Bowel preparation for colonoscopy: what is best and necessary for quality?

PURPOSE OF REVIEW: Colonoscopy is recognizably, the best colon cancer prevention test, provided the quality of the preparation is adequate for detection of precancerous polyps but also allowing for accurate identification of margins, thereby facilitating complete endoscopic resection. As there are many aspects effecting colon prep outcomes, it is timely to review new standards for optimizing outcomes, including product selection based on patient demographics. RECENT FINDINGS: New national guidelines have set a minimum quality threshold for adequacy and also defined a split day delivery for oral options as the "standard of care". Several new prep options have been recently released and these data are discussed. SUMMARY: Optimizing the quality of colon preps has major implications for clinical practice. Clinicians must recognize new targets for standard of care, providing the best approach for each individual patient, considering variable factors which may otherwise compromise success.

The Effects of Sleep on the Commensal Microbiota: Eyes Wide Open?

Sleep dysfunction is an epidemic, the implications of which have a profound impact on a variety of gastrointestinal disease. Recent data suggests a relationship between sleep dysfunction and intestinal dysbiosis, a known proinflammatory driver. This article evaluates the interplay between sleep dysfunction and gastrointestinal health and disease, with a focus on the impact of circadian rhythm disruption on the commensal microbiota.

Wake-up Call to Clinicians: The Impact of Sleep Dysfunction on Gastrointestinal Health and Disease.

Sleep dysfunction is an epidemic affecting a large portion of the adult population. Recent studies have linked sleep dysfunction with an upregulation of proinflammatory cytokines (eg, tumor necrosis factor-α, interleukin-1 and interleukin-6), the implications of which can have a profound impact on a variety of gastrointestinal disease. In particular, sleep dysfunction seems to accelerate disease states characterized by inflammation (eg, gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia, chronic liver disease, inflammatory bowel disease, and colorectal cancer). This article evaluates the complex interplay between sleep dysfunction and gastrointestinal health and disease.

Comparison of central-line-associated bloodstream infections between central venous catheters lined by combined chlorhexidine and silver sulfadiazine versus silver ionotrophes alone: A before-after-before retrospective study.

A before-after-before direct comparison between catheters lined with chlorhexidine and silver sulfadiazine (CHSS) versus silver ionotrophes (SI) with a primary objective of comparison of rate of central-line-associated infection (CLABSI) in three 10-month windows. The CHSS catheters were associated with a lower rate of CLABSI.

Differential Effect of Light and Dark Period Sleep Fragmentation on Composition of Gut Microbiome and Inflammation in Mice.

Bi-directional interactions amongst the gut microbiota, immune system, and brain function are thought to be critical mediators of health and disease. The role sleep plays in mediating these interactions is not known. We assessed the effects of sleep fragmentation (SF) on the microbiota-gut-brain axis. Male C57BL/6NCrl mice (4 to 5 per cage, fed standard lab chow) experienced SF via mechanical stimulation at 2 min intervals during the light (SF) and dark (DD, dark disturbances) periods. Home cage (HC) controls were undisturbed. After 10 days, fecal samples were collected at light onset, midday, light offset, and midnight. Samples were also collected after 10 days without SF. Subsequently, the mice were randomized across groups and allowed 20 additional days of recovery followed by 10 days of SF or DD. To assess effects on the microbiota, 16S rRNA sequencing was used, and mesenteric lymph nodes (MLNs) and cortex and medial prefrontal cortex were analyzed using cytokine arrays. SF and DD produced significant alterations in the microbiota compared to HC, and DD had greater impact than SF on some organisms. SF produced marked suppression in MLNs of chemokines that regulate inflammation (CCL3, CCL4 and their receptor CCR5) and maintain the immune mucosal barrier (Cxcl13) at the same time that cortical cytokines (IL-33) indicated neuroinflammation. DD effects on immune responses were similar to HC. These data suggest that SF alters the microbiome and suppresses mucosal immunity at the same time that mediators of brain inflammation are upregulated. The translational implications for potential application to clinical care are compelling.

Gastrointestinal cytomegalovirus disease in the immunocompromised patient.

Cytomegalovirus (CMV) has emerged as a significant opportunistic pathogen in the era of immunosuppression. CMV was a common cause of gastrointestinal disease in AIDS patients, but the introduction of highly active antiretroviral therapy has led to a dramatic decline in AIDS-related disease. Among patients with solid organ transplants, CMV has become an increasingly important cause of gastrointestinal disease as more routine use of early CMV prophylaxis has increased delayed-onset disease, which is often tissue invasive at presentation. The role of CMV in inflammatory bowel disease is controversial; treatment may be indicated in selected cases of steroid-refractory disease with evidence of CMV. Diagnosis of gastrointestinal CMV disease generally requires endoscopic biopsy with histologic confirmation. CMV culture of biopsy material may be falsely positive because of contamination from latently infected cells. The standard induction treatment of gastrointestinal CMV disease uses intravenous ganciclovir, though the use of oral valganciclovir is increasing, especially for long-term maintenance or suppression therapy.

