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Fecal immunochemical test (FIT) is a yearly alternative colorectal screening modality for average risk individuals unwilling or unable to undergo invasive colorectal cancer (CRC) screening due to cost and accessibility. This study aims to determine whether FIT should be interpreted within the context of patient demographics and medical history.Patients50 years old who had a FIT followed by colonoscopy within 1 year were analyzed based on age, race, BMI, social and medical comorbidities. False positive (FP) and false negative (FN) FIT results within each patient demographic and medical history variable were determined by comparing with the gold standard of colonoscopy using Chi-square analysis.1025 patients were reviewed. 21.8% of FIT results were positive. Factors which differed in positive FIT rates were age (p=0.003), smoking (p0.001), alcohol (p=0.001), and hypertension (p0.001). The difference in rates of FP and FN FIT outcomes among each variable underwent further sub-analysis. The FP was 66.8% and the FN rate was 12.8%. Higher FN outcomes were noted in those above 70, males and smokers, though the result was only statistically significant for males (p=0.009). Females were observed to have higher FP rates (p=0.019).Females had higher FP FIT rates compared to males, indicating that sex may influence FIT outcomes and should be accounted for when interpreting FIT results. This information can be utilized to identify populations at higher risk of FP or FN FIT results to target CRC screening. Additionally, recalculating the FP and FN rates for each variable may help determine new FIT targets.

Haemophagocytic lymphohistiocytosis (HLH) is a rare condition of uncontrolled immune activation as a result of an inherited genetic defect or in response to malignancy, autoimmune disease, rheumatological disease, AIDS infection or post-transplant immunosuppression. Described here is the case of a 19-year-old Caucasian man who presented with complaints of worsening fever, new-onset jaundice and lethargy after failing treatment for suspected infectious mononucleosis. Physical examination was significant for fever and splenomegaly while laboratory results revealed transaminitis, cytopaenia, indirect hyperbilirubinaemia and elevated ferritin, raising the likelihood of both autoimmune haemolytic anaemia and HLH. He tested positive for Epstein-Barr virus (EBV), and bone marrow biopsy revealed hypercellular marrow with haemophagocytosis and no evidence of malignancy. High dose steroids were initiated with significant improvement in haemoglobin, resulting in a final diagnosis of HLH secondary to acute EBV infection. The patient was discharged on continued high-dose prednisone with planned taper and consideration of outpatient rituximab therapy for 4 weeks. High clinical suspicion and prompt evaluation were critical to early treatment and decreased morbidity.

Alexandra Halalau,1,2 Fadi Odish,3 Zaid Imam,4 Aryana Sharrak,2 Evan Brickner,2 Paul Bumki Lee,2 Adam Foglesong,1 Adrian Michel,1 Inayat Gill,1 Lihua Qu,2,5 Amr E Abbas,2,6 Christopher F Carpenter1,2,7 1Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA; 2Oakland University William Beaumont School of Medicine, Rochester, MI, USA; 3Section of Gastroenterology and Hepatology, Department of Internal Medicine, Wright State University, Dayton, OH, USA; 4Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA; 5Outcome Research Department, Research Institute Beaumont Health, Royal Oak, MI, USA; 6Cardiovascular Department, Beaumont Health, Royal Oak, MI, USA; 7Infectious Disease Section, Beaumont Health, Royal Oak, MI, USACorrespondence: Alexandra HalalauWilliam Beaumont Hospital, 3601 W 13 Mile Road, Royal Oak, MI, 48073, USATel +1 248 551-3481Email Alexandra.Halalau@beaumont.orgBackground: Most outpatients with coronavirus disease 2019 (COVID-19) do not initially demonstrate severe features requiring hospitalization. Understanding this population’s epidemiological and clinical characteristics to allow outcome anticipation is crucial in healthcare resource allocation.Methods: Retrospective, multicenter (8 hospitals) study reporting on 821 patients diagnosed with COVID-19 by real-time reverse transcriptase–polymerase chain reaction assay of nasopharyngeal swabs and discharged home to self-isolate after evaluation in emergency departments (EDs) within Beaumont Health System in March, 2020. Outcomes were collected through April 14, 2020, with a minimum of 12 day follow-up and included subsequent ED visit, admission status, and mortality.Results: Of the 821 patients, mean age was 49.3 years (SD 15.7), 46.8% were male and 55.1% were African-American. Cough was the most frequent symptom in 78.2% of patients with a median duration of 3 days (IQR 2– 7), and other symptoms included fever 62.1%, rhinorrhea or nasal congestion 35.1% and dyspnea 31.2%. ACEI/ARBs usage was reported in 28.7% patients and 34.0% had diabetes mellitus. Return to the ED for re-evaluation was reported in 19.2% of patients from whom 54.4% were admitted. The patients eventually admitted to the hospital were older (mean age 54.4 vs 48.7 years, p=0.002), had higher BMI (35.4 kg/m2 vs 31.9 kg/m2, p=0.004), were more likely male (58.1% vs 45.4%, p=0.026), and more likely to have hypertension (52.3% vs 29.4%, p< 0.001), diabetes mellitus (74.4% vs 29.3%, p< 0.001) or prediabetes (25.6% vs 8.4%, p< 0.001), COPD (39.5% vs 5.4%, p< 0.001), and OSA (36% vs 19%, p< 0.001). The overall mortality rate was 1.3%.Conclusion: We found that 80.8% of patients did not return to the ED for re-evaluation. Sending patients with COVID-19 home if they experience mild symptoms is a safe approach for most patients and might mitigate some of the financial and staffing pressures on healthcare systems.Keywords: COVID-19, infectious disease, epidemiology, SARS-CoV-2, demographics, outpatient

