Karthik Gnanapandithan

BACKGROUND Adalimumab is a humanized therapeutic monoclonal antibody that blocks tumor necrosis factor-alpha (TNF-a). Kaposi sarcoma is a rare complication associated with adalimumab treatment. It is a cancer with an indolent course and is highly responsive to chemotherapy agents. This report describes the case of a 65-year-old HIV-negative man with gastrointestinal Kaposi sarcoma associated with adalimumab treatment for cardiac sarcoidosis. CASE REPORT A 65-year-old man with cardiac sarcoidosis on adalimumab presented with gastrointestinal bleeding. Endoscopic evaluation revealed Kaposi sarcoma involving the stomach and colon, confirmed by histopathology showing spindle cell proliferation with vascularity and human herpesvirus-8 positivity. HIV testing was negative. Adalimumab was discontinued, and he was treated with paclitaxel. He improved, and the lesions were resolved with treatment as demonstrated in repeat endoscopy. The patient was moved to active surveillance. CONCLUSIONS The endoscopic and clinical presentations of gastrointestinal Kaposi sarcoma are highly variable. In most cases, definitive diagnosis requires endoscopic biopsy and histopathology. Multiple and deep endoscopic biopsies are crucial to avoid false-negative results. Maintaining a high index of suspicion of Kaposi sarcoma in those on immunosuppressants like adalimumab is vital for the timely diagnosis and treatment of this potentially fatal condition. Such patients are usually responsive to withdrawal of the immunosuppressive agent and/or chemotherapy.

Kaposi sarcoma (KS), an angioproliferative neoplasm driven by human herpesvirus 8, predominantly affects patients with acquired immune deficiency syndrome (AIDS) or those on immunosuppressive therapy. Gastrointestinal involvement in KS is underreported, with limited literature highlighting its clinical significance and morphological diversity on endoscopy. This case report illustrates the complexities of diagnosing and managing gastrointestinal KS in an AIDS patient who presented with upper gastrointestinal bleeding. The diagnosis was established through the characteristic endoscopic appearance of the lesions, supported by histopathological confirmation. This case emphasizes the variable endoscopic manifestations of KS, ranging from linear ulcers to nodular lesions, and underscores the necessity for heightened clinical vigilance and multiple deep biopsies to avoid false‐negative results. Treatment options, primarily palliative, include highly active antiretroviral therapy, chemotherapy, and radiation, yet the prognosis remains poor with high short‐term mortality. This report contributes to the sparse literature on gastrointestinal KS, advocating for increased awareness and early intervention to potentially improve outcomes in this patient population.

HCV is marked by genetic diversity that impacts disease progression and outcome. Using the NHANES data from 266 HCV‐infected adults (2011–2020), this study infers that genotype 1a is the most prevalent (60.2%). Genotype 3 was associated with higher transaminase levels, though not statistically significant. These findings suggest a more aggressive phenotype for genotype 3. Despite pan‐genotypic treatment guidelines, this underscores the importance of continued HCV genotype surveillance and consideration for genotype‐specific treatment and monitoring strategies.

Background The effect of radiation on the ileal pouch is less well studied in patients with inflammatory bowel disease (IBD) and ileal pouch-anal anastomosis. Aims This retrospective study investigates the impact of external radiation therapy on the outcomes of ileal pouches. Methods The study included 82 patients with IBD and ileal pouches, of whom 12 received pelvic radiation, 16 abdominal radiation, 14 radiation in other fields, and 40 served as controls with no radiation. Pouch-related outcomes, including pouch failure, worsening of symptoms, pouchitis, and development of strictures, along with changes in Pouch Disease Activity Index (PDAI) scores pre- and post-radiation were assessed. Results The pelvic radiation group exhibited a significantly higher rate of pouch failure (25%, p < 0.004) and worsening pouch-related symptoms (75%, p = 0.012) compared to other groups. Although not statistically significant, a higher incidence of pouchitis was observed in the pelvic radiation group (45.5%, p = 0.071). Strictures were more common in the pelvic radiation group (25%, p = 0.043). Logistic regression analysis revealed that pelvic radiation significantly increased the odds of pouch-related adverse outcomes (OR 5.66; 95% confidence interval: 1.61–21.5). Conclusion Pelvic radiation significantly impacts the outcomes of ileal pouches in patients with IBD, increasing the risk of pouch failure, symptom exacerbation, and structural complications. These findings underscore the need for careful consideration of radiation therapy in this patient population and highlight the importance of closely monitoring and managing radiation-induced pouch dysfunction.

Hepatitis C virus (HCV) is a global health issue with an estimated prevalence of 2.4 to 3 million people in the US and 58 million worldwide. Previous reports from the US have shown that close to half of those with the infection are unaware of their status. Although the current therapy for HCV is very effective, the primary barrier has been the inability to diagnose a large fraction of those infected. We studied public awareness of HCV in the US using National Health Nutrition and Examination Survey data from 2013 to 2020. Our aim was to measure awareness of infection in individuals with HCV and identify possible barriers to diagnosis. In total, 206 individuals with HCV were included in the weighted analysis. The weighted awareness of infection was 60.1%, suggesting that over 0.8 million are unaware nationally. Awareness was significantly low in the Mexican American and Asian populations. Non-US citizens and non–US-born individuals also had poor awareness. The transaminases were more elevated in those unaware of the infection, suggesting their higher risk of liver fibrosis. Although the proportion of infected people aware of their illness has been rising, over 0.8 million are still unaware of their infection and their risk of liver damage. We believe policy measures focused on further intense screening and educational campaigns, particularly in high-risk groups, are vital in realizing the World Health Organization’s goal of eliminating HCV as a global health threat.

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

There are several classes of medications that can cause prolongation of the corrected QT (QTc) interval and potentially Torsades de Pointes (TdP). Most of these medications are commonly used in the emergency department, and interaction between these medications increases the risk of this iatrogenic complication. We describe a patient on methadone therapy who developed TdP after she received metoclopramide and metronidazole. Interaction between different classes of medications can increase the risk of QTc prolongation and TdP. Awareness of this condition and its risk factors need continuous reinforcement among all hospital personnel to reduce the risk of this life-threatening complication.