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Kamionkowski S, Shibli F, Saleh S, Trujillo S, Mengalle E, El Mokahal A, Thomas C, Song G, Fass R. Clinical value of random esophageal biopsies in patients with dysphagia and normal endoscopy who are treated with a proton pump inhibitor. Dis Esophagus 2024; 37:doad070. [PMID: 38197434 DOI: 10.1093/dote/doad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/22/2023] [Accepted: 11/24/2023] [Indexed: 01/11/2024]
Abstract
Rome IV recommended esophageal biopsies in patients with dysphagia and normal endoscopy to exclude mucosal disease. Thus far, studies evaluating the utility of this recommendation remain scarce. The aims of this study were to determine the value of random esophageal biopsies in heartburn patients with dysphagia and normal endoscopy and compare the yield of random esophageal biopsies between younger versus older patients. Data were collected from consecutive patients presenting with dysphagia, 18 years and older, who were on proton pump inhibitors and had normal upper endoscopy. Biopsy results of patients with and without heartburn were recorded. Logistic regression analysis was used to compare normal versus abnormal biopsy results in younger and older patients accounting for confounding variables. The number of abnormal biopsies was significantly higher than normal biopsies (68% and 32%, respectively, P = 0.0001). Among abnormal biopsy results, microscopic gastroesophageal reflux disease was significantly more common than all other findings (39%, P = 0.0495). There was no significant difference in biopsy results in patients with and without heartburn as well as younger versus older patients (P = 0.3384, P = 0.1010, and P = 0.8468, respectively). Our study demonstrated that most patients with dysphagia and normal upper endoscopy who are on proton pump inhibitor have some type of histologic mucosal abnormality, which can direct future management. Among abnormal biopsies, microscopic reflux was by far the most common finding in patients with or without a history of heartburn. While this supports the management strategy proposed by Rome IV, age did not drive esophageal biopsy results.
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Affiliation(s)
- Sara Kamionkowski
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Fahmi Shibli
- Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Sherif Saleh
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Sophie Trujillo
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Erika Mengalle
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Ali El Mokahal
- Department of Internal Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Charles Thomas
- Department of Research and Scholarship, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
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Jabak SJ, Kawam L, El Mokahal A, Sharara AI. Management of acute diarrhea in the emergency department of a tertiary care university medical center. J Int Med Res 2022; 50:3000605221115385. [PMID: 35942579 PMCID: PMC9373141 DOI: 10.1177/03000605221115385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To examine the management of acute diarrhea in the emergency department (ED)
of a large university medical center. Methods Retrospective cross-sectional study over a 10-month period of adult patients
(age ≥18 years) presenting to the ED with acute diarrhea. Results Data for 780 patients were reviewed; 101 met the exclusion criteria. Of the
679 patients with acute community-acquired diarrhea, 582 (85.7%) were
discharged home and constituted the study cohort of mostly healthy adults
(mean age: 32.5 ± 14.5 years). The rate of antibiotic prescription at
discharge was 26%. Inappropriate use of antibiotics occurred in 28% of the
patients. The presence of fever (odds ratio (OR) = 3.52), leukocytosis
(OR = 1.72), and older age (OR = 1.16) were predictors of antibiotic
prescription. Patients with dehydration, comorbidities, or bloody diarrhea
were more likely to receive antibiotics. Microbiological studies and
cross-sectional imaging were ordered in 12.4% and 11.7% of the patients,
respectively, but provided very low yield (<10% for both) resulting in
significantly higher visit charges. Inappropriately prescribed antibiotics
at discharge resulted in higher charges in the ED compared with no
antibiotic prescription. Conclusion Acute diarrhea management in our ED is suboptimal and does not adhere to
practice guidelines, resulting in unnecessary antibiotic prescriptions,
investigations, and cost.
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Affiliation(s)
| | | | | | - Ala I Sharara
- Ala I. Sharara, Professor of Medicine,
Division of Gastroenterology, American University of Beirut Medical Center, Riad
El-Solh, Beirut 1107 2020, Lebanon.
