Helicobacter pylori Treatment Regimen Selection and Eradication Rates Across Department of Defense Patients for Fiscal Years 2016-2018.

INTRODUCTION: The objective of this study was to measure the number of treatment successes and failures of various Helicobacter pylori treatment regimens among DoD beneficiaries. MATERIALS AND METHODS: This was a retrospective cross-sectional study of all adult DoD beneficiaries with H. pylori diagnosis, treatment, and eradication testing from October 2015 to September 2018. All stool antigen testing, urea breath test, and immunoglobulin G serologies were identified. Patients were excluded if they did not have a positive test, did not have treatment, or did not have eradication testing. RESULTS: In total, 20,548 H. pylori diagnostic tests were performed over the study period. A total of 1,592 non-active duty and 374 active duty patients were diagnosed with H. pylori, were treated, and had eradication testing. The best performing regimens were tetracycline-based bismuth quadruple therapy and tinidazole-based clarithromycin triple therapy with eradication rates of 85% and 82%, respectively. Clarithromycin triple therapy was the most prescribed (63.9% of all regimens included in analysis). Of the 1,592 non-active duty and 374 active duty patients, 75.5% (1,202) and 70.6% (264) cleared the infection with treatment, respectively (P = 0.0449). Although trends were identified in differences in geographic eradication rates, none of these achieved the threshold of significance. CONCLUSIONS: This is the largest and most geographically widespread H. pylori treatment efficacy study in the USA over 20 years. None of the treatment regimens (when used in over five patients) achieved an eradication rate greater than 90%, but tetracycline-based bismuth quadruple therapy performed best among all regimens and populations. Eradication rates were lower in the active duty populations, with no treatment regimen achieving an eradication rate greater than 80%.

A Small Blemish: Isotretinoin-Induced Microscopic Colitis.

Microscopic colitis is a form of colonic inflammation that presents with chronic nonbloody diarrhea that can only be diagnosed histologically with biopsies obtained during colonoscopy. We report a rare case of isotretinoin-induced microscopic colitis in a patient who was prescribed this medication for nodular acne with a 1-year history of nonbloody diarrhea, bloating, cramping, and foul-smelling gas. Cessation of this medication in addition to initiating treatment with budesonide resulted in remission of the patient's symptoms. The presence of chronic diarrhea in patients who are taking isotretinoin should raise suspicion for this condition and warrant further investigation.

The Patterns and Associated Cost of Serologic Testing for Helicobacter pylori in the U.S. Military Health System.

INTRODUCTION: Helicobacter pylori (H. pylori) infection affects about half of the world's population and can lead to multiple complications if left untreated. Testing for H. pylori infection in appropriate patients with prompt treatment followed by the testing of eradication is the standard of care in the United States. Active Duty Service members (ADSMs) in the U.S. military are a unique patient population that may be at higher risk for acquiring H. pylori infection given frequent deployments to developing countries. Noninvasive diagnostic strategies include the urea breath test, the stool antigen test, and serologic testing, which include H. pylori immunoglobulin M (IgM), immunoglobulin A (IgA), and immunoglobulin G (IgG) antibodies. Among noninvasive methods, the least sensitive is serology, and although there is clinical utility in testing for H. pylori IgG antibodies, H. pylori IgA or IgM antibodies have limited clinical utility. Despite this, H. pylori IgA and IgM antibodies are still widely ordered across the Military Health System. MATERIALS AND METHODS: In order to determine how frequently this testing is being ordered and the associated cost, we conducted a retrospective cross-sectional study of H. pylori serologic testing utilization in the MHS from October 2015 to September 2018 in adult patients using the MHS Data Repository. All H. pylori IgM, IgA, and IgG antibodies, H. pylori stool antigen tests, and H. pylori urea breath tests were queried during this time period across all ADSMs, retirees, and ADSM dependents for all adults. Cost information was obtained from LabCorp, and the institutional price used for cost analysis was the same throughout all military treatment facilities in the Department of Defense (DOD). RESULTS: We discovered that over a 3-yr period, 1,916 H. pylori IgA and 2,492 IgM antibodies were ordered. In total, the DOD spent close to $400,000 on antibody-based testing for H. pylori not accounting for indirect associated costs like personnel, supplies, repeat testing, as well as the costs of delayed diagnosis and associated complications. CONCLUSION: H. pylori IgM and IgA have limited clinical utility, are inaccurate, and are costly to maintain, especially when more accurate alternative tests are available. Based on our analysis, we strongly recommend the removal of the H. pylori IgA and IgM serologic tests throughout the DOD in order to improve the efficiency and quality of care for patients suspected of having an H. pylori infection. Further research is needed to determine how these tests are ordered, how providers are responding to the results of the serologic tests, and if noninvasive testing is being ordered appropriately.

