Incidence and prevalence of advanced colorectal neoplasia in Lynch syndrome

BACKGROUND AND AIMS

Lynch syndrome (LS) is the most common hereditary cause of colorectal cancer (CRC) and endometrial cancer (EC). Although colonoscopy reduces CRC in LS, the protection is variable. We assessed the prevalence and incidence of neoplasia in LS during surveillance colonoscopy in the United States and factors associated with advanced neoplasia.

METHODS

Patients with LS undergoing ≥1 surveillance colonoscopy and with no personal history of invasive CRC or colorectal surgery were included. Prevalent and incident neoplasia was defined as occurring <6 months before and ≥6 months after germline diagnosis of LS, respectively. We assessed advanced adenoma (AA), CRC, and the impact of mismatch repair pathogenic variant (PV) and typical LS cancer history (personal history of EC and/or family history of EC/CRC) on outcome.

RESULTS

A total of 132 patients (inclusive of 112 undergoing prevalent and incident surveillance) were included. The median examination interval and duration of prevalent and incident surveillance was .88 and 1.06 years and 3.1 and 4.6 years, respectively. Prevalent and incident AA were detected in 10.7% and 6.1% and invasive CRC in 0% and 2.3% of patients. All incident CRC occurred in MSH2 and MLH1 PV carriers and only 1 (.7%) while under surveillance in our center. AAs were detected in both LS cancer history cohorts and represented in all PVs.

CONCLUSIONS

In a U.S. cohort of LS, advanced neoplasia rarely occurred over annual surveillance. CRC was diagnosed only in MSH2/MLH1 PV carriers. AAs occurred regardless of PV or LS cancer history. Prospective studies are warranted to confirm our findings.

Knowledge, Attitude and Practice of Undergraduate Medical Students of Bangladesh Regarding COVID-19 and its Vaccination

Medical students are one of the socially active, reliable, and persuading population of information, prevention and control, and incentive of vaccination to stop the current pandemic situation. Consequently, knowing the status of medical students' knowledge, about symptoms, and transmission of disease, prevention of COVID-19 and their attitudes towards a vaccine is important. This multi-center cross-sectional descriptive study was one of the first ones in Bangladesh among the undergraduate medical students who completed pathology, microbiology, and pharmacology. The study was conducted from March to April 2021, using a convenience sampling method in twelve government and non-government medical colleges. Among 1132 who completed the questionnaire, and 15 students from different centers were excluded from the pre-testing and face validation. The age of the 1117 respondents were 22 to 23 years, of which the majority of the respondents were female 749 (67.0%), and 368 (33.0%) were male. Almost all participants had correct knowledge (84.1%) about the symptoms of COVID-19. But 59.2% had wrong knowledge about transmission of disease by an afebrile person. Above 60.0 % of the participants have worn a facial mask when contacting people, refrained from shaking hands, washed hands, avoided people with signs and symptoms suggestive of COVID-19, and avoided crowded places as a practice of prevention. 37.6% of medical students showed positive attitudes about the participation of management of a COVID-19 patient. Most of the participants' decided to have a vaccine depending on its availability. But 31.5% had trust in natural immunity rather than vaccination. Most undergraduate Medical college students understood the basic information, possessed a positive attitude, and presented good practice towards the COVID-19 and vaccination. They play a crucial role in motivation and acceptance of vaccines among the general citizen to fight back against the pandemic in the country with limited resources.

Characteristics of Immune Checkpoint Inhibitor-Associated Gastritis: Report from a Major Tertiary Care Center

BACKGROUND

Immune checkpoint inhibitors (ICIs) have increased our ability to treat an ever-expanding number of cancers. We describe a case series of 25 patients who were diagnosed with gastritis following ICI therapy.

MATERIALS AND METHODS

This was a retrospective study involving 1712 patients treated for malignancy with immunotherapy at Cleveland Clinic from January 2011 to June 2019 (IRB 18-1225). We searched electronic medical records using ICD-10 codes for gastritis diagnosis confirmed on endoscopy and histology within 3 months of ICI therapy. Patients with upper gastrointestinal tract malignancy or documented Helicobacter pylori-associated gastritis were excluded.

