Objective: Access to care is key to effective rectal cancer treatment. We hypothesized that ethnic/racial minorities living in high population density areas would have the greatest delays in cancer care compared to whites living in medium population density areas. Methods: Using 2004-2016 National Cancer DataBase data, we identified stage I-III patients with invasive rectal adenocarcinoma who underwent surgery. The data were analyzed by race/ethnicity (whites, blacks, or Hispanics) and population density (metropolitan or urban/rural). Multivariable ANCOVA was performed to evaluate the duration of time from diagnosis to surgery. Results: The study population consisted of 76,131 patients: 65,172 Non-Hispanic whites (NHW; 85.6%), 6,167 Non-Hispanic blacks (NHB; 8.1%), and 4,792 Hispanics (6.3%). Of these, 61,363 patients (80.6%) lived in metropolitan areas. Among direct-to-surgery patients, the greatest difference in mean time from diagnosis to surgery was 20.3 days (urban/rural NHW, 53.3 days, vs. metropolitan Hispanics, 73.6 days). Among patients receiving neoadjuvant therapy, the greatest difference in mean time from diagnosis to surgery was 18.8 days (urban/rural NHW, 136.9 days, vs. metropolitan NHB, 155.7 days). After multivariable adjustment for several socioeconomic and clinical factors, among direct-to-surgery patients, metropolitan Hispanics had a 16.5-day delay (95% CI 12.9-20.0) compared with urban/rural NHW. In patients receiving neoadjuvant therapy, metropolitan NHB had an 18.1-day delay (95% CI 16.1-20.0) compared to urban/rural NHW. Conclusion: The combination of high population density and racial/ethnic minority status was associated with delays in rectal cancer care that persisted after adjusting for other important factors. Understanding which populations are at risk and perceived obstacles to timely care will help inform interventions to minimize treatment access disparities.

Crohn’s disease is an inflammatory bowel disease that may involve any part of the gastrointestinal tract with a variety of extraintestinal features. A flare of Crohn’s disease may present as partial small bowel obstruction or peritonitis. Dehydration, infectious agents, and cigarette smoking are some of the factors linked to a relapse of Crohn’s disease. Plesimonas Shigelloides, a bacterium that belongs to the enterobacteriaceae group may rarely lead to a flare of Crohn’s disease. We describe the case of a 31-year-old male with Crohn’s disease who developed a flare triggered by Plesimonas Shigelloides infection presenting as partial small bowel obstruction with ileal narrowing, and regional lymphadenopathy that responded to immunosuppressants.

Acute Pancreatitis (AP) is a common disease with systemic complications, specifically pulmonary complications that are well-documented [1]. Here we present, to the best of our knowledge, the first reported case of tracheobronchomalacia as a respiratory complication of AP. A 54-year-old white male with multiple chronic comorbidities developed necrotizing acute pancreatitis (NAP) following a surgical procedure. Internal Medicine evaluated and managed his NAP according to protocol. Within one week of NAP onset, the patient developed rapid respiratory distress. Chest radiography and ABGs were unable to diagnose ARDS. A CT scan with IV contrast was completed to investigate a pulmonary embolus and found the tracheal diameter variations during inspiration and expiration of the respiratory cycle consistent with tracheobronchomalacia (TBM). The patient’s respiratory status continued to deteriorate requiring endotracheal intubation and mechanical ventilation with weaning trials proving to be futile. The patient eventually developed fungemia and expired after his family opted for palliative extubation. Airway collapse related to TBM is an under-recognized diagnosis which should be suspected in patients with NAP who develop acute respiratory distress in whom no specific etiology has been determined.

An evidence-based clinical practice guideline was developed to prevent and manage constipation in the long-term care (LTC) resident. Constipation is a prevalent condition in the LTC resident. Guidelines do not address this vulnerable population. Constipation may result in poor nutritional status, quality of life along with increased health care costs and hospitalizations. A literature review was completed and evidence was evaluated and included into the initial draft recommendations. The guideline was reviewed for content validity using a Delphi Committee of clinical experts in gastroenterology, geriatrics, and pharmacy. The updated guidelines were presented to an interdisciplinary team of long-term care residents. Participants were asked to review and complete a survey regarding clinical applicability of the guideline. Thirty-one interdisciplinary members participated in the education session and 30 surveys were received. Overall, the interdisciplinary team members agreed or strongly agreed the guideline was clinically applicable. Finally, the guideline was evaluated by a group of doctoral prepared practicing nurse practitioners using the AGREE II instrument. The scores were >80% in every domain, with an overall score of 91%, indicating the guideline is high in quality. Development of this guideline signifies an initial step in the management and prevention of constipation in the LTC resident.

