Erik C. von Rosenvinge

Multiple endoscopic biopsies in research subjects : safety results from a National Institutes of Health series

BACKGROUND Routine endoscopic mucosal biopsies are generally considered safe. However, the outcomes of performing large numbers of biopsies in subjects enrolled in research protocols have not been reported. OBJECTIVE Our purpose was to assess the safety of taking numerous mucosal biopsy specimens during endoscopic procedures (eg, >20/endoscopic procedure) in research subjects. DESIGN Single-center retrospective chart review. SETTING Research hospital: National Institutes of Health (NIH) Clinical Center. PATIENTS Volunteers who underwent research protocol endoscopies with large numbers of biopsies during 2001 to 2008 at the NIH. MAIN OUTCOME MEASUREMENTS Charts were reviewed for the occurrence of procedure-related major/minor complications. RESULTS A total of 253 research endoscopies were performed on 133 patients: 169 colonoscopies, 64 sigmoidoscopies, and 20 upper endoscopies. A total of 9,661 biopsy specimens were obtained for research and histopathologic examination (mean 38.2 +/- 15.6 per procedure). No major complications were identified. Minor complications occurred with 13 (5.1%) lower endoscopic procedures and included self-limited bleeding (4), pain (5), or both (4). There was no statistically significant association between the number of biopsies, type of procedure, location of research biopsies, operator, polypectomy, or the use of nonsteroidal anti-inflammatory drugs and the risk of complications. LIMITATIONS Retrospective design, modest sample size. CONCLUSIONS This is the first report on the safety of performing large numbers of endoscopic biopsies in research subjects. This practice is well tolerated and appears to have no more than minimal risk without appreciably increasing the risk of otherwise routine endoscopy.

Clostridium difficile-associated disease: Adherence with current guidelines at a tertiary medical center

AIM To assess adherence with the the Society for Healthcare Epidemiology of America (SHEA)/ the Infectious Diseases Society of America (IDSA) guidelines for management of Clostridium difficile (C. difficile)-associated disease (CDAD) at a tertiary medical center. METHODS All positive C. difficile stool toxin assays in adults between May 2010 and May 2011 at the University of Maryland Medical Center were identified. CDAD episodes were classified as guideline adherent or non-adherent and these two groups were compared to determine demographic and clinical factors predictive of adherence. Logistic regression analysis was performed to assess the effect of multiple predictors on guideline adherence. RESULTS 320 positive C. difficile stool tests were identified in 290 patients. Stratified by disease severity criteria set forth by the SHEA/IDSA guidelines, 42.2% of cases were mild-moderate, 48.1% severe, and 9.7% severe-complicated. Full adherence with the guidelines was observed in only 43.4% of cases. Adherence was 65.9% for mild-moderate CDAD, which was significantly better than in severe cases (25.3%) or severe-complicated cases (35.5%) (P < 0.001). There was no difference in demographics, hospitalization, ICU exposure, recurrence or 30-d mortality between adherent and non-adherent groups. A multivariate model revealed significantly decreased adherence for severe or severe-complicated episodes (OR = 0.18, 95%CI: 0.11-0.30) and recurrent episodes (OR = 0.46, 95%CI: 0.23-0.95). CONCLUSION Overall adherence with the SHEA/IDSA guidelines for management of CDAD at a tertiary medical center was poor; this was most pronounced in severe, severe-complicated and recurrent cases. Educational interventions aimed at improving guideline adherence are warranted.

Gastric Masses in Multiple Endocrine Neoplasia Type I-Associated Zollinger–Ellison Syndrome

D uestion: A 59-year-old man with multiple endocrine eoplasia type 1 and Zollinger–Ellison syndrome sympomatically controlled on proton pump inhibitor therapy nderwent evaluation at the National Institutes of ealth Clinical Center. His abdominal examination was nremarkable. His gastrin level was 6,050 pg/mL (noral, 100), chromogranin A 35,500 ng/mL (normal, 225), and hemoglobin 15.1 g/dL (on iron replacement herapy). Computed tomography scan revealed multiple

Characteristics of Clostridium difficile infection in patients hospitalized with myelodysplastic syndrome or acute myelogenous leukemia

