Leonard J. Chabert Medical Center

This work deals with the generation of theoretical correlation matrices with specific sparsity patterns, associated to graph structures. We present a novel approach based on convex optimization, offering greater flexibility compared to existing techniques, notably by controlling the mean of the entry distribution in the generated correlation matrices. This allows for the generation of correlation matrices that better represent realistic data and can be used to benchmark statistical methods for graph inference.

Alternatives to the conventional farrowing crates for indoor keeping can be divided into two principally different pen types. Systems with partly solid floor that allows the sow to divide the pen area into functional zones, and for provision of nest materials enabling sows to carry out net-building behaviour in a more natural way. The other system is pens with fully slatted floor, where sows are unable to divide the pen into functional zones, and where allocation of nest materials as straw is difficult due to the risk of clotting the slats and the slurry system. Within these two different pen systems either zero confinement or temporary confinement can be practiced. Zero confinement can also be achieved by keeping sows outdoor in a larger fenced paddock with voluntary access to a farrowing hut positioned in the paddock. In the following we describe alternatives to the permanent confinement system and the likely outcome of the alternative systems on animal welfare including piglet mortality. Further, an overview is given on national legislation and voluntary label schemes in various EU countries where permanent confinement is banned.

Introduction: Adenocarcinoma (NSCLC) is the most common primary lung cancer in the United States, making up 30% of all lung cancers and accounting for nearly 25% of all cancer mortality. Lung cancer metastasis occurs in many organs, including the adrenal glands, bone, lymph nodes, brain and liver. More commonly associated with small cell lung carcinoma, metastasis of non-small cell lung carcinoma to the stomach and small bowel have been rarely reported, many of which were found incidentally or during autopsy. We present a case of a patient with NSCLC who developed metastasis to the duodenum almost four months after diagnosis. Case Description/Methods: The patient is a 43 year old female with a medical history of NSCLC and recent pulmonary embolism treated with eliquis presented with intermittent episodes of hematemesis and hemoptysis for three weeks. She described medium sized blood clots during episodic coughing and vomiting. On exam, she was afebrile, BP was 187/78, pulse 140, RR 26, and SpO2 94% on room air. She was ill appearing exhibiting epigastric tenderness without guarding. Lab studies revealed a Hg of 9.3, ALK 296, AST 67, ALT 56 and an elevated lactic acid at 4.4. All other lab tests were normal. Two large bore IVs were placed, initiated PPI, type and screened. Eliquis was stopped and the patient was transferred to the ICU for further monitoring. An EGD revealed a 2.5 cm fungating mass in the first portion of the duodenum, which did not require cauterization or clipping. Pathology reported a malignant mass and cells consistent with metastatic carcinoma from the lung primary. After discussing the pathology results with the patient, a decision was made to discontinue anticoagulation as the risk of bleeding outweigh the risk of pulmonary embolism (Figure). Discussion: Common primary tumors that metastasize to the duodenum are renal cell carcinoma, melanoma, breast cancer and small cell carcinoma of the lung. Metastasis to the small intestine may be indolent and a challenge to diagnosis given vague symptoms like nausea, vomiting, abdominal pain and lack of overt bleeding, which can lead to a delay in endoscopy and diagnosis. In this case, anticoagulation likely exacerbated bleeding resulting in a need for an EGD. Duodenal metastasis is a grim prognosis with a survival rate less than 12 months. The case displays that distant metastasis from a primary malignancy can present with vague gastrointestinal symptoms and should not be discarded in certain clinical settings.Figure 1.: 2.5 cm fungating mass in the first portion of the duodenum.