Treatment-resistant severe capecitabine-induced diarrhoea resolved with oral budesonide.

Chemotherapy-induced diarrhoea (CID) is a risk of antineoplastic regimens, often associated with 5-fluorouracil (5-FU), irinotecan and capecitabine. Current treatment guidelines for CID include the use of loperamide and octreotide but do not account for other therapies, including budesonide. Small case reports have shown benefit with budesonide in CID secondary to 5-FU and irinotecan, but there is no literature base addressing budesonide use in CID secondary to capecitabine. We describe a case of a patient with severe capecitabine-induced diarrhoea that was refractory to guideline based therapy but resolved with the use of budesonide.

Memantine-Induced Liver Injury With Probable Causality as Assessed Using the Roussel Uclaf Causality Assessment Method (RUCAM).

Presentations of drug-induced liver injury (DILI) are highly variable. Although biochemical evidence of cholestasis is common, the extent of aminotransferase elevations and patterns of liver injury vary. Patients may be asymptomatic, and many cases may never be diagnosed. We describe a case of memantine-induced hepatotoxicity in an elderly patient with Alzheimer's dementia, with probable causality for drug-induced liver injury, as assessed using the Roussel Uclaf Causality Assessment Method (RUCAM) score.

Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program.

INTRODUCTION: In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula. We designed and implemented an iterative POCUS curriculum for trainees at a large military IM residency program over a two-year period. METHODS: In collaboration with our critical care and simulation departments, we developed a pilot curriculum consisting of five, 60-minute courses offered on a voluntary basis at monthly intervals throughout 2017. Based on the pilot's success we incorporated a POCUS curriculum into the core academics received by all IM trainees during the 2017-2018 academic year. Trainees attended seven, 3-hour sessions during their scheduled academic time taught by subspecialists with POCUS expertise in an on-site simulation center. Baseline surveys and knowledge assessment examinations were administered during orientation and repeated at the end of the academic year. Comparison of results before and after the POCUS curriculum was the primary outcome evaluated. RESULTS: Intervention #1: Pilot, 2016-2017 Academic Year45 trainees attended at least one course with an average of 1.8 sessions per trainee. Baseline survey data showed 91% of trainees believe POCUS is quite or extremely beneficial for their patients, but 73% feel slightly or not at all confident in POCUS knowledge. The pre-test mean and median scores were 71% and 77% respectively, which both increased to a post-test mean and median of 81%. Post-test mean percentage correct for trainees attending 1, 2, or 3 courses was 74%, 82%, and 91% respectively. Intervention #2: Incorporation of POCUS into Core Academics, 2017-2018 Academic YearAll 75 trainees participated in training with an average of 3.77 sessions attended per trainee. Survey analysis revealed significant improvement in confidence of performing ultrasound-guided procedures (p = 0.0139), and a 37% absolute increase in respondents who anticipate using ultrasound in their clinical practice (p = 0.0003). The mean pre-test score was 67.8% with median of 63.6% while mean and median post-test scores were 82.1% and 81.8%, with an absolute improvement of 14.3% and 18.2% respectively (p = 0.0004). CONCLUSION: A structured POCUS curriculum was successfully incorporated at a large multiservice military IM residency program, with demonstrated retention of knowledge, improved confidence in performance of ultrasound guided invasive procedures, and increased interest in the use of POCUS in future clinical practice. Similar programs should be implemented across all IM programs in military graduate medical education to enhance operational readiness and battlefield care.