RESULTS

Twenty-five patients were found to meet the criteria for diagnosis of gastritis. Of these 25 patients, most common malignancies were non-small cell lung cancer (52%) and melanoma (24%). Median number of infusions preceding symptoms was 4 (1-30) and time to symptom onset 2 (0.5-12) weeks after last infusion. Symptoms experienced were nausea (80%), vomiting (52%), abdominal pain (72%), and melena (44%). Common endoscopic findings were erythema (88%), edema (52%), and friability (48%). The most common diagnosis of pathology was chronic active gastritis in 24% of patients. Ninety-six percent received acid suppression treatment and 36% of patients also received steroids with an initial median dose of prednisone 75 (20-80) mg. Within 2 months, 64% had documented complete resolution of symptoms and 52% were able to resume immunotherapy.

CONCLUSION

Patients presenting with nausea, vomiting, abdominal pain, or melena following immunotherapy should be assessed for gastritis and if other causes are excluded, may require treatment as consideration for complication of immunotherapy.

Risk of hernia-related complications after transjugular intrahepatic portosystemic shunt creation in patients with pre-existing ventral abdominal hernias: 15-year experience at a quaternary medical center

Objective

Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat the sequelae of portal hypertension, including refractory variceal bleeding, ascites and hepatic hydrothorax. However, hernia-related complications such as incarceration and small bowel obstruction can occur after TIPS placement in patients with pre-existing hernias. The aim of this study was to determine the incidence of hernia complications in the first year after TIPS placement and to identify patient characteristics leading to an increased risk of these complications.

Design

This retrospective analysis included patients with pre-existing abdominal hernias who underwent primary TIPS placement with covered stents at our institution between 2004 and 2018. The 1-year hernia complication rate and the average time to complications were documented. Using a Wilcoxon rank-sum test, the characteristics of patients who developed hernia-related complications versus the characteristics of those without complications were compared.

Results

A total of 167 patients with pre-existing asymptomatic abdominal hernias were included in the analysis. The most common reason for TIPS placement was refractory ascites (80.6%). A total of 36 patients (21.6%) developed hernia-related complications after TIPS placement, including 20 patients with acute complications and 16 with non-acute complications. The mean time to presentation of hernia-related complications was 66 days. Patients who developed hernia-related complications were more likely than those without complications to have liver cirrhosis secondary to alcohol consumption (p=0.049), although this association was no longer significant after multivariate analysis.

Conclusion

Within 1 year after TIPS placement, approximately 20% of patients with pre-existing hernias develop hernia-related complications, typically within the first 2 months after the procedure. Patients with pre-existing hernia undergoing TIPS placement should be educated regarding the signs and symptoms of hernia-related complications, including incarceration and small bowel obstruction.

Immune checkpoint inhibitor induced colitis: A nationwide population-based study

BACKGROUND

ICIs are used in the management of several malignancies. However, they can result in immune-related adverse events, such as colitis. The aim of this study is to obtain an epidemiological survey of patients who develop immune checkpoint inhibitor (ICI)-induced colitis and identify underlying risk factors.

METHODS

A cohort study was performed using Explorys, a US-based population database. Our cohort included all patients in a five-year interval on an ICI. We further identified those who developed colitis after initiating an ICI. Demographic data and possible risk factors were assessed. Odds ratios were calculated and multivariable statistical analysis was performed.

RESULTS

3.6% of patients developed ICI-induced colitis. Women [OR: 1.2; 95% CI 1.224-1.231, p <0.001], Caucasians [OR: 2.3; 2.284 - 2.299], individuals older than 65 years [OR: 1.3; 1.319 - 1.326], obese patients [OR: 3.3; 3.273 - 3.302], and those with a history of alcohol abuse [OR: 2.5; 2.485 - 2.523] were more likely to develop colitis. Patients who received Nivolumab [OR: 2.8; 2.563 - 3.022], Ipilimumab [OR: 4.9; 3.937 - 6.061], Pembrolizumab [OR 2.7; 2.463 - 2.868], and Atezolizumab [OR 2.9; 2.430 - 3.388] had an increased odds of developing colitis. The majority of cases were diagnosed in the first 6 months of therapy.

CONCLUSIONS

This is the largest study to describe the epidemiology of ICI-induced colitis and it is the first to identify underlying risk factors. Ipilimumab poses the greatest risk for ICI-induced colitis. The risk of colitis should be discussed with all patients prior to initiating an ICI, as it may be a factor in choosing among ICIs.