Pancreatic ganglioneuromas occur mostly in children and rarely in young adults, with no cases reported in adults older than 60 years. An 86-year-old-woman, with active advanced multiple myeloma, presented with epigastric pain for 2 days. Abdominal and pelvic computed tomography demonstrated a distended gallbladder, mildly dilated biliary tree, and a 13 × 8-mm hypodense mass in pancreatic body, without extrapancreatic invasion at endoscopic ultrasound. Fine-needle endoscopic ultrasound–guided core biopsy revealed characteristic histopathology of ganglioneuroma, as confirmed by immunohistochemical positivity for S100, SOX-10, and synaptophysin. This demonstrates novel finding of pancreatic ganglioneuroma occurring in the elderly. Lesion inclusion in the differential diagnosis may mandate tissue for pathologic diagnosis and complete lesion resection.

Goals and backgroundThe utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with HE.StudyRetrospective review of cirrhotic patient encounters with HE between 2016 and 2018 at Beaumont Health, in Michigan was performed. A low-risk (LR) indication for HCT was defined as altered mental status (AMS), which included dizziness and generalised weakness. A high-risk (HR) indication was defined as trauma/fall, syncope, focal neurological deficits (FNDs) or headache. Descriptive statistics and univariate/multivariate analyses by logistic regression were performed using SPSS to identify HCT abnormality correlates.ResultsFive hundred twenty unique encounters were reviewed. Mean age was 63.4 (12.1) years, 162 (37.5%) had alcoholic cirrhosis and median Model for End-Stage Liver Disease (MELD)-score was 17 (13–23). LR indication was reported in 408 (78.5%) patients and FNDs reported in 24 (4.6%) patients. Only 13 (2.5%) patients were found to have an acute intracranial pathology (seven haemorrhagic stroke, two ischaemic stroke, four subdural haematoma). Aspirin use prior to presentation (aOR 4.6, 95% CI 1.1 to 19.2), and HR indication (aOR 7.3, 95% CI 2.3 to 23.8) were independent correlates of acute intracranial pathology on HCT. Age, sex, MELD-score, haemoglobin, platelet count, race and cirrhosis aetiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 in HR indications versus 82 for LR indications.ConclusionRoutine HCTs in cirrhotic patients presenting with HE with AMS in the absence of history of trauma, headache, syncope, FNDs or aspirin use is of low diagnostic yield.

Radiation esophagitis is a serious complication occurring in patients receiving radiotherapy for head and neck cancers. Current treatment with proton pump inhibitors and mucosal protectants provides symptomatic relief with few studies showing improvement in erosive esophagitis or ulceration. Use of self-expandable metal stents (SEMS) in cases of erosive radiation esophagitis refractory to medical therapy has not been studied. We report a case of a patient presenting with recurrent hematemesis from late (chronic) radiation esophagitis with bleeding esophageal ulceration successfully treated with SEMS placement after failure of conservative medical management, proposing a possible utility for SEMS in this setting.

INTRODUCTION: Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States. DESIGN: Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h. RESULTS: The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h. CONCLUSION: Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.

Introduction: A Dieulafoy's lesion is a large tortuous arteriole that can cause life-threatening hemorrhagic shock, occurring in 1-2% of cases of upper gastrointestinal bleeding. It is an underdiagnosed cause of obscure massive hematemesis because its small size and location makes it difficult to visualize. Case Description/Methods: An 84-year-old white male with atrial fibrillation, on apixaban, presented for large-volume hematemesis. Physical examination revealed blood pressure of 80/60 mmHg, pulse of 110 beats/minute, orthostasis, temperature of 36.9°C, and an ill-appearing individual with a diffusely tender abdomen. Laboratory examination revealed leukocytes of 19.9 bil/L (normal: 3.5-10.1 bil/L), hemoglobin of 11.2 g/dL (normal: 13.5-17 g/dL) which dropped to 7.5 g/dL in 2 hours. Computed tomography of the abdomen and pelvis without contrast demonstrated diffusely distended stomach with internal debris concerning for blood products. He was intubated for airway protection and transfused 1-unit of packed-erythrocytes. Intravenous pantoprazole and norepinephrine were administered, and he was transferred to the medical intensive care unit. He was also incidentally found to have coronavirus disease (COVID-19). With precautions taken for COVID-19 infection, he underwent emergent esophogastroduodenoscopy revealing a bleeding vessel, Dieulafoy's lesion, proximal to the gastroesophageal (GE) junction (Figure 1) with a huge amount of clotted blood at the gastric fundus and body. The vessel was injected with 3 mL of epinephrine and two clips were placed achieving hemostasis. The next day, the patient's blood pressures improved, his hemoglobin stabilized to 9.2 g/dL and he was extubated. Discussion: A Dieulafoy's lesion is commonly located in the stomach, with majority found proximal to the GE junction however it can be hidden in the gastric mucosal folds. Treatment includes heat probe coagulation, epinephrine injection or banding. Our case demonstrates that rare diagnoses such as a Dieulafoy's lesion should be considered in the differential diagnosis in patients presenting with hematemesis as timely endoscopic treatment can often result in immediate cessation of bleeding. When the bleeding vessel cannot be located, these patients are often referred for angiography.