The A's and B's of vaccine-preventable hepatitis: improving prevention in high-risk adults.

Acute hepatitis A and acute hepatitis B are associated with significant morbidity, time away from work or usual activities, substantial cost to the healthcare system, and some mortality. Despite the availability of vaccines against hepatitis B and hepatitis A since 1981 and 1995, respectively, and a combined hepatitis A and B vaccine since 2001, immunization rates against these vaccine-preventable diseases are appallingly low. In particular, several groups of adults, such as men who have sex with men, heterosexuals with multiple partners, injection drug users, persons with human immunodeficiency virus infection, travelers to endemic areas, and persons with chronic liver disease, are at particularly high risk for acute hepatitis A and B or for a more severe illness or a higher rate of chronicity in the case of hepatitis B. Studies have confirmed that hepatitis A and hepatitis B vaccines are safe and immunogenic in patients in these populations, although patients with more advanced disease may respond less well. These observations have led to the recommendation that patients falling into the above risk groups undergo hepatitis A and B vaccination early in the natural history of their underlying risk behavior or diseases. Vaccination rates are low in clinical practice, and public health and educational programs are needed to overcome barriers to facilitate timely implementation of these recommendations. The use of a combined vaccination, possibly using an accelerated administration schedule, provides convenience and may increase compliance.

Clostridium difficile-associated diarrhea: resurgence with a vengeance.

There has been a significant increase in the incidence and severity of Clostridium difficile-associated diarrhea (CDAD) in the past several years, including outbreaks in multiple states and provinces in the United States and Canada, as well as in the United Kingdom. A new, highly virulent strain of C. difficile has appeared that is less responsive to standard therapy and associated with a high rate of recurrence. Along with nosocomially acquired infections there has been a rise in the number of community-acquired cases of CDAD, even among those without prior antibiotic exposure. Many factors have contributed to this epidemic, including the development of resistance to the widely used fluoroquinolones class of antibiotics. Because this new strain is less responsive to standard therapy, particularly metronidazole, a number of new antibiotics and other therapies are actively being investigated for use in both primary and recurrent CDAD. A multifaceted approach to managing CDAD is called for, including active surveillance, antibiotic stewardship, and meticulous attention to contact precautions, including gloves, gowns, and hand washing.

Dexlansoprazole: delayed-release orally disintegrating tablets for the treatment of heartburn associated with non-erosive gastroesophageal reflux disease and the maintenance of erosive esophagitis.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common condition afflicting millions of patients, whose prevalence continues to rise owing to the aging population and increasing burden of comorbid conditions, such as obesity. Currently, the mainstay of therapy for GERD is treatment with proton pump inhibitors (PPIs), which have proven efficacy, safety, and tolerability. Despite this, a considerable number of patients have refractory symptoms to PPI therapy. Dexlansoprazole is a new addition to the class of PPIs, which has a unique dual delayed drug release system, which aims to address the current limitations of acid suppressive therapy by offering extended acid suppression and improved ease of administration. Areas covered: This manuscript covers the pharmacokinetics, pharmacodynamics, clinical efficacy, and regulatory approval of dexlansoprazole. Additionally, there is further discussion concerning the current market settings and the potential future impact of dexlansoprazole. Expert commentary: Overall, dexlansoprazole offers benefits in its ease of administration and proven efficacy in the healing, maintenance of erosive esophagitis, and symptomatic non-erosive GERD. Long-term, dexlansoprazole will likely find a niche market among patients who fail other acid suppressive therapy or who desire simplified administration for compliance concerns, but will likely come at a higher out of pocket expense than comparable generic PPIs.

Conceptualizing a subtype of patients with chronic pain: The necessity of obtaining a history of sexual abuse.

Lifetime history of sexual abuse is estimated to range between 15% and 25% in the general female population. Cross-sectional studies have shown that sexual assault survivors frequently report chronic musculoskeletal pain and functional somatic syndromes. Treating chronic pain with opioids went from being largely discouraged to being included in standards of care and titrating doses until patients self-report adequate control has become common practice, with 8% to 30% of patients with chronic noncancer pain receiving opioids. In this clinical review, we will discuss the association between survivors of sexual assault and chronic pain/functional somatic syndromes. We will further review evidence-based treatment strategies for this "pain-prone phenotype."