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Mokahal AE, Ahmad A, Habib JR, Nasrallah AA, Francis G, Sabra R, Zgheib NK. Do Medical Students' Learning Styles and Approaches Explain Their Views and Behavior Regarding Lecture Attendance? Med Sci Educ 2021; 31:1693-1702. [PMID: 34603842 PMCID: PMC8446112 DOI: 10.1007/s40670-021-01362-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Medical students' attendance at lectures, particularly in the preclinical years, has been steadily declining over the years. One of the many explanations offered for this observation is that students have different learning styles and approaches, such that not all of them benefit from attending lectures; however, no studies have specifically examined this possibility. While there is evidence against learning styles as affecting objective measures of learning, they are associated with subjective measures of learning and may therefore influence student behavior. We hypothesized that students' learning styles and/or approaches influence their views about the value and purpose of lectures and their motivation to attend them, which, in turn will affect their behavior. MATERIALS AND METHODS A LimeSurvey was distributed to all preclinical students at the American University of Beirut. The survey included questions about demographic data, self-reported attendance rates in Year 1 of medical school, two validated and standardized questionnaires assessing the students' learning styles (visual, auditory, kinesthetic, tactile, group, individual) and learning approaches (superficial, deep, strategic), and a series of questions exploring the students' views about the purpose and value of lectures and their motivation to attend lectures. RESULTS No associations were found between learning styles or approaches and attendance rates, but this may have been confounded by the mandatory attendance policy at the time. There were, however, a few positive associations between some learning styles or approaches and the students' views about the value of attending lectures. In particular, students with high scores as auditory learners tended to see absolutely no value in attending lectures, and those with high scores as group, auditory or visual learners, tended to see less value in taking their own notes in lectures. Students with superficial approaches to learning felt that watching videos of a lecture provides equivalent education to attending a lecture. There were no statistically significant associations with either the perceived purpose of lectures or the motivation to attend lectures after correction for multiple testing. CONCLUSIONS This study reveals that except for some interesting findings related to auditory learners, differences in learning styles or approaches among students cannot adequately explain differences in their attitudes, and likely, behavior, regarding lecture attendance. The idea that learning styles and approaches can influence educational preferences and outcomes, while attractive and intuitive, continues to require supporting evidence. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s40670-021-01362-3.
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Affiliation(s)
- Ali El Mokahal
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ali Ahmad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Joseph R. Habib
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ali A. Nasrallah
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - George Francis
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ramzi Sabra
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Program for Research and Innovation in Medical Education, Department of Pharmacology and Toxicology, Faculty of Medicine
, American University of Beirut, PO. Box 11-0236, Riad El Solh, Beirut, Lebanon
| | - Nathalie K. Zgheib
-
Program for Research and Innovation in Medical Education, Department of Pharmacology and Toxicology, Faculty of Medicine
, American University of Beirut, PO. Box 11-0236, Riad El Solh, Beirut, Lebanon
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Abi Doumeth S, Bou Daher H, El Mokahal A, Tawil A, Sharara AI. Prevalence and characteristics of post-gastroscopy gastric cancer: A retrospective study from an academic medical center. Arab J Gastroenterol 2021; 22:193-198. [PMID: 34090833 DOI: 10.1016/j.ajg.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND STUDY AIMS Gastric cancer is diagnosed by endoscopy but false negative rates of up to 10% in the west and 40% in Asia have been reported. In Lebanon, little is known about the rates of post-gastroscopy gastric cancer (PGGC), defined as the proportion of patients diagnosed with gastric cancer with a negative previous examination within 2 years of diagnosis. We aimed to examine the rate of PGGC and its risk factors, clinico-pathologic and endoscopic characteristics at a University medical Center. PATIENTS AND METHODS Retrospective analysis of patients with histologically proven gastric malignancy over the last 14 years. Patients with history of upper endoscopy preceding the index diagnostic endoscopy by 6 to 24 months were included. RESULTS 18,976 patients underwent upper endoscopy and gastric cancer was diagnosed in 323 (1.7%). Of those, only 4 (1.2%) had a preceding endoscopy within 6 to 24 months of diagnosis: 3 adenocarcinoma and one MALT lymphoma. Upon review of the initial endoscopy, a mucosal abnormality had been noted in all 4 patients and biopsies taken in 3 were negative for cancer. The mean time to cancer diagnosis was 8 months (range 6-13 months). CONCLUSION A small proportion of gastric carcinomas are missed on endoscopy in this study. Patients with endoscopic evidence of mucosal abnormalities and negative biopsies should undergo repeat examination with multiple biopsies. Proper endoscopic technique, lesion recognition and adoption of performance improvement measures are important to optimize endoscopic practice.
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Affiliation(s)
- Sarah Abi Doumeth
- Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 11072020, Beirut, Lebanon
| | - Halim Bou Daher
- Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 11072020, Beirut, Lebanon
| | - Ali El Mokahal
- Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 11072020, Beirut, Lebanon
| | - Ayman Tawil
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon
| | - Ala I Sharara
- Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 11072020, Beirut, Lebanon.