INTRODUCTION: Collagenous colitis (CC) classically produces watery diarrhea attributed to a thick collagen layer blocking colonic reabsorption of water/electrolytes Four cases of CC have been associated with protein-losing enteropathy (PLE), but CC by itself should not produce PLE because the colon does not reabsorb amino acids About ten cases of collagenous duodenitis with CC have been reported, but none had (severe) PLE A novel case is reported of severe PLE associated with collagenous duodenitis and CC This association is biologically reasonable because duodenum/small bowel is responsible for amino acid absorption, which could be blocked by collagenous duodenitis CASE DESCRIPTION/METHODS: A 65-year-old female with a heavy smoking history and no prior renal insufficiency, presented with 5 watery stools/day and 14 kg involuntary weight loss for 3 months Physical exam revealed dry mucous membranes and non-tender, non-distended abdomen Laboratory tests revealed serum creatinine 5 3 61 mg/dL (normal: 0 6-1 3 mg/dL) Stool tests for Clostridium difficile toxins and ova and parasites were negative Stool culture for bacterial pathogens was sterile Abdomino-pelvic CT was within normal limits Colonoscopy with biopsy of endoscopically normal colonic mucosa revealed CC (Fig 1) She was treated with aggressive IV hydration and budesonide with reversal of renal failure She was readmitted 1 month later for refractory nausea and vomiting Physical exam revealed severe anasarca, with albumin 5 2 3 g/dl (normal: 3 5-4 9 g/dL), normal liver and cardiac functions and no proteinuria Stool alpha-1-antitrypsin was 369 mg/dl (normal: < 54 mg/dl), diagnostic of PLE EGD revealed endoscopically normal duodenum Histopathology of endoscopic biopsies showed severe collagenous duodenitis (Figs 2, 3) She was diagnosed with severe PLE, from collagenous duodenitis/CC and malnutrition, treated with azathioprine and budesonide She returned 2 months later with dyspnea, worsening diarrhea, severe hypoalbuminemia, and hypogammaglobulinemia She tested positive for COVID-19 She was discharged 11 days later without dyspnea and TPN was initiated DISCUSSION: This case demonstrates that simultaneous presentation of collagenous duodenitis/CC can result in PLE due to the thick collagen layer preventing absorption of amino acids in small bowel and water/electrolytes in colon Immunosuppression from hypoalbuminemia, hypogammaglobulinemia, and malnutrition from PLE rendered this patient susceptible to severe COVID- 19 infection (Figure Presented)

This article documents the increasing use of the English curse word fuck worldwide, as well as its degree of adaption into the host language, its syntactic function, and its meaning and its strength as taboo. Comparing the use of fuck with a special focus on the Nordic countries (Norway, Denmark, and Iceland) with its use in Eurasia and Africa (with different alphabets, namely Cyrillic in Russia, Devanāgarī in India and Ge’ez script in Ethiopia), we found some similar developmental patterns, but also differences, for example to what degree the English loan word has replaced local curses and in what ways among social groups within a country. Comparing the terms used for the same concept was challenging because some countries have better text corpora and more research on written languages and especially on taboos, and those without such resources required additional minor investigations for a baseline. Findings revealed that fuck has spread worldwide from English, and it is commonly used in Nordic languages today. In Russian fuck is also adopted into the heritage language to a relatively high degree, and it has further gained importance in the vocabulary of India, where English has become the most used language by the higher and middle classes, but less so by lower classes. In contrast, the study of Amharic language in Ethiopia shows that the f-word is rarely used at all, and only by youngsters. We found a pattern starting from the outer North with Icelandic having adapted and adopted the word fuck the most, a slight decline in use in Norwegian and Danish, with less adaption and use in Russian, even less in Indian-English or Hindi, and being more or less absent in the African language Amharic. Formally though it is used conceptually both in Hindi and Amharic.

Background: Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis. Aim: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported. Methods: Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: [“epidural pneumatosis” OR “pneumorrhachis”] AND [“diabetes” OR “diabetic ketoacidosis” or “DKA”]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper. Results-systematic-literature-review: Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space. Results-illustrative-case-report: Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days. Study limitations: Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population. Conclusions: Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.