Introduction: Fundic gland polyps are commonly encountered in Western countries where PPI use is high and H.pylori prevalence is low, thought to be precipitated by an iatrogenic hypergastrinemic state. They can also be seen in polyposis syndromes: FAP, MAP, and GAPPS. Those associated with PPI typically have no malignant potential, however may show low grade dysplasia. Patient with GAPPS have a high risk of gastric cancer, while fundic gland polyps associated with FAP rarely progress to malignancy. We present a case of a patient without known family hx of polyposis syndrome presenting with a high burden of fundic gland polyps exhibiting low and high-grade dysplasia. Case Description/Methods: A 57F with PMH of HTN, HLD, GERD, hypothyroidism was referred to GI clinic for evaluation of intermittent, burning epigastric abdominal pain, worse after eating. Her symptoms showed minimal response to PPI; endorsed occasional NSAID use. No known FHx of gastric cancer. 4 years prior EGD showed evidence of gastritis and C-scope with hyperplastic polyps. She underwent repeat C-scope which showed diverticulosis and EGD which revealed over 20 3-20 mm polyps throughout the stomach. Some large and ulcerated polyps were removed, but overall none removed exhibited drastically concerning appearance to suggest malignancy. She reported improvement in her symptoms post-polypectomy along with PPI BID. Antral biopsies were negative for H.pylori. Interestingly pathology of the polyps revealed fundic gland polyps with low and high-grade dysplasia; findings were confirmed by a second pathologist. Given these findings, plans were made to continue with serial EGDs until all polyps could be removed. At the time of writing, she has undergone 6 additional EGDs with polypectomy with all further pathology showing fundic gland polyps negative for dysplasia or malignancy. Discussion: Endoscopists sometimes rely on the gross morphology of polyps in assessing the probability of malignant potential and determining the need for polypectomy. As illustrated by this case, visual inspection alone may not suffice in developing therapy plans. The resultant implications to practice patterns is significant, as practitioners may opt to similarly aim to remove all polyps, though tedious, over serial EGDs given the risk of potentially malignant polyps masquerading behind a benign facade. Furthermore, there may be implications to endoscopic surveillance trends in such patients that exhibited high-grade dysplasia on pathology in the past.Figure 1.: Figure A - Endoscopic view of mass Figure B - CD117 Negative Figure C - S-100 Positive Figure D - Sox1 Positive.

INTRODUCTION: The current regimen of clear liquid diet prior to colon prep is uncomfortable and often fraught with various issues resulting in non-compliance. This has lead to poor colonoscopy preparations delaying diagnosis and treatment, and raising healthcare costs. Recently better-tolerated diets have been studied one of which involves the “low residue diet.” This diet involves various food items that are believed to not only have a short GI course, but also stimulate gut motility. Among them include boiled or scrambled eggs. Several studies have been undertaken with results generally favorable for the low residue diet. No studies, to our knowledge, have been done specifically targeting a low socioeconomic population that may have limited food access or low literacy rates making it difficult to follow specific instructions. This study was designed to target such a group by devising simple and affordable instructions with the overall goal to increase patient satisfaction, compliance, and obtain adequate prep quality. METHODS: A single blinded study was devised that involved 72 patients, with 36 patients in the experimental arm (Egg Breakfast/Low Residue) and 36 patients, age and gender matched, in the conventional arm (Clear Liquid Diet). Study was carried out at a single hospital center with the following exclusion criteria: egg allergy, known history of gastroparesis or chronic constipation. Patients were instructed to have 1–2 boiled/scrambled eggs in the morning prior to colonoscopy and continue with clear liquids and then the standard bowel prep that evening. The performing gastroenterologist was not aware of which patients were in the study. RESULTS: The quality of the colonoscopy preparations was separated in poor, fair, adequate, and good. The results revealed 75% (27) of the patients in the experimental group with either adequate or good prep quality versus 72% (26) in the conventional group. This left 25% for poor/fair prep in the experimental and 28% in the conventional. CONCLUSION: In conclusion, the data collected yielded comparable results between the two arms. Moreover, when considering factors such as tolerably or satisfaction, Egg Breakfast Diet appears to be superior to conventional. Thus, this study despite targeting a challenging group of a low socioeconomic population with poor access to resources, limited funds, low literacy rates achieved its overall goal to increase patient satisfaction yet still maintain standard if not better results with colonoscopy prep quality.

Gonorrhea is the 2nd most common sexually transmitted disease in the US with 800,000 cases of gonorrhea each year. Disseminated gonorrhea infection occurs in 0.5 percent - 3 percent of these patients and is more frequent in woman younger than 40 years of age. A 36 year old woman with a history of polysubstance abuse presented with 10 day history of feeling generally unwell. At presentation, vitals were remarkable for tachycardia and hypotension. Physical exam was remarkable for conjunctival pallor, bibasilar crackles, and tachycardia with grade III/VI systolic murmur loudest over the 2nd inter-costal space and loudest with expiration. No skin lesions were noted. Labs demonstrated leukocytosis (WBC 20,200 with 84 percent neutrophils);, anemia (Hb 6.7);, thrombocytosis (platelets 423 k/uL);, abnormal liver function tests (alkaline phosphatase 239 IU, AST 151 IU ALT 71 IU, albumin 2.5g/dL);, PT/INR 17.1/1.5. Troponin 0.42, BNP 823, D-dimer 619, and a urine drug screen that was positive for benzodiazepines, opiates, barbiturates, amphetamine, and THC. Hep panel and HIV were negative. Chest radiograph showed mild cardiomegaly and early interstitial edema. The patient was placed on broad spectrum antibiotics and given adequate fluid resuscitation and blood products. Blood cultures grew Neisseria gonorrhoeae. 2D ECHO showed a large pedunculated/mobile echo density adherent to the non-coronary and lefts cusps of the aortic valve. Proximal aortic root and aorto-mitral continuity were thickened, consistent with aortitis and/or abscess formation. Initial EKG on arrival showed junctional tachycardia which progressed into complete heart block. Cardiology was consulted and a pacemaker was placed emergently. However despite all aggressive measures the patient died of cardiac complications. Endocarditis is a rare complication of disseminated gonorrhea, occurring in only 1-2 percent of patients with gonoccocemia. The aortic valve is most commonly affected. Valve replacement is warranted in cases with severe dysfunction. Mortality remains around 19-20. Neisseria gonorrhoeae endocarditis should be included in the differential diagnosis in sexually active patients with endocarditis.

