Lipodystrophy in HIV patients: its challenges and management approaches

HIV-associated lipodystrophy is a term used to describe a constellation of body composition (lipoatrophy and lipohypertrophy) and metabolic (dyslipidemia and insulin resistance) alterations that accompany highly active antiretroviral therapy. These changes, which resemble metabolic syndrome, have been associated with a variety of adverse outcomes including accelerated cardiovascular disease. The body composition and metabolic changes appear to cluster in HIV infection, although they are distinct alterations and do not necessarily coexist. Epidemiological studies have demonstrated multiple pathogenic influences associated with host, disease, and treatment-related factors. The adverse treatment effects were more prominent in early regimens; continued drug development has led to the application of metabolically safer regimens with equal or greater potency than the regimens being replaced. Disease-related factors include HIV infection as well as inflammation, immune activation, and immune depletion. The body composition changes promote anxiety and depression in patients and may affect treatment adherence. Treatment of dyslipidemia and alterations in glucose metabolism is the same as in non-HIV-infected individuals. Lipoatrophy is managed by strategic choice of antivirals or by antiviral switching, and in some cases by plastic/reconstructive surgery. Lipohypertrophy has been managed mainly by lifestyle modification, ie, a hypocaloric diet and increased exercise. A growth hormone releasing factor, which reduces central fat, has recently become available for clinical use

Emphysematous gastritis: a case series and review of the current trend favoring conservative management

Emphysematous gastritis [EG] is a rare condition associated with a high mortality rate which involves the invasion of gas-forming organisms into the gastric mucosa. Risk factors include mucosal defects such as gastric ulceration as well as systemic illnesses such as diabetes. Clinical presentation includes abdominal pain as well as signs of sepsis. Air in the gastric wall and portal venous system on abdominal imaging are characteristic radiographic findings. The ideal treatment of the condition is unclear, given its rarity. Cases have typically involved either surgical options or conservative management with bowel rest and intravenous antibiotics. We report on two patients treated successfully at our institution with conservative management and a review of the current knowledge in this area. Recent case literature shows a trend towards conservative management for emphysematous gastritis with several successfully managed cases, suggesting that patients can avoid surgery in the majority of cases. Keywords: Case report; Conservative management; Emphysematous gastritis; Stomach

Vedolizumab (Entyvio®) for the Treatment of Pyoderma Gangrenosum in a Crohn\u27s Disease Patient

Vedolizumab is a humanized monoclonal integrin blocker with gut selective effects on lymphocyte trafficking. Its efficacy and safety for the treatment of moderate to severe Crohn\u27s disease and ulcerative colitis were demonstrated by phase III GEMINI studies (GEMINI 1 trial: Vedolizumab as Induction and Maintenance Therapy for Ulcerative Colitis; GEMINI 2 trial: Vedolizumab as Induction and Maintenance Therapy for Crohn\u27s Disease). Post hoc analyses of the GEMINI studies further showed the potential benefit of vedolizumab for treating various extraintestinal manifestations, including arthralgias, pyoderma gangrenosum, erythema nodosum, and uveitis. However, findings lacked statistical significance highlighting the need for more clinical data describing vedolizumab\u27s effects on extraintestinal manifestations. There are currently few case reports describing the effect of vedolizumab on pyoderma gangrenosum specifically. We report a Crohn\u27s disease patient whose severe pyoderma gangrenosum of her legs, abdomen, and face have been inactive since starting vedolizumab. Keywords: crohn\u27s disease; entyvio; inflammatory bowel disease; pyoderma gangrenosum; ulcerative colitis; vedolizumab

P066 Real-World Experience of Ustekinumab in Crohn\u27s Disease Patients With Prior Anti-TNF Therapy at a Tertiary Care Hospital

Background: Ustekinumab (UST) is a monoclonal antibody against the p40 subunit of IL-12/23. It is approved for the treatment of moderate to severe Crohn\u27s disease (CD) and Ulcerative Colitis. We performed a retrospective study to demonstrate the efficacy and outcomes of UST in CD patients who received prior anti-TNF therapies. Methods: We collected a list of all patients who received UST until May 2021. In addition, the list was screened for patients who were on anti-TNFs for treatment of CD in the past. Data was collected for patient demographics, disease characteristics, comorbidities, disease phenotype, age of initiation of UST, prior biologic therapy, time since last biologic therapy, concomitant use of steroids or immunomodulator, inflammatory markers, induction of remission, deep remission. Chi-square tests were used for statistical analysis. Results: We identified 34 patients (59% females) with CD on UST who failed at least one anti-TNFs before induction with UST. Clinical remission was documented in 70.5% of patients. 29 percent of patients who achieved clinical remission were on concomitant steroids or immunomodulators at the time of induction of remission along with UST. Fifty percent of patients had a fistulizing disease, of which 70% achieved clinical remission with UST. C-reactive protein (CRP) was reported in 70 percent of patients. Mean CRP prior to initiation of UST was 2.4. CRP trended down to 1.98 (p = 0.079, 95% CI: -0.064-1.08). Eighteen percent of patients had fecal calprotectin reported. Mean fecal calprotectin before initiation of UST was 386, and it trended down 175 while on UST (p = 0.148, 95% CI: -106.25-528.46). Conclusion: Our study demonstrates that remission rates in CD patients who have failed prior anti-TNF therapy are high, including for patients with perianal disease. In patients with fistulizing CD, we suggest using UST for higher rates of remission after induction. We also found that for fecal calprotectin, although an excellent surrogate of colon inflammation, compliance amongst patients remains low

Abrikossoff Tumor (Granular Cell Tumor) Presenting in the Esophagus

Abrikossoff tumors, also known as granular cell tumors, are rare and often benign soft tissue neoplasms of Schwann cell origin. The vast majority of cases are reported in the skin and subcutaneous tissue. Only 0.001% of Abrikossoff tumors are estimated to occur in the esophagus. We report a rare case of Abrikossoff tumor of the esophagus in a patient who underwent esophagogastroduodenoscopy for abdominal pain and nausea. Keywords: abrikossoff tumor; esophagogastroduodenoscopy (egd); esophagus; granular cell tumor

Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective

Background and aims: Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI. Methods: Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis. Results: Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72). Conclusions: In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care