Aijaz Sofi

Relationship of symptom duration and fecal bacteriotherapy in Clostridium difficile infection-pooled data analysis and a systematic review

Abstract Objective. Clostridium difficle-associated infection (CDI) is usually treated with antibiotics; nevertheless, the infection has a high relapse rate. Case series and case reports using fecal microbiota transplant (FMT) for CDI show promising results. However, there are no large studies to provide evidence for the efficacy of this therapy. The aim of this pooled patient data meta-analysis was to determine the efficacy of FMT in CDI. Methods. We performed a literature search for FMT for CDI or pseudomembranous colitis. Individual patient data were obtained from each study. The primary endpoint was to assess the rate of diarrhea resolution. Secondary endpoints were to identify variables associated with treatment failure and side effects of therapy. Results. A total of 289 patients from 25 published articles who received FMT for CDI were included in the pooled data analysis. FMT had an overall success rate of 91.2%. On univariate analysis, shorter duration of symptoms before FMT (< 60 days) and gastroduodenal route of fecal instillation were associated with treatment failure. On multivariate regression analysis, shorter duration of symptoms (< 60 days) before the FMT (OR= 11.08; p = 0.0009) was associated with treatment failure. Reported adverse events following FMT were irritable bowel syndrome (n = 1), symptoms of mild enteritis (n = 3), and suspected peritonitis following the procedure (n = 1). Conclusion. FMT is a safe and effective treatment option for CDI. Shorter duration of symptoms (< 60 days) before administering FMT is associated with treatment failure.

BODY MASS INDEX PREDICTS CECAL INSERTION TIME: THE HIGHER, THE BETTER

Background:  It is essential to determine the factors that predict prolonged procedural time during colonoscopy. The aim of this study was to determine the effect of body mass index (BMI) on cecal insertion time (CIT) during colonsocopy.

Physician Outlook Toward Fecal Microbiota Transplantation in the Treatment of Clostridium difficile Infection

Physician Outlook Toward Fecal Microbiota Transplantation in the Treatment of Clostridium difficile Infection

Local therapy in metastatic breast cancer is associated with improved survival.

Patients presenting with stage-IV breast cancer are usually offered systemic chemotherapy to control metastatic tumor burden and palliative radiation therapy to manage the symptomatic primary tumor. The aim of this study was to assess the result of local therapy on the overall outcome of patients with metastatic breast cancer. We reviewed medical records of all patients with metastatic breast cancer that presented to our institution between 2000 and 2009. Based on the treatment received, the patients were grouped as follows: group 1 included patients who underwent surgery and also received radiotherapy and chemotherapy/hormonal therapy, group 2 included patients who received radiotherapy and chemotherapy/hormonal therapy only, and group 3 included patients who received chemotherapy/hormonal therapy alone. Of the 37 patients included in the study, 10 patients were placed in group 1, 17 patients in group 2, and 10 patients in group 3. About 38% had high to anaplastic tumor grade, and 48% had ≥2 metastatic sites in the body. Overall, the average survival time was 3.13 years (range: 0–17 years). A significant difference in survival estimates was noted between groups 1, 2, and 3 with mean survival times of 8.83, 4.9, and 2.26 years, respectively (log rank &khgr;2 = 10.44, P = 0.005). In age-adjusted multivariate Cox regression model (&khgr;2 = 21.729, P= 0.001), high/anaplastic tumor grade (P = 0.036), African American race (P = 0.009), central nervous system metastasis (P = 0.003), group 2 (P = 0.006), and group 3 (P = 0.002) were associated with poor survival. Survival was not associated with estrogen and progesterone receptor and visceral or bone metastases. We conclude that aggressive local control of primary tumor in patients presenting with stage-IV breast cancer is associated with improved survival.

Does endoscopic sphincterotomy reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis after biliary stenting? A systematic review and meta-analysis

Endoscopic biliary sphincterotomy (ES) is often carried out prior to placement of a biliary stent apparently to reduce the risk of post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, the protective effect of ES prior to biliary stenting is controversial. The objective of this meta‐analysis is to compare the risk of PEP and other complications after the placement of biliary stent with or without ES in patients with biliary obstruction and bile leak.

Aberrant Right Hepatic Duct Draining into the Cystic Duct: Clinical Outcomes and Management

Background. Aberrant right hepatic duct (ARHD) draining into cystic duct (CD) is relatively rare but clinically important because of its susceptibility to injuries during cholecystectomy. These injuries are often-times missed or diagnosed late and as a result can develop serious complications. Methods. Four consecutive patients diagnosed with ARHD draining into CD were identified for inclusion. Results. The mean age of patients was 42.5 years. The diagnosis in one of the patient was incidental during a routine endoscopic retrograde cholangiopancreatography (ERCP). Other three patients were diagnosed post-cholecystectomy- one presented with suspected intra-operative biliary injury, one with persistent bile leak and another with recurrent cholangitis. Inadequate filling of the segment of liver on ERCP with dilation of intrahepatic ducts in the corresponding segment on imaging was present in two patients with complete obstruction of ARHD which was managed surgically. In another patient, the partially obstructed ARHD was managed by endoscopic therapy. Conclusion. ARHD draining into the CD can have varied clinical manifestations. In appropriate clinical settings, it should be suspected in patients with persistence of bile leak early after cholecystectomy, segmental dilation of intrahepatic-bile ducts on imaging and paucity of intrahepatic filling in a segment of liver on ERCP.