Antibiotic prophylaxis in severe acute pancreatitis: the never-ending controversy.

Infections are the most common late cause of morbidity and mortality in severe acute pancreatitis. Between 1993 and 2004, a number of prospective controlled trials, meta-analyses, and guidelines all concluded that antibiotics were indicated for the prophylaxis of infections in severe acute pancreatitis. However, in 2004, the first prospective, double-blind, placebo-controlled trial was published showing no effect of prophylactic antibiotics, thus rekindling the controversy surrounding this subject. For those physicians who choose to use prophylactic antibiotics, their use should be limited to patients with pancreatic necrosis, and the choice of antibiotic should be guided by the drug's proven ability to penetrate into the pancreas. Evidence supports imipenem, meropenem, or cefepime for this indication. One third of patients will develop infection of pancreatic necrosis despite the use of prophylactic antibiotics. Vigilance must be maintained for evidence of recurrence of markers of inflammation or persistence beyond the first week, which would suggest the need for fine-needle aspiration and culture to detect infection. Physicians who choose not to use prophylactic antibiotics for pancreatic necrosis should be aware that they will need to initiate antibiotics in 54% to 77% of patients for either infection of pancreatic necrosis or extrapancreatic infections.

New issues in infectious diarrhea.

Infectious diarrhea remains a leading cause of both mortality and morbidity worldwide. Novel organisms recently have been described as causes of previously undiagnosed diarrhea. In addition, changes in epidemiologic trends of known pathogens, such as Clostridium difficile, are occurring, including multiple outbreaks of a newly recognized epidemic strain associated with increased severity of cases and poor response to current antibiotics. Given rising resistance rates, new antimicrobial agents are being studied. Rifaximin is a nonabsorbable, gut-selective antibiotic recently approved by the US Food and Drug Administration for the treatment of travelers' diarrhea caused by noninvasive Escherichia coli. This novel antibiotic has also shown promise in the prevention of travelers' diarrhea, as well as a host of other gastrointestinal disorders. Development of a vaccine against diarrheagenic organisms is of high global importance but has been a challenge, owing to the multiple causative serotypes of E. coli and other organisms.

Current Strategies to Reduce Gastrointestinal Bleeding Risk Associated with Antiplatelet Agents.

Antiplatelet agents remain the cornerstone in the primary and secondary therapeutic intervention for cardiovascular disease. Some patients may be subjected to a year or more of dual antiplatelet therapy to reduce the risk of subsequent cardiovascular events. Patients on antiplatelet therapy have an increased risk of gastrointestinal bleeding; however, not all patients benefit from concomitant acid suppressive therapy. This review will provide an overview of the pharmacology of antiplatelet agents and outline patient risk profiles that ought to be considered when considering prophylactic therapy to reduce gastrointestinal toxicity. In addition, we discuss the current risk-reduction strategies intended to mitigate against the potential for related gastroduodenal injury.

A Review of Select Centralized Pain Syndromes: Relationship With Childhood Sexual Abuse, Opiate Prescribing, and Treatment Implications for the Primary Care Physician.

Pain can be broadly divided into 3 classes, including nociceptive or inflammatory pain (protective), neuropathic (pathological, occurring after damage to the nervous system), or centralized (pathological, due to abnormal function but with no damage or inflammation to the nervous system). The latter has been posited to occur when descending analgesic pathways are attenuated and/or glutamatergic transmission is facilitated. Additionally, this "pain prone phenotype" can be associated with early life trauma and a suboptimal response to opiates. This article will review the relationships between centralized pain syndromes (ie, fibromyalgia, chronic low back pain), childhood sexual abuse, and opiate misuse. Finally, treatment implications, potentially effecting primary care physicians, will be discussed.

Clostridium difficile-associated diarrhea: risk factors, diagnostic methods, and treatment.

Clostridium difficile-associated diarrhea (CDAD) has become the most common cause of infectious diarrhea acquired in the hospital, with an estimated 3 million annual cases and an annual cost of $1 billion. Risk factors for CDAD include antibiotic use (especially ampicillin, clindamycin, and cephalosporins), advanced age, and gastrointestinal surgery. Specific diagnosis of CDAD is made with an enzyme immunoassay to detect toxins A and B. Metronidazole remains the initial treatment of choice, with a 95% success rate. Vancomycin is reserved for failures. Despite the high initial success rates, recurrence of CDAD remains a significant problem in 20% to 30% of cases, with increased cost and substantial morbidity. Efforts to prevent CDAD will need to be strengthened, including education and better compliance with isolation, use of gloves, and hand washing.