AIM To evaluate factors associated with Clostridium difficile infection (CDI) and outcomes of CDI in the myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) population. METHODS After IRB approval, all MDS/AML patients hospitalized at the University of Maryland Greenebaum Comprehensive Cancer Center between August 2011 and December 2013 were identified. Medical charts were reviewed for demographics, clinical information, development of CDI, complications of CDI, and mortality. Patients with CDI, defined as having a positive stool PCR done for clinical suspicion of CDI, were compared to those without CDI in order to identify predictors of disease. A t-test was used for comparison of continuous variables and chi-square or Fisher’s exact tests were used for categorical variables, as appropriate. RESULTS Two hundred and twenty-three patients (60.1% male, mean age 61.3 years, 13% MDS, 87% AML) had 594 unique hospitalizations during the study period. Thirty-four patients (15.2%) were diagnosed with CDI. Factors significantly associated with CDI included lower albumin at time of hospitalization (P < 0.0001), prior diagnosis of CDI (P < 0.0001), receipt of cytarabine-based chemotherapy (P = 0.015), total days of neutropenia (P = 0.014), and total days of hospitalization (P = 0.005). Gender (P = 0.10), age (P = 0.77), proton-pump inhibitor use (P = 0.73), receipt of antibiotics (P = 0.66), and receipt of DNA hypomethylating agent-based chemotherapy (P = 0.92) were not significantly associated with CDI. CONCLUSION CDI is common in the MDS/AML population. Factors significantly associated with CDI in this population include low albumin, prior CDI, use of cytarabine-based chemotherapy, and prolonged neutropenia. In this study, we have identified a subset of patients in which prophylaxis studies could be targeted.

Unusually late-onset mycophenolate mofetil–related colitis

PURPOSE Serious gastrointestinal complications arising 13 years after the initiation of posttransplant immunosuppressant therapy with mycophenolate mofetil are reported. SUMMARY Over a three-month period, a male heart transplant recipient who had taken oral mycophenolate mofetil (2 g daily) for 13 years as part of an immunosuppressant maintenance regimen developed diarrhea and weight loss leading to renal failure and metabolic acidosis. There was no evidence of opportunistic infection, and immunostaining for cytomegalovirus yielded negative results. Colonoscopy revealed areas of congested, erythematous, and nodular mucosa. Histological examination of mucosal biopsy specimens revealed pathological abnormalities typical of those seen in cases of mycophenolate mofetil-associated colitis. On discontinuation of mycophenolate mofetil use, the patients diarrhea resolved and his renal function improved. Colitis, diarrhea, and other gastrointestinal complications are commonly reported in patients receiving mycophenolate mofetil, an immunosuppressant widely used to prevent rejection of solid organ or bone marrow transplants; however, the onset of such symptoms after more than a decade of continuous use of the drug has not been previously reported. This case suggests that mycophenolate mofetil toxicity should be considered in the evaluation of late-onset posttransplant diarrhea regardless of the duration of therapy. CONCLUSION A 33-year-old man maintained on mycophenolate mofetil for 13 years after heart transplantation developed diarrhea, weight loss, and acute kidney injury over a three-month period. Colonoscopy and biopsy revealed pathological changes consistent with mycophenolate mofetil toxicity, and the patients symptoms resolved after the drug was discontinued.

Chronic granulomatous disease

chronic granulomatous disease is a rare disorder of phagocyte oxidative metabolism. The disease is characterised by recurrent infections in childhood that require prolonged courses of antimicrobial therapy. Adjunctive therapy with interferon-γ has been shown to reduce the frequency and severity of infections. Combined use of daily prophylactic antibiotics and thrice weekly therapy with interferon-γ is an effective and well tolerated treatment that reduces the risk of serious infection. We also update the progress that defines the molecular basis of the disease.

When to leave a stone unturned

A 16-year-old, 41 kg boy with chronic granulomatous disease presented with fever, chills, and diaphoresis. CT showed necrotising mediastinal lymphadenitis and a contracted but otherwise normal gallbladder (figure 1A). The patient was started on intravenous antibiotics and clinically improved. Culture of the lymphadenitis obtained by CT-guided aspiration grew Granulibacter bethesdensis. …

W1143 Colonic Distribution of Mantle Cell Lymphoma

G A A b st ra ct s patients required contiguous organ resection, the most common of which were kidney (n=25), colon (n=14), and small bowel (n=6). 3.8% (n=6) of patients required vascular reconstruction. Multivariate logistic regression revealed ASA classification as an independent predictor of post-operative complications or death (composite endpoint, OR 3.23, CI 1.337.84). Pre-operative RT, creatinine, hematocrit, and albumin were not statistically significant. Similarly, extent of contiguous organ resection (OR 1.38, CI 0.49-3.89), nephrectomy (OR 1.73, CI 0.39-7.75), bowel resection (OR 0.29, CI 0.04-1.95), splenectomy (OR 2.19, CI 0.13-38.49), and vascular reconstruction (OR 3.77, CI 0.59-24.23) were not associated with increased 30-day morbidity or mortality. Conclusions: NSQIP data demonstrate acceptable rates of post-operative morbidity and mortality following RPS resection even in the setting of aggressive multivisceral resection. Contiguous organ resection should not be viewed as a contraindication to RPS resection.