EUS-FNA for the Diagnosis of Retroperitoneal Primitive Neuroectodermal Tumor

Primitive neuroectodermal tumor (PNET) is a rare “small round blue cell tumor” that is diagnosed by open biopsy or percutaneous biopsy of the lesion under radiologic guidance. In this case report, we present a novel approach to the diagnosis of a retroperitoneal PNET by endoscopic ultrasound- (EUS-) guided fine needle aspiration (FNA). A 35-year-old man presented with the history of left-sided flank pain and swelling of 3-weeks duration. Computerized tomography (CT) scan of his abdomen revealed a 12.8 × 13 × 12.5 cm cystic and solid mass arising from the retroperitoneum and displacing the third and fourth portions of the duodenum. He underwent EUS which revealed a well-circumscribed heterogeneous mass abutting the inferior portion of the stomach. EUS-FNA of the mass revealed malignant cells consistent with primitive neuroectodermal tumor (PNET)/Ewings sarcoma. EUS-guided FNA is an appropriate technique for diagnosing retroperitoneal PNET/Ewings sarcoma.

Hand-foot hyperpigmentation skin lesions associated with combination gemcitabine-carboplatin (GemCarbo) therapy.

Gemcitabine (Gemzar) is a nucleoside analogue used as a cytotoxic agent for the treatment of various carcinomas: pancreatic cancer, bladder cancer, breast cancer, and non-small-cell-lung cancer. Carboplatin, a DNA alkylating agent, is used alongside with gemcitabine in a regimen known as GemCarbo chemotherapy to treat several different types of cancer, most commonly lung cancer. We report an unusual case of hand-foot hyperpigmentation after the use of GemCarbo therapy on a man with stage IV non-small cell lung carcinoma. Physical examination revealed hyperpigmented lesions that were approximately 1-2 mm in diameter, of brown/purple discoloration localized to the palmar surface of his hands and the dorsum of his feet. A rapid plasma reagin blood test, used for the screening of syphilis was nonreactive. Discontinuation of both agents resulted in the dramatic disappearance of the lesions over the course of 2 weeks. In this report, we describe, to our knowledge, the first case of hand-foot hyperpigmentation that has been reported with the use of either of these 2 agents.

Lubiprostone plus PEG electrolytes versus placebo plus PEG electrolytes for outpatient colonoscopy preparation: a randomized, double-blind placebo-controlled trial.

Bowel preparation using large volume of polyethylene glycol (PEG) solutions is often poorly tolerated. Therefore, there are ongoing efforts to develop an alternative bowel cleansing regimen that should be equally effective and better tolerated. The aim of this study was to assess the efficacy of lubiprostone (versus placebo) plus PEG as a bowel cleansing preparation for colonoscopy. Our study was a randomized, double-blind placebo-controlled design. Patients scheduled for screening colonoscopy were randomized 1:1 to lubiprostone (group 1) or placebo (group 2) plus 1 gallon of PEG. The primary endpoints were patients tolerability and endoscopists evaluation of the preparation quality. The secondary endpoint was to determine any reduction in the amount of PEG consumed in the lubiprostone group compared with the placebo group. One hundred twenty-three patients completed the study and were included in the analysis. There was no difference in overall cleanliness. The volume of PEG was similar in both the groups. The volume of PEG approached significance as a predictor of improved score for both the groups (P = 0.054). Lubiprostone plus PEG was similar to placebo plus PEG in colon cleansing and volume of PEG consumed. The volume of PEG consumed showed a trend toward improving the quality of the colon cleansing.

Comparison of esophageal placement of Bravo capsule system under direct endoscopic guidance with conventional placement method

Background: Conventional placement of a wireless esophageal pH monitoring device in the esophagus requires initial endoscopy to determine the distance to the gastroesophageal junction. Blind placement of the capsule by the Bravo delivery system is followed by repeat endoscopy to confirm placement. Alternatively, the capsule can be placed under direct vision during endoscopy. Currently there are no published data comparing the efficiency of one method over the other. The objective of this study was to compare the method of Bravo wireless pH device placement under direct visualization with the conventional method. Methods: A retrospective study involving 58 patients (29 patients with indirect and 29 patients with direct visualization) who had Bravo capsule placement. The physician endoscopy procedure notes, nurse’s notes, postprocedure notes, recovery notes, and pH monitoring results were reviewed. The safety of the procedures, length of the procedures, and patient tolerability were evaluated. Results: None of the 58 patients had early detachment of the device and had no immediate procedure-related complications. The overall incidence of complications in both the groups was similar. No failures due to the technique were noted in either group. Average amount of time taken for the procedure was similar in both groups. Conclusion: The technique of placing a Bravo pH device under direct visualization is as safe and effective as the conventional method. In addition, there is an added advantage of avoiding a second endoscopic intubation in the direct visualization technique.