Cardio-oncology is a collaborative approach between cardiologists and oncologists in the treatment of patients with cancer and heart disease. Radiation and chemotherapy have played a major role in the decreased cancer-related mortality achieved in the past 2 decades. However, anthracycline-, tyrosine kinase-, and radiation-based therapies are each associated with independent cardiovascular (CV) risks, and these risks are cumulative when these therapies are used in combination. We analyzed several published articles, studies, and guidelines to provide a focused review of cardiotoxicity associated with anthracyclines, human epidermal growth factor receptor 2 inhibitors, and radiation therapy and its management. The focus on CV risk among individuals being treated with cardiotoxic agents is important because once the cancer is cured, CV disease becomes the number 1 cause of death among cancer survivors. Cardio-oncology focuses on assessing CV risk prior to starting therapy, optimizing modifiable risk factors, and providing surveillance and treatment for any early signs of cardiotoxicity in patients undergoing radiation and chemotherapy. A collaborative approach between oncologists and cardiologists is integral to the optimal care of patients with cancer. Although radiation and chemotherapy treatments have evolved with the aim of targeting cancer cells while having minimal effect on the heart, the increased risk of cardiomyopathy in patients receiving these treatments remains significant. Proper screening and treatment of cardiotoxicity are essential for patients with cancer. As cardiac diseases and cancer remain the first and second causes of mortality in developed nations, respectively, cardio-oncology is the answer to this group of individuals who are especially vulnerable to both causes of mortality.

Voght Koyonagi Harada syndrome (VKH) is a rare systemic disorder involving many organ systems. VKH results from T-cell mediated autoimmune reaction against melanocyte antigens in genetically predisposed patients.

While there have been several studies evaluating the prevalence of electrocardiogram (ECG) conduction abnormalities such as left bundle branch block (LBBB) and atrial fibrillation (AF) in the general population, there are none currently describing that of the Hispanic population in patients with systolic heart failure. Given the need for examining race and ethnic differences in ECG abnormalities, the primary purpose of this study is to compare the prevalence of ECG abnormalities in three systolic heart failure populations from two indigent heart failure clinics. The study examines EKG difference among three ethnic groups: Caucasians, African-Americans, and Hispanics. We also investigated ECG differences between genders. This is a cross sectional study. A total of 926 patients were enrolled in a systolic heart failure disease management program in two safety net hospitals in Florida and Louisiana. Inclusion criteria was an ejection fraction (EF) < or equal to 40% by echocardiography, and ECGs which were obtained closest to the date of enrollment. Caucasian patients had more atrial fibrillation than African-American patients. Hispanics had more paced rhythm, left bundle branch block and abnormal QT intervals than Caucasian or African-American patients. A QRS interval greater than 120 milliseconds (ms) was less prevalent among African-Americans. ECG conduction abnormalities vary across race, ethnicity, and gender. Adequate medical attention should be addressed to these variations since relevant ECG findings can offer additional guidance for therapeutic interventions, as well as provide important prognostic information and potentially modify morbidity and mortality rates.

The authors sought to obtain objective evidence for impacting the American College of Cardiology Heart Failure Guidelines for the routine use of serial echocardiography by assessing the reliability of the use of clinician-assessed patient symptoms and New York Heart Association (NYHA) functional classification compared with ejection fraction (EF) measured by echocardiography. A prospective study in 256 patients with systolic heart failure (HF) enrolled into an HF disease management program with EF ≤40% and at least 2 annual echocardiograms were included. Only 86 of 256 (33.5%) patients were correctly classified by NYHA class as showing improvement, no change, or deterioration as compared with echocardiographic assessments. Patients whose NYHA class showed no change between echocardiograms had the lowest survival rate. Quantification in patient's status with NYHA classification is not always a reliable assessment to evaluate prognosis and guide medical therapy for patients with systolic HF.