Vaccination against COVID-19 in Bangladesh: Perception and Attitude of Healthcare Workers in COVID-dedicated Hospitals

Healthcare professionals are the crucial and influencing source of information for vaccines and their communication among patients and communities that can accelerate successful vaccination in a country. This cross-sectional study was one of the first and foremost ones in Bangladesh to observe the basic perception and attitudes towards vaccination against COVID-19 among the healthcare workers (HCWs) - doctors, interns, nurses, ward boys, cleaners, and medical technologists of major COVID-dedicated hospitals. The cross-sectional questionnaire-based study was conducted in February 2021 among 550 HCWs to assess the perception and attitude towards vaccination against COVID-19. The study participants were targeted as the priority group for COVID-19 vaccination, working in two major COVID-dedicated hospitals, Holy Family Red Crescent Medical College Hospital (HF-center), and Sheikh Russel National Gastro-liver Institute and Hospital (SR-center) in Dhaka, Bangladesh during the pandemic. The questionnaire was structured with a three-point scale of responses from 'true', 'false', and 'do not know'. The responses were calculated on point-score as +1 for the correct response, -1 for the wrong response, and 0 for 'do not know' with an overall highest and the lowest possible score of +5 to -5. Absolute (n) and relative frequencies (%) were presented for qualitative variables, while quantitative variables were presented as mean (± standard deviation). Chi-square test was done for univariate analysis of qualitative variables and Student's t-test for quantitative variables. With the 95.27% response rate, including 204 males and 320 were female and the male: female ratio was 1: 1.56. The majority of the participants were doctors (45.8%) followed by nurses (27.9%), and MLSS (26.3%) respectively. The respondents were between 18 to 64 years of age with a mean of 36.17±10.94 years. Most of the respondents (95.99%) responded correctly about the cost-free availability of a vaccine against COVID-19 in the country, 87.40% preferred vaccination as safe and effective. Again 29.77% HCWs think the vaccine might not be safe or effective due to emergency authorization. Only 38.93% of respondents could respond correctly about the necessity of vaccines for children, 31.10% think the vaccination was not required instead of natural immunity. The positive perception and attitude of the frontline HCWs in COVID-dedicated hospitals in Bangladesh are crucial which will positively influence motivation and wide acceptance among the general population for the attainment of the nationwide vaccination program, and adopt effective strategic modification to minimize the gaps for a low-middle income country like Bangladesh with its resource constrain.

Outpatient Evaluation of Knee Pain

Knee pain is present in up to 20% of the adult general population and can be significantly debilitating to patients. A thorough history and physical examination can help localize the source of inflammation or injury to further determine if imaging, physical therapy, specialty referral, or surgery is necessary. By following a systematic approach to evaluating knee pain, primary care physicians can make the correct diagnosis and formulate an appropriate therapeutic strategy for patients.

Histopathological alterations in post-infectious irritable bowel syndrome in Bangladeshi population

Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder encountered in general practice. Although enormous progress in the pathogenesis of IBS has been made, it is still poorly understood. A significant proportion of patients with IBS, report onset of symptoms following an episode of acute gastroenteritis. Aim of the study was to determine whether post infective irritable bowel syndrome (PI-IBS) has histological or clinical features that are distinct from those of IBS patients with no history of preceding infection. A total of 50 consecutive IBS out patients and 10 healthy control subjects completed a questionnaire detailing symptoms, mode of onset, and previous psychiatry history. All underwent a full diagnostic workup including colonic biopsy and histopathology. Patients were divided according to onset of symptoms into post infectious IBS (PI-IBS, N=18) and non-post infectious IBS (non-PI-IBS, N=32) patients. Diarrhea predominantly occurred more frequently in PI- IBS (70%) than in non-PI-IBS (40%) patients (p<0.05). Histopathological examination of the biopsy specimen from the sigmoid colon of the observed individuals showed a significant increase in the number of chronic inflammatory cells in both groups of IBS patients comparing to the control group (p<0.001). Lymphoid follicles were increased in both groups of IBS patients in comparison to control group (p<0.05). Mast cells were increased in IBS patients comparing to the control group (p<0.05) and it was significantly increased in the PI-IBS patients than the non-PI-IBS patients (p<0.001). Individuals with PI-IBS are clinically distinct subgroup characterized by predominant diarrheal symptoms and increased mast cells compared to those with non PI-IBS.