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OBJECTIVES: Fecal occult blood testing (FOBT) is performed routinely before starting therapeutic anticoagulation in patients despite it never being validated to predict gastrointestinal bleeding (GIB) risk. Our objective was to determine the utility in checking the guaiac FOBT test (gFOBT) before initiating therapeutic anticoagulation in patients with a new diagnosis of venous thromboembolism (VTE). METHODS: This was a retrospective chart review that examined patients with a diagnosis of VTE admitted during a 2-year period in one mid-sized tertiary care center. The gFOBT was performed before initiating anticoagulation, excluding patients with overt GIB, and analysis was performed to determine GIB outcomes. In addition, demographics, laboratory data, and comorbidities were recorded at the time of admission, and an admission hypertension, abnormal renal/liver function, stroke history, GIB history or predisposition, labile international normalization ratio, elderly, drugs/alcohol concomitantly (HAS-BLED) score was recorded to determine other factors that were predictive of new-onset GIB when starting anticoagulation. RESULTS: Initially, 718 patients with a new diagnosis of VTE were screened for 2 years. Ultimately, 375 patients were prescribed anticoagulation therapy and 244 had documented gFOBT. Of these 375, 14 (3.73%) had a GIB episode. A positive gFOBT was present on admission in 85.7% of those who bled (P < 0.001). The negative predictive value of gFOBT was 99.02%; however, the positive predictive value was only 30.77%. A HAS-BLED score >2 at admission significantly predicted GIB during admission as well (median 2.4 for those with GIB and 1.6 for those without GIB, P = 0.02). CONCLUSIONS: Despite its beneficial negative predictive value, gFOBT before initiating therapeutic anticoagulation is unlikely to change the management of patients without evidence of overt GIB.

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Ritonavir is a protease inhibitor (PI) frequently prescribed with highly active antiretroviral therapy. It functions to boost the effectiveness of other PIs as a result of blocking their breakdown by the cytochrome P450 (3A4) pathway. Through this same mechanism, ritonavir has been shown to cause iatrogenic Cushing's syndrome (ICS) in patients using inhaled fluticasone. In addition, a small number of recent cases suggest that ritonavir may also cause this disorder by prolonging the duration of injected corticosteroids, such as triamcinolone. This case report presents a human immunodeficiency virus (HIV) patient taking ritonavir with ICS and secondary adrenal insufficiency, presumably due to systemic absorption and decreased metabolism of an epidural triamcinolone injection. To the authors knowledge, there have only been 4 previously reported cases describing ritonavir-potentiating ICS after receiving a corticosteroid epidural. This provides further proof that caution should be taken with nonparenteral use of triamcinolone in HIV patients on PIs.

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An elevated factor VIII level has been shown to be an independent risk factor for venous thrombosis. However, physicians screen for this factor far less frequently than they screen for other coagulopathies. The causes of increased factor VIII levels are likely a combination of genetic and acquired variables. The authors describe a case of a healthy 48-year-old woman found to have a cerebral venous thrombosis, with her only identifiable risk factor being an elevated factor VIII level.

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Small cell carcinoma (SCC) is most commonly found in the lung but is occasionally found in the gastrointestinal tract and other extrapulmonary sites. Incidences of SCC in the esophagus and stomach are rare and have been reported almost exclusively in older individuals. The following case presents the discovery of small cell carcinoma of the stomach and esophagus in a 35 year old woman, which is the youngest reported incidence of this to date. Additionally, her course reflects the importance of early diagnostic endoscopy with biopsy and adequate sampling with appropriate immunohistochemical staining when malignancy is in the differential diagnosis, regardless of age or risk factors.

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BACKGROUND: Proton pump inhibitors (PPIs) cause a sharp elevation of gastro-duodenal luminal pH which in turn has resulted in reports of reduced absorption of magnesium and certain other nutrients. METHODS: Gastroesophageal reflux disease (GERD) patients on long-term PPI therapy (> 6 months) or healthy test subjects (not on any acid preventive or neutralizing medication) were administered oral doses of zinc gluconate (26.2 mg zinc, twice daily) for 14 days followed by 5 cc venous blood samples. Plasma was analyzed for total zinc content by atomic absorption spectrophotometry. Baseline plasma and red blood cell zinc levels were also measured in these two groups when not taking any zinc supplementation. RESULTS: Plasma zinc levels of healthy controls increased by 126% during the period of zinc supplementation compared to only a 37% increase for individuals on long-term PPI therapy. On their normal diet (with no zinc supplementation), PPI-users had a 28% lower plasma zinc level than healthy controls (P < 0.005). CONCLUSIONS: PPI use dramatically reduces supplemental zinc uptake and can result in decreased zinc body stores. Certain individuals on long-term PPI therapy, such as infants being treated for colic, may be at risk for decreased systemic levels of trace metals needed for developmental, regenerative and immunological requirements.