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Background and aim We sought to determine the association between alanine aminotransferase (ALT) in the normal range and mortality in the absence of liver dysfunction to better understand ALT’s clinical significance beyond liver injury and inflammation. Methods A cohort of 2,708 male and 3,461 female adults aged 20–75 years without liver dysfunction (ALT<30 in males & <19 in females, negative viral serologies, negative ultrasound-based steatosis, no excess alcohol consumption) from the National Health and Nutrition Examination Survey (NHANES)-III (1988–1994) were linked to the National Death Index through December 31, 2015. Serum ALT levels were categorized into sex-specific quartiles (Females: <9, 9–11, 11–14, ≥14 IU/L, Male: <12, 12–15, 15–20, ≥20 U/L). The primary outcome was all-cause mortality. Hazard ratios (HRs) were estimated, adjusting for covariates and accounting for the complex survey design. Results Relative to males in the lowest quartile (Q1), males in the highest quartile (Q4) had 44% decreased risk of all-cause mortality (aHR [95% CI]: 0.56 [0.42, 0.74]). Females in Q4 had 45% decreased risk of all-cause mortality (aHR [95% CI]: 0.55 [0.40, 0.77]). Males with BMI <25 kg/m2 in Q4 had significantly lower risk of all-cause mortality than Q1; however, this association did not exist in males with BMI ≥25 (BMI<25: 0.36 [0.20, 0.64], BMI≥25: 0.77 [0.49, 1.22]). Risk of all-cause mortality was lower in males ≥50 years than in males<50 (age≥50: 0.55 [0.39, 0.77], age<50: 0.81 [0.39, 1.69]). These age- and BMI-related differences were not seen in females. Conclusion ALT within the normal range was inversely associated with all-cause mortality in U.S. adults.

Objective To determine whether a low aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ ALT ratio) is associated with insulin resistance among those without liver dysfunction. Methods In this cross-sectional study of the National Health and Nutrition Examination Survey (NHANES) 2011-2016, we included 2747 (1434 male and 1313 nonpregnant female) adults ≥20 years without evidence of liver dysfunction (ALT<30 in male and <19 in female, negative viral serologies, no excess alcohol consumption, no elevated transferrin saturation, AST/ALT <2). Serum AST/ALT ratio was categorized into sex-specific quartiles (female: <1.12, 1.12-1.29, 1.29-1.47, ≥1.47 and male: <0.93, 0.93-1.09, 1.09-1.26, ≥1.26). The primary outcome was insulin resistance, as determined by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) index score ≥3. Covariate-adjusted odds ratios (ORs) were estimated. Study analysis completed from 13 March 2020 to 21 April 2021. Results Among the 2747 individuals, 33% had insulin resistance. Those in the lowest quartile (Q1) of AST/ALT had 75% higher adjusted odds of insulin resistance compared to the highest quartile (Q4) [aOR (95% confidence interval (CI), 1.75 (1.20-2.57)]. This association was more pronounced in those with elevated BMI [Q1 vs. Q4;, BMI < 25: 0.66 (0.26-1.69); NAFLD per Fatty Liver Index ≥ 60: 2.04 (1.21-3.44), No NAFLD: 1.68 (0.94-3.01)]. Conclusion Lower AST/ALT ratio is associated with increased insulin resistance among those with healthy-range ALT, especially in those with BMI greater than or equal to 25 kg/m 2 .

Minoxidil is the only topical drug approved by the US FDA to regrow hair. It is approved for use in men and women and is a ubiquitous over-the-counter product. Unfortunately, minoxidil has a relatively low efficacy rate. In clinical trials, minoxidil was shown to regrow hair in approximately 35% of subjects after 16 weeks of use. 1,2 Compliance with the 16-week topical regimen remains a major barrier to success, while 30%-40% of subjects in physician-guided studies report success, that number is drastically reduced in subjects that self-administer minoxidil. 3 A Consumer Report survey of approximately 8,000 users of minoxidil found that only 4% of users were satisfied with the results of treatment. 4 Given the length of time required to observe efficacy, improving the number of patients

Background: Medical advances prolong life and treat illness but many patients have chronically debilitating conditions that prevent them from making end-of-life (EOL) decisions for themselves. These situations are difficult to navigate for both patient and physician. This study investigates physicians’ feelings and approach toward EOL care, physician-assisted suicide (PAS), and euthanasia. Methods: An anonymous, self-administered online survey was distributed through the New Jersey Medical School servers and American College of Surgeons forums. The survey presented clinical EOL vignettes and subjective questions regarding PAS and euthanasia. Results: We obtained 142 responses from attending physicians. Respondents were typically male (61%), married (85%), identified as Christian (54%), had more than 20 years of experience (55%), and worked at a university hospital (57%). Religious beliefs and years of work experience seemed to be significant contributors in EOL decision making, whereas gender and medical specialty were not significantly influential. Conclusion: Factors such as years of work experience and religious belief may influence medical professionals’ opinions about PAS and euthanasia and their subsequent actions regarding EOL care. In many cases, the boundaries are blurred and require further study before concrete conclusions can be made.