Non-alcoholic fatty liver disease (NAFLD) is an increasingly prevalent issue in the modern world, predisposing patients to serious pathology such as cirrhosis and hepatocellular carcinoma. Mitochondrial dysfunction, and in particular, diminished hepatic oxidative phosphorylation (OXPHOS) capacity, have been observed in NAFLD livers, which may participate in NAFLD pathogenesis. To examine the role of OXPHOS in NAFLD, we generated a model of enhanced hepatic OXPHOS using mice with liver-specific transgenic expression of LRPPRC, a protein which activates mitochondrial transcription and augments OXPHOS capacity. When challenged with high-fat feeding, mice with enhanced hepatic OXPHOS were protected from the development of liver steatosis and inflammation, critical components in the pathogenesis of NAFLD. This protection corresponded to increased liver and whole-body insulin sensitivity. Moreover, mice with enhanced hepatic OXPHOS have increased availability of oxidized NAD+, which promotes complete fatty acid oxidation in hepatocytes. Interestingly, mice with enhanced hepatic OXPHOS were also protected from obesogenic effects of long-term high-fat feeding. Consistent with this, enhanced hepatic OXPHOS increased energy expenditure and adipose tissue oxidative gene expression, suggesting a communication between the liver and adipose tissue to promote thermogenesis. Examination of pro-thermogenic molecules revealed altered bile acid composition in livers and serum of LRPPRC transgenic mice. These mice had increased expression of bile acid synthetic enzymes, genes which are induced by NAD+ dependent deacetylase SIRT1 activation of the transcriptional co-regulator PGC-1a. These findings suggest that enhanced hepatic OXPHOS transcriptionally regulates bile acid synthesis and dictates whole-body energy expenditure, culminating in protection from obesity.

Ischemic colitis is a known complication of abdominal aortic aneurysm (AAA) repair. There is still no established consensus regarding the individual significance of factors related to this phenomenon. We detail the hospital course of a patient who unexpectedly developed acute colonic ischemia following open AAA repair. The pathophysiology, diagnostic modalities, potential preventative measures, and effect on patient morbidity and mortality will be presented. Reviewing the current literature, this will focus on the reported statistical importance of various risk factors including the incidence following traditional open repair and endovascular aneurysm repair.

Hepatitis C is the most common chronic bloodbourne infection in the United States, with an estimated prevalence of 2.7 million. The total cost of care for this patient population was estimated to be $6.5 billion in 2013. Since 1998, the Centers for Disease Control (CDC) have recommended hepatitis C screening for specific high risk populations, but until recently there was no recommendation for age-based screening. The recent advent of new, more efficacious therapies for hepatitis C have made early identification significantly more important. Consequently, the CDC updated its recommendations in 2012 based on recent evidence to include one-time screening for all individuals born between 1945 and 1965. In 2013, the US Preventive Services Task Force (USPSTF) also incorporated this recommendation into their hepatitis C screening guidelines. In spite of this, there is some debate in the medical community regarding cohort screening for hepatitis C, and some data indicates widespread misunderstanding of current screening recommendations among primary care providers. The purpose of this project was to evaluate current knowledge and understanding of hepatitis C screening guidelines among a group of family medicine residents at East Tennessee State University, and to improve their knowledge in order to promote more appropriate screening practices in their patient population. To accomplish this, 13 question surveys were administered to residents to assess their current knowledge. Following these surveys, residents attended an education session covering current recommendations from the CDC and USPSTF. The 13 question survey was administered again in the post-intervention period. A t-test revealed that post-intervention survey scores increased significantly on 8 out of 13 questions. The intervention was successful at improving knowledge of current hepatitis C screening recommendations in the target population. Future research should be directed at broadening the intervention to include a variety of other providers, and at assessing the impact on execution of screening in the patient population, particularly regarding application to people born in the specified birth cohort.

