Ishan Patel

Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality

Objectives The objective of this study was to determine our institutions compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes. Methods We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality. Results We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023). Conclusions Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.

Video capsule endoscopy: is bowel preparation necessary?

There is no standardized protocol for bowel preparation prior to video capsule endoscopy, although one is strongly recommended. The purpose of our study was to see if there was a statistical significance between small bowel mucosal visualization rates for those who received bowel preparation and those who did not. We retrospectively analyzed all patients who had a video capsule endoscopy from August 2014 to January 2016 at a tertiary care center. All patients fasted prior to the procedure. Bowel preparation when used consisted of polyethylene glycol. A long fast consisted of 12 or more hours. The grading system used to assess the small bowel was adapted from a previously validated system from Esaki et al. Statistical analyses were performed using Fishers exact test or Welchs 2-sample t-test and statistical significance was present if the p value was ≤0.05. 76 patients were carried forward for analysis. Small bowel mucosal visualization rates were similar between those who received bowel preparation and those who did not (92.5% vs 88.9%, p=0.44). Small bowel mucosal visualization rates were significantly better in those patients who had a long fast compared with those who had a short fast (97.7% vs 81.3%, p=0.019). Our study demonstrates that the addition of bowel preparation prior to video capsule endoscopy does not significantly improve small bowel mucosal visualization rates and, in addition, there is a statistically significant relationship between increased fasting time and improved small bowel mucosal visualization. A prolonged fast without bowel preparation might be satisfactory for an adequate small bowel visualization but further randomized, prospective studies are necessary to confirm these findings.

Acute hepatitis E presenting with clinical feature of autoimmune hepatitis

A 32-year-old immigrant man presented with new onset jaundice. His past medical history was significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. His initial laboratory finding and liver biopsy were suggestive of autoimmune hepatitis (AIH). The plan was to start steroids pending negative results for viral serology, but it came back positive for hepatitis E virus. The patients liver function test and clinical condition improved significantly on conservative management over a period of 1 month. Therefore, we suggest testing for hepatitis E especially in immigrants or recent travelers to endemic areas who presents with clinical features suggestive of AIH.

A multicenter, retrospective, case-cohort study of the epidemiology and risk factors for Clostridium difficile infection among cord blood transplant recipients

Clostridium difficile infection (CDI) is the leading cause of health‐care associated infectious diarrhea. The aim of this study was to evaluate the epidemiology and risk factors for CDI in the 100 days following umbilical cord blood transplantation (UCBT) at three Boston hospitals.

Cytomegalovirus triggering autoimmune hepatitis: case report and literature review -

Cytomegalovirus (CMV) is considered to play a role in triggering autoimmune hepatitis (AIH). It is difficult to diagnose autoimmune hepatitis because its presentation can be acute, severe, asymptomatic or chronic. Diagnosis requires multiple findings and exclusions of similar diseases. When excluding, viral etiologies are part of the differential, which in this case is CMV. If a trigger is required to set off a sequence of events leading to autoimmune hepatitis in these predisposed individuals, viruses are among the most likely candidates. In this study, a case of a 54 year-old female who presents with new onset of jaundice, associated with abdominal distension, lower extremity edema and 10 pound weight gain is reported. The autoimmune workup of the patient was significant for an elevated antibodies to nuclei (ANA) titer, anti-smooth muscle ab titer and a significant increase in immunoglobulins, specifically IgG. Interestingly, CMV Ab IgM was positive as well as CMV Ab IgG. A liver biopsy was performed which showed heavy infiltration with lymphoplasmacytic inflammatory cells, interface hepatitis, bridging necrosis and fibrosis. These pathologic and laboratory findings led us to a definitive diagnosis of AIH Type 1. In the setting of positive CMV IgG and IgM ab titers, we suggest that the trigger for AIH in this case was a preceding CMV infection. Patient improved with combination of azathioprine and corticosteroid therapy despite intermittent flares of the patient’s AIH.

Acute Gastric Ischemia After Chemoembolization in a Patient with Hepatocellular Carcinoma

A 72-year-old man presented with severe diffuse abdominal pain and melena. His past history was significant for hepatitis C cirrhosis and hepatocellular carcinoma status post partial resection five years ago and recurrent malignant lesions treated with multiple sessions of transarterial chemoembolization (TACE). He had received his last TACE treatment of a lesion in segment 6 via a distal branch of the right renal artery 2.5 months prior to the presentation. His examination was significant for moderate abdominal distension and tenderness. Laboratory findings were notable for the following: hemoglobin, 7.4 g/dl; creatinine, 2.4 mg/dl; and lactate, 10.1 mmol/l. Initial computerized tomography of the abdomen/pelvis without contrast showed cirrhosis and a hepatic mass, a markedly distended stomach, and gas in the gastric wall, an intrahepatic portion of the portal vein, and the gastric veins (a). Esophagogastroduodenoscopy showed ulceration and necrosis localized to the fundus and proximal lesser curvature (b). The patient was managed conservatively with bowel rest, intermittent nasogastric tube suction, intravenous (IV) fluids, IV pantoprazole, and broad-spectrum antibiotics. He responded well to medical management, showing marked improvement on repeat imaging with contrast (c). (Informed consent was obtained from the patient to publish these images.)

