REPORT: A 62-year-old male patient presented with a PI with fistulous tract and tunneling infected with Actinomyces, which was successfully treated with amoxicillin-clavulanic acid. CONCLUSIONS: The outcomes in this case support the use of surgical debridement, meticulous wound care, and appropriate antibiotic coverage to achieve accelerated wound healing of sacral PI with actinomycotic involvement.

On-Demand Therapy with Proton Pump Inhibitors for Maintenance Treatment of Nonerosive Reflux Disease or Mild Erosive Esophagitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Proton pump inhibitors (PPIs) are widely used for the long-term management of gastroesophageal reflux disease (GERD). However, concerns about the cost and/or inconvenience of continuous maintenance PPI treatment have led to the evaluation of various alternative approaches. AIM: To assess the effectiveness of on-demand PPI therapy in the maintenance treatment of nonerosive reflux disease (NERD) or mild erosive esophagitis (EE). METHODS: We searched MEDLINE, EMBASE, Web of Science, and Cochrane Library from inception until October 2, 2017, for randomized controlled trials (RCTs) comparing on-demand PPI versus placebo or daily PPI in the management of NERD or mild EE (Savary-Miller grade 1). Discontinuation of therapy during the trial was used as a surrogate for patient dissatisfaction and failure of symptomatic control. We calculated pooled odds ratios (OR) to evaluate the efficacy of on-demand PPI treatment. Separate analyses were conducted for studies comparing on-demand PPI with daily PPI and with placebo. Subgroup analysis was done based on NERD studies alone and on studies of both NERD and mild EE. These were analyzed using a random effects model. RESULTS: We included 10 RCTs with 4574 patients. On-demand PPI was superior to daily PPI (pooled OR = 0.50; 95% confidence interval (CI) = 0.35, 0.72). On subgroup analysis in NERD patients only, pooled OR was 0.44 (0.29, 0.66). In studies including patients with NERD and mild EE, pooled OR was 0.76 (0.36, 1.60). For studies comparing on-demand PPI with placebo, pooled OR was 0.21 (0.15, 0.29); subgroup analyses of studies evaluating NERD only and studies conducted in NERD and mild EE showed similar results (pooled OR was 0.22 (0.13, 0.36) and 0.18 (0.11, 0.31), resp.). CONCLUSIONS: On-demand PPI treatment is effective for many patients with NERD or mild EE. Although not FDA-approved, it may be adequate for those patients whose symptoms are controlled to their satisfaction.

Ectopic Pancreas in the Gastric Antrum Wall Complicated by Ectopic Pancreatitis and Persistent Gastric Abscess.

Ectopic pancreas is an uncommon finding in the stomach. Complications are rare but can lead to significant morbidity and even mortality. We report a 49-year-old man who presented with upper abdominal pain, vomiting, and weight loss and was found to have a gastric wall abscess that developed a few weeks after endoscopic biopsy of a gastric ulcer. After medical treatment failed to resolve his symptoms, he underwent distal gastrectomy with Roux-en-Y gastrojejunostomy. Postoperatively, the gastric wall abscess was determined to have derived from a focus of ectopic pancreatic tissue with evidence of ectopic chronic pancreatitis.

Improving Internal Medicine Residents' Colorectal Cancer Screening Knowledge Using a Smartphone App: Pilot Study.

BACKGROUND: Colorectal cancer (CRC) is the third most common type of cancer and the second leading cause of cancer death in the United States. About one in three adults in the United States is not getting the CRC screening as recommended. Internal medicine residents are deficient in CRC screening knowledge. OBJECTIVE: The objective of our study was to assess the improvement in internal medicine residents' CRC screening knowledge via a pilot approach using a smartphone app. METHODS: We designed a questionnaire based on the CRC screening guidelines of the American Cancer Society, American College of Gastroenterology, and US Preventive Services Task Force. We emailed the questionnaire via a SurveyMonkey link to all the residents of an internal medicine department to assess their knowledge of CRC screening guidelines. Then we designed an educational intervention in the form of a smartphone app containing all the knowledge about the CRC screening guidelines. The residents were introduced to the app and asked to download it onto their smartphones. We repeated the survey to test for changes in the residents' knowledge after publication of the smartphone app and compared the responses with the previous survey. We applied the Pearson chi-square test and the Fisher exact test to look for statistical significance. RESULTS: A total of 50 residents completed the first survey and 41 completed the second survey after publication of the app. Areas of CRC screening that showed statistically significant improvement (P<.05) were age at which CRC screening was started in African Americans, preventive tests being ordered first, identification of CRC screening tests, identification of preventive and detection methods, following up positive tests with colonoscopy, follow-up after colonoscopy findings, and CRC surveillance in diseases. CONCLUSIONS: In this modern era of smartphones and gadgets, developing a smartphone-based app or educational tool is a novel idea and can help improve residents' knowledge about CRC screening.

Gastrointestinal manifestations associated with systemic sclerosis: results from the nationwide inpatient sample.

BACKGROUND: Systemic sclerosis (SSc) is a multisystem disease associated with significant morbidity and increased mortality. The prevalence of different gastrointestinal (GI) manifestations has been investigated in multiple, but mainly small, retrospective studies. In this study, we investigated the prevalence and risk for a broad spectrum of GI disorders and malignancies in a large sample of inpatients with SSc in the United States. METHODS: We conducted a retrospective analysis using the 2010-2011 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS). SSc patients were identified by ICD-9-CM code 710.1. Non-SSc patients ("controls") were matched to cases 4:1 by age and sex. We examined demographics, clinical characteristics, and a range of GI conditions. RESULTS: From 15,824,031 total patients, 13,633 cases of SSc were matched to 54,532 controls. The prevalence of GI manifestations among SSc patients was 59.24% compared to 29.96% for controls (P<0.0001). Significantly elevated GI manifestations in SSc patients included dysphagia (4.3% vs. 1.9%, P<0.0001), esophageal reflux (34.8% vs. 15.4%, P<0.0001), Barrett's esophagus (1.7% vs. 0.3%, P<0.0001), constipation (6% vs. 4.6%, P<0.0001), diarrhea (4.5% vs. 2.4%, P<0.0001), fecal incontinence (0.4% vs. 0.2%, P<0.0001), and celiac disease (0.2% vs. 0%, P<0.0001). Some GI disorders were significantly lower in SSc patients, including cholelithiasis (1.6% vs. 2.1%, P<0.0001) and GI malignancies (1% vs. 2.2%, P<0.0001). CONCLUSIONS: Our results emphasize the established association between SSc and esophageal disorders, such as dysphagia and reflux disease. Our analysis indicated a significant positive association between SSc and celiac disease, and a negative association between SSC and cholelithiasis.

Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula.

Over-the-Scope Clip system, also called "Bear Claw," is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.