Infliximab-Induced Aseptic Meningitis in a Patient with Crohn's Disease.

Infliximab is an anti-tumor necrosis factor α (TNFα) monoclonal antibody that treats moderate-to-severe Crohn's disease. In rare cases, infliximab has been associated with drug-induced aseptic meningitis. We present a 46-year-old woman with migraines and inflammatory Crohn's colitis treated with intravenous infliximab and methotrexate. She developed nuchal rigidity, photophobia, and headache 2 days after each of her infliximab infusions, with symptom resolution 1 week post-infusion. Her exam, imaging, and cerebrospinal fluid analysis were consistent with drug-induced aseptic meningitis. She discontinued infliximab and started vedolizumab with continued remission of her Crohn's disease.

Heart Under Attack: Cardiac Manifestations of Inflammatory Bowel Disease.

There is a well-established association between chronic inflammation and an elevated risk of heart disease among patients with systemic autoimmune conditions. This review aims to summarize existing literature on the relationship between inflammatory bowel disease and ischemic heart disease, heart failure, arrhythmia, and pericarditis, with particular attention to approaches to management and treatment.

Novel use of rituximab in macrophage activation syndrome secondary to systemic lupus erythematosus.

Macrophage activation syndrome (MAS) is a rare disease characterised by aberrant immune hyperactivation of T lymphocytes and macrophages driven by cytokine dysfunction. The HLH-2004 protocol is commonly used for the treatment of MAS, but significant toxicities are associated. We describe a case of MAS secondary to systemic lupus erythematosus in a young female that responded well to rituximab in lieu of etoposide. She continues to be in remission 1 year following the completion of rituximab infusion and is maintained on hydroxychloroquine. This case highlights the need for further research on the use of rituximab and other available biologics in the setting of MAS in order to help guide further alternative treatment decisions.

Hepatitis C eradication with sofosbuvir leads to significant metabolic changes.

AIM: To assess the effect of sofosbuvir (SOF) based regimens on glycemic and lipid control. METHODS: This is a retrospective analysis of hepatitis C virus (HCV)-infected patients treated and cured with a SOF regimen [SOF/ribavirin/interferon, SOF/simeprevir, or SOF/ledipasvir (LDV) ± ribavirin] from January 2014 to March 2015. Patients with hemoglobin A1C (HbA1C) and lipid panels within six months before and six months after therapy were identified and included in our study. Due to the known hemolytic effect of ribavirin, HbA1C was obtained a minimum of three months post-treatment for the patients treated with a ribavirin regimen. Medical history, demographics, HCV genotype, pre-therapy RNA, and liver biopsies were included in our analysis. The patients who started a new medication or had an adjustment of baseline medical management for hyperlipidemia or diabetes mellitus (DM) were excluded from our analysis. RESULTS: Two hundred and thirty-four patients were reviewed, of which 60 patients met inclusion criteria. Sixty-three point three percent were male, 26.7% were Caucasian, 41.7% were African American and 91.7% were infected with hepatitis C genotype 1. Mean age was 60.6 ± 6.7 years. Thirty-nine patients had HbA1C checked before and after treatment, of which 22 had the diagnosis of DM type 2. HbA1C significantly decreased with treatment of HCV (pretreatment 6.66% ± 0.95% vs post-treatment 6.14% ± 0.65%, P < 0.005). Those treated with SOF/LDV had a lower HbA1C response than those treated with other regimens (0.26% ± 0.53% vs 0.71% ± 0.83%, P = 0.070). Fifty-two patients had pre- and post-treatment lipid panels; there was a significant increase in low-density lipoprotein (LDL) and total cholesterol (TC) after treatment (LDL: 99.5 ± 28.9 mg/dL vs 128.3 ± 34.9 mg/dL, P < 0.001; TC: 171.6 ± 32.5 mg/dL vs 199.7 ± 40.0 mg/dL, P < 0.001). Pre-treatment body-mass index (BMI) did not differ from post-treatment BMI (P = 0.684). CONCLUSION: Eradication of HCV with a SOF regimen resulted in a significant drop in HbA1C and an increase in LDL and TC post therapy.