IntroductionYouTube, an unregulated video-sharing website, is the second most visited website on the internet. As more patients turn to the internet for information about colon cancer screening, it is important to understand what they are consuming online. Our goal was to evaluate YouTube videos about colon cancer screening to better understand the information patients are accessing. MethodsWe searched YouTube on October 28, 2020, using the following search terms sorted by relevance and view count: colonoscopy, colon cancer screening, virtual colonoscopy, colonoscopy alternatives, and cologuard. Videos longer than 10 minutes, not in English, and duplicates were excluded. Three evaluators graded each video using the DISCERN criteria. Numerical data were averaged into a composite score. Two-sided t-tests and one-way ANOVA tests were used to compare mean ratings between groups. ResultsFifty videos were analyzed, with a total of 23,148,938 views, averaging 462,979 views per video. The average overall rating was 3.16/5. There was no difference between search methods, search terms, or presence of a physician. The average ratings for videos with gastroenterologists (3.08), other physicians (3.35), and nonphysicians (3.09) were not significantly different. Videos without physicians had more views on average (1,148,677) compared to videos with gastroenterologists (157,846, p=0.013) or other physicians (35,730, p=0.013). ConclusionYouTube videos related to colon cancer screening were of good quality regardless of search terms, search methods, or presence of a physician. However, videos without physicians were viewed more frequently. Physicians should continue making videos that address deficits while increasing viewership.

Introduction: Crohn's Disease (CD) is a chronic idiopathic inflammatory bowel disease with variable clinical and histologic manifestations. Microscopic findings include transmural inflammation and may show granuloma in a subset of patients. The impact of extraintestinal granulomatous inflammation in CD is not well understood. We present an atypical initial presentation of CD in the form of diffuse granulomatous mesenteric adenitis. Case Description/Methods: A 31-year-old woman with ampiginous choroiditis presented with a month of diffuse abdominal pain and fever. Computed tomography (CT) of the abdomen/pelvis showed diffuse mesenteric lymph node enlargement with normal appearing bowels. Given her fevers, lymphadenopathy, mild leukocytosis, and elevation in inflammatory markers, thorough infectious and rheumatologic workups were pursued and unrevealing. Whole body positron emission tomography showed hypermetabolic mesenteric lymph nodes and terminal ileitis; subsequent colonoscopy noted inflamed, friable mucosa with biopsies showing active ileitis, ulceration, architectural distortion, and well-formed intramucosal granuloma consistent with Crohn's ileitis. CT-guided lymph node biopsy also showed granulomatous inflammation, making sarcoidosis a differential diagnosis. The patient was discharged in stable condition and followed at the outpatient gastroenterology clinic. Given uncertainty regarding the underlying diagnosis, she was trialed on 2 months of budesonide. MRE following treatment showed significantly improved inflammation of the terminal ileum with resolution of mesenteric lymphadenopathy. Discussion: Mesenteric adenitis with terminal ileitis has been shown to occur in infectious ileitis, CD, and sarcoidosis. Rarely, CD can coexist with sarcoidosis. CD has transmural inflammation, with ulceration and granuloma formation, in contrast to intestinal sarcoidosis which only involves the mucosa. Granulomas outside the gastrointestinal tract favor the diagnosis of sarcoidosis but can still occur with CD. In CD, the location of granulomatous inflammation may play a role in predicting clinical course. The presence of mesenteric lymph node (MLN) granulomas has been associated with younger age, transmural inflammation, and postoperative disease recurrence risk. (Figure) Mesenteric granulomatous adenitis without intestinal involvement can be the initial presentation of CD, as noted in our patient. Prompt evaluation of competing diagnoses is warranted to ensure timely diagnosis and management. [2761] Figure 1. A. Computed tomography showing mesenteric haziness and terminal ileitis (red arrow). B. Endoscopic findings of inflamed terminal ileum with congested, erythematous, and ulcerated mucosa.

Background and Aim The literature is lacking on associations of endoscopic retrograde cholangiopancreatography (ERCP) related outcomes in rheumatoid arthritis (RA) patients. The aim of this study is to evaluate the effects of RA on clinical outcomes and hospital resource utilization in patients undergoing ERCP. Methods The National Inpatient Sample database was used to identify hospitalized patients who had underwent an ERCP study from 2012 to 2014 using International Classification of Diseases‐Ninth Edition (ICD‐9) codes. Primary outcomes were mortality, hospital charges, and length of stay. Secondary outcomes were ERCP‐related complications. Chi‐squared tests for categorical data and independent t‐test for continuous data were utilized. Multivariate analysis was performed to assess the primary outcomes. Results There was 83 890 ERCP procedures performed, of which 970 patients had RA. In patients with RA, 74.2% were female, and the average age was 65.7 years. RA primary outcomes of mortality rate and hospital cost were lower and statistically significant. There was no statistically significant difference in secondary outcomes except for lower cholecystectomy rates in RA patients. Conclusion With a high inflammatory state, it was hypothesized that RA would be associated with worse outcomes after ERCP. Yet, the primary outcomes of mortality and hospital cost were found to be lower than controls, with no difference in secondary outcomes. We posit that immunosuppressants used to treat RA provides a protective effect to overall complications with ERCP.