Background. Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a high-quality screening program, especially in safety net systems with limited resources. We sought to assess colonoscopy quality and ensure appropriate surveillance in a network of safety net practices. Methods. We identified age-eligible patients ages 50-75 within a Federally Qualified Health Center (FQHC) clinic system with evidence of colonoscopy in preceding 10 years. We performed chart reviews to assess key aspects of colonoscopy quality: bowel preparation quality, evidence of cecal intubation, cecal withdrawal time, and the adenoma detection rate. We then utilized established guidelines to assess and revise surveillance colonoscopy intervals, determine whether appropriate surveillance had taken place, and schedule overdue patients as appropriate. Results. Of 26,394 age-eligible patients, a total of 3,970 patients had evidence of prior colonoscopy and 1,709 charts were selected and reviewed. Mean age was 57, 54% identified as women and 51% identified as Hispanic. Of 1709 colonoscopies reviewed, 77% had data on bowel preparation, and of those, 85% had adequate preparation quality. Cecal intubation was documented in 89% of procedures. Adequate cecal withdrawal time was documented in 59% of those with documented cecal intubation. Overall adenoma detection rate was 42%. Initial surveillance interval was clearly stated in 72% ( n = 1238 ) of procedures. Of these, initial recommended intervals were too short in 24.5% ( n = 304 ) and too long in 3.6% ( n = 45 ). A total of 132 patients (10.7%) were overdue for appropriate surveillance and were referred for follow-up colonoscopy. Conclusions. Overall, the quality of screening colonoscopy was high, but reporting was incomplete. We found fair adherence to evidence-based surveillance guidelines, with significant opportunities to extend surveillance intervals and improve adherence to best practices.
Cannabis is one of the most commonly used illicit drugs and is now legally used recreationally or medicinally in more than half of the United States. Cannabis use has been proposed as a cause of acute pancreatitis in patients with no other identifiable etiology. Our case highlights acute pancreatitis in a young male patient with no medical problems. It is important to identify the etiology in acute pancreatitis to prevent recurrence and complications.
INTRODUCTION: Bariatric surgery is one of the most commonly performed surgeries in the US. Several types exist including vertical sleeve gastrectomy (VSG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB). VSG and RYGB work through caloric restriction and neurohormonal changes. While there are many benefits of bariatric surgeries, there are also many complications including malabsorption of nutrients. CASE DESCRIPTION/METHODS: A 41-year-old African-American female with prior RYGB in 2014 presented to the hospital with general malaise, crampy abdominal pain, back and joint pain, nausea, dyspnea, and intermittent headaches with photophobia and phonophobia for the past 1 month. Labs revealed moderate microcytic anemia with hemoglobin of 9. Reticulocytes were depressed at 13.8. Metabolic panel was within normal limits. Rheumatologic panel including ANA, C3/C4 was negative. On exam, pertinent findings included tachycardia and epigastric tenderness with deep palpation. She had multiple 1 cm hyperpigmented circular lesions on the forehead, upper back, and bilateral upper arms. This prompted testing for copper and zinc, which were decreased at 26 and 54, respectively. CT abdomen/pelvis with contrast showed a small pericardial effusion but was otherwise normal. MRI brain showed no changes to prior images. The patient was discharged on a multivitamin with zinc and copper to follow up with her PCP. DISCUSSION: Copper and zinc are essential nutrients for humans and act as cofactors for a variety of metalloenzymes that participate in critical body functions. Deficiency in these nutrients is rare in the US as it’s found in commonly consumed foods. Copper deficiency results in brittle hair, skin depigmentation, neurologic dysfunction, and osteoporosis. Zinc deficiency can result in pustular skin rash, impaired taste, and immune dysfunction 4Zinc and copper are usually not added to multivitamins and not routinely measured by physicians, however patients with modified GI physiology due to bariatric surgery can be at risk. RYGB reduces the stomach’s capacity and re-routes ingested food to bypass the duodenum, where copper and zinc are absorbed. Patients with a history of gastric bypass surgery and ill-defined symptoms should be tested for trace mineral deficiencies. Patients who recently underwent a gastric bypass, particularly a RYGB, should be placed on a multivitamin that includes zinc and copper.
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