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Chehab H, BouDaher H, Mokahal AE, ElHaddad A, Rimmani H, Hamadeh G, Tawil A, Sharara AI. Positive predictive value of fecal immunochemical test for high-risk colonic adenomas and carcinoma: A health maintenance organization cohort screening study in Lebanon. Arab J Gastroenterol 2021; 22:174-176. [PMID: 33965367 DOI: 10.1016/j.ajg.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 02/01/2021] [Accepted: 04/08/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND STUDY AIMS Fecal Immunochemical Test (FIT) is one of the leading modalities for colorectal cancer screening. Studies show that FIT is highly sensitive for the detection of colorectal cancer (CRC) but not similarly accurate for detection of pre-cancerous advanced adenomas (AA). We studied the performance metrics of FIT for the detection of CRC and AA in ahealth maintenance organization (HMO) cohort screening program. PATIENTS AND METHODS Retrospective cohort study of asymptomatic persons of screening age belonging to a HMO. Endoscopy and pathology reports of those who tested positive were used to calculate the positive predictive value (PPV) of FIT, and characterize endoscopic findings on colonoscopy. RESULTS Between 1995 and 2017, 3000 persons had screening fecal occult testing as part of their Employee Health Care plan. Of those, 150 had a positive qualitative FIT (cutoff 10 µg hemoglobin/g feces). All underwentcolonoscopy, and median time to colonoscopy was 27 days. 4 (2.6%) had carcinoma(2 stage IIIA and 2 stage IIIB), 106 (70.6%) had adenomas of which 40 (26.6% of the total cohort) had advanced adenomas (≥1 cm, villous features, or high-grade dysplasia) giving a PPV for AA and carcinoma of 29% and 3% respectively. When stratified by age, the PPV of AA; carcinoma was [50-59 (21.7%; 0.0%)], [60-69 (14.6%; 4.2%)], [70-79 (42.6%; 2.1%)], [80-89 (33.3%; 11.1%)]. CONCLUSION The performance characteristics of FIT testing are acceptable for population screening in resource-limited settings. The resultsof this study are helpful when discussing expectations prior to colonoscopy in people with positive FIT.
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Affiliation(s)
- Hamed Chehab
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon
| | - Halim BouDaher
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon
| | - Ali El Mokahal
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon
| | - Aline ElHaddad
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon
| | - Hussein Rimmani
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon
| | - Ghassan Hamadeh
- Department of Family Medicine, American University of Beirut Medical Center, PO Box: 11-0236, Riad El Sol, 1107 2020 Beirut, Lebanon
| | - Ayman Tawil
- Department of Pathology & Laboratory Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 11072020, Beirut, Lebanon
| | - Ala I Sharara
- Division of Gastroenterology, American University of Beirut Medical Center, P.O. Box 11-0236/16-B, Beirut, Lebanon.
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Sharara AI, El Mokahal A, Harb AH, Khalaf N, Sarkis FS, M El-Halabi M, Mansour NM, Malli A, Habib R. Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals. World J Gastroenterol 2020; 26:5705-5717. [PMID: 33088163 PMCID: PMC7545395 DOI: 10.3748/wjg.v26.i37.5705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In resource-limited countries, risk stratification can be used to optimize colorectal cancer screening. Few prospective risk prediction models exist for advanced neoplasia (AN) in true average-risk individuals.
AIM To create and internally validate a risk prediction model for detection of AN in average-risk individuals.
METHODS Prospective study of asymptomatic individuals undergoing first screening colonoscopy. Detailed characteristics including diet, exercise and medications were collected. Multivariate logistic regression was used to elucidate risk factors for AN (adenoma ≥1 cm, villous histology, high-grade dysplasia or carcinoma). The model was validated through bootstrapping, and discrimination and calibration of the model were assessed.
RESULTS 980 consecutive individuals (51% F; 49% M) were enrolled. Adenoma and AN detection rates were 36.6% (F 29%: M 45%; P < 0.001) and 5.1% (F 3.8%; M 6.5%) respectively. On multivariate analysis, predictors of AN [OR (95%CI)] were age [1.036 (1.00-1.07); P = 0.048], BMI [overweight 2.21 (0.98-5.00); obese 3.54 (1.48-8.50); P = 0.018], smoking [< 40 pack-years 2.01 (1.01-4.01); ≥ 40 pack-years 3.96 (1.86-8.42); P = 0.002], and daily red meat consumption [2.02 (0.92-4.42) P = 0.079]. Nomograms of AN risk were developed in terms of risk factors and age separately for normal, overweight and obese individuals. The model had good discrimination and calibration.
CONCLUSION The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West. Age, smoking, and BMI are important predictors of AN, with obesity being particularly powerful. Though external validation is needed, this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.
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Affiliation(s)
- Ala I Sharara
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Ali El Mokahal
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Ali H Harb
- Digestive and Liver Diseases Division, University of Texas-Southwestern, Dallas, TX 75390, United States
| | - Natalia Khalaf
- Division of Gastroenterology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Fayez S Sarkis
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, MO 66160, United States
| | - Mustapha M El-Halabi
- Division of Gastroenterology, St Elizabeth Healthcare, Crestview Hills, KY 41017, United States
| | - Nabil M Mansour
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Ahmad Malli
- Gastroenterology, Hennepin Healthcare, Minneapolis, MN 55404, United States
| | - Robert Habib
- Department of Internal Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
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