Oral iron replacement therapy is often used as a first-line modality for the treatment of iron deficiency anemia (IDA). Oral iron replacement options include tablets, capsules, and liquid formulations. Esophagitis due to iron tablet administration is a well-documented phenomenon, yet peptic ulcer disease secondary to iron tablet administration is less well-known. An 83-year-old female with a past medical history of chronic kidney disease stage V, anemia of inflammatory disease, heart failure with preserved ejection fraction, and gastroesophageal reflux disease presented to the hospital with diffuse abdominal pain and dark red emesis. She was started on ferrous sulfate supplementation two weeks ago and described progressive abdominal pain and nausea since beginning the medication. She was not taking nonsteroidal anti-inflammatories (NSAIDs), antiplatelets, or anticoagulants. Six months ago, she had an unremarkable upper endoscopy performed for new-onset gastroesophageal reflux disease. Laboratory studies revealed a hemoglobin of 7.3 mg/dL and due to a concern for rapid blood loss, she was given one unit of packed red blood cells. A non-contrast computed tomography was performed showing wall thickening of the stomach and the first two portions of the duodenum. A possible ulcer was seen in the distal posterior stomach. The patient was made NPO, and twice daily intravenous pantoprazole was started. An upper endoscopy was performed which revealed a 2.5 cm clean-based ulcer in the duodenal bulb. Biopsies showed acute inflammation and positivity for iron debris but were negative for Helicobacter pylori. Once daily pantoprazole was continued, and her ferrous sulfate tablets were discontinued. Her symptoms did not return. Ferrous sulfate may erode and ulcerate the gastric and duodenal mucosa like that of a chemical burn. Iron deposits may be seen on biopsies performed with Prussian blue staining. Brown crystalline deposits may be seen on hematoxylin and eosin staining. Iron injury may be seen in pill or capsule formulations due to a concentration effect, but this is typically not seen with solution forms. Treatment includes discontinuation of tablet or capsule formulations and substitution with liquid forms.

Complete or partial obstruction of the duodenum by the superior mesenteric artery (SMA) is a rare cause of bowel obstruction. SMA syndrome results from the compression of the 3rd part of the duodenum between the superior mesenteric artery and the abdominal aorta. Causes include anatomical variation in the superior mesenteric artery, trauma, burns, surgeries, malignancy, and rapid weight loss. Diagnosis of SMA syndrome in patients may be difficult, as the clinical findings often resemble other forms of small bowel obstructions. This syndrome was first described in the literature by Carl Freiherr von Rokitansky in 1861. Subsequently, David Wilke provided a comprehensive description of the disease in a series of 75 patients. There has been skepticism about the existence of SMA syndrome due to scant literature reports and non-specific symptomatology. However, modern cross-sectional imaging has confirmed the existence of this rare syndrome. Here we present the case of a 50-year-old female with longstanding symptoms of gastrointestinal discomfort, weight loss, nausea, and vomiting. She underwent an exhaustive gastrointestinal workup until a diagnosis of SMA syndrome was made. We elected to proceed with a minimally invasive three-port laparoscopic, trans-mesenteric side-to-side duodenojejunostomy. The patient was discharged on postoperative day one after tolerating a regular diet. On one month follow-up, our patient reported improvement in symptoms with no postprandial pain or nausea and normal bowel movements. In conclusion, we report a case of superior mesenteric artery syndrome in a patient with recurrent abdominal pain and nausea. CT scan has the highest sensitivity for the diagnosis of SMA syndrome, findings suggestive of the diagnosis include an abnormal aortomesenteric angle and distance. While supplemental tube feeds and gastric drainage may resolve the condition without the need for surgery, this often takes many weeks to months to be effective. Minimally invasive surgical bypass is an attractive option because of the rapidity of symptom resolution, lack of need for long-term invasive tubes, short inpatient length of stay, and high success rate.

Esophageal and biliary stents are indwelling devices used in the treatment of selected gastrointestinal and biliary disorders. Stenting is accepted as a standard procedure for palliation of malignant obstruction of the esophagus and biliary system. Review of the early and late complications associated with these devices is made with emphasis on the clinical and radiographic features. A suggested approach to diagnosis and treatment recommendations are made for each complication that the emergency department physician may encounter.