Sa1304 Bone Mineral Density in Celiac Disease

Background/Aims: A gluten-free diet (GFD) is the only available long-life therapy for celiac disease (CD). Clinical presentation is diverse with few patients with underweight, while the great majority has either normal or overweight. In the general population, overweight causes increase in the waist circumference (WC), an anthropometric measurement associated to the cardiometabolic risk. However, this association has not been established in CD patients. Moreover, there are several evidences that suggest that these anthropometric changes are due to an unbalanced GFD as consequence of an inadequate food selection by patients. Our aims were double: (1) to determine body mass index (BMI) at diagnosis of CD, and (2) to assess changes in the BMI induced by treatment, and the WC and composition the food intake at least two-years after initiation of a GFD. Materials and methods: From July to November 2013, all adult patients with CD attending the ambulatory celiac disease clinic were enrolled in the study if they were on a GFD for at least 2 years. BMI (normal: 18.524.9 kg/m2) and WC (normal: women < 80 cm; men < 94 cm) were determined according to conventional measurements. The composition of food intake was estimated according to conventional formulas based on a food questionnaire by an expert nutritionist. Results: 56 consecutive patients (52 women; median age 48 years [range: 20-65]; time on a GFD: 5 years [range: 2-15]) were enrolled in the study. At diagnosis, 59% of patients had normal BMI, 25% had overweight or were obese, and 16% had underweight. Compared with findings at diagnosis, 93% of GFD treated CD patients had a significantly increased BMI (21 kg/m2 [range: 14-36] vs. 24 kg/m2 [range: 17-37], respectively; p<0.0001). Migration to a higher category was shown in 41% of patients. Twenty four out of 56 patients (43%) showed an abnormally high WC with an highly significant correlation with the final BMI ( r=0.86; 95% CI: 0.77-0.92; p<0.0001). Our dietary analysis has showed that 71% and 86% of patients did not cover the daily recommendation of vegetables and fruits, and that 48% and 71% reported a higher cereal and simple sugar consumption than recommended, respectively. Nevertheless, anthropometric measures did not correlated with the composition of food intake. Conclusions: Our study evidences that a long-term GFD significantly increases BMI generating a migration to higher categories. The WC, an anthropometric surrogate of cardiovascular risk, correlated with overweight and is abnormal in 43% of patients. According to our observations, these anthropometric findings did not seem to be associated to the inadequate composition of food intake.

348 Clostridium difficile Toxin a Harbors Bacterial DNA and Activates TLR9-Dependant Innate Immune Responses

Background/Aim: Mucosal healing (MH) at endoscopy is a major therapeutic goal in ulcerative colitis (UC). Endoscopy, however, is invasive, time consuming and uncomfortable. Computed tomography colonography (CTC) has emerged as a noninvasive screening procedure for colorectal neoplasia but radiation exposure is a major concern if applied to patients with UC. We aimed to examine ultra-low dose CTC (uCTC) for evaluating mucosal inflammation in patients with UC. Methods: Patients with UC underwent colonoscopy and uCTC acquired with low dose at 75 mAs or ultra-low dose at 5 mAs levels on the same day. As bowel preparation, patients took low residue diets on the previoursday and 1.8L of isotonic magnesium solution on the day. CTC images were evaluated for UC, in which selected valuables (loss of colonic haustra, luminal narrowing, bowel wall thickness, mural hyperenhancement and mesenteric hyper-vascularity in both air images or multiplanar reconstruction (MPR) images) were scored from 0 to 1 in the worst affected segment of colon, to create a novel uCTC score from 0 to 5. Endoscopic severity was evaluated by Mayo Clinic endoscopy sub-score (eMCS, 0-3) and the two score were correlated. Results: In 90 patients the median uCTC score was 3.56 (range 0-5) and eMCS 1.89 (range 0-3). The uCTC score correlated with eMCS (r = 0.727, p< 0.001). The CTC score for each Mayo e-score were as follows (mean±SD): score 0, 0.77±0.77; 1, 2.56±1.40; 2, 3.69±1.69; 3, 4.83±0.34. The uCTC score showed significant differences between endoscopic activity and MH (eMCS 0 vs 1 P<0.001; 1 vs 2 or 3, P<0.01 and <0.001, respectively). Furthermore, uCTC air images alone revealed a significant relationship with eMCS, even with ultra-low dose CTC at 5 mAs levels. Conclusion: uCTC may be a non-invasive tool to assess mucosal activity in UC and may be a technique to determine MH. Ultra-low dose CTC resolves concern about radiation exposure.