Fecal Microbiota Transplantation (FMT) with Colonoscopy Is Superior to Enema and Nasogastric Tube While Comparable to Capsule for the Treatment of Recurrent Clostridioides difficile Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Several routes of fecal microbiota transplantation (FMT) administration are available for treating recurrent Clostridioides difficile infections (CDI), the most recent of which are capsules. AIM: To assess the efficacy of colonoscopy, capsule, enema, and nasogastric tube (NGT) FMT for the treatment of recurrent CDI. METHODS: We reported clinical outcomes of colonoscopy, capsule, enema, and NGT FMT for the treatment of recurrent CDI according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. During January 2000 to January 2018, three databases were searched: PubMed, EMBASE, and CINAHL. Primary outcome was overall cure rate which was assessed using a random effects model; secondary outcomes included adverse effects as well as subgroup analyses comparing donor relationship, sample preparation, and study design. RESULTS: Twenty-six studies (1309 patients) were included in the study. FMT was administered using colonoscopy in 16 studies (483 patients), NGT in five studies (149 patients), enema in four studies (360 patients), and capsules in four studies (301 patients). The random effects of pooled FMT cure rates were colonoscopy 94.8% (CI 92.4-96.8%; I2 15.6%), capsule 92.1% (CI 88.6-95.0%; I2 7.1%), enema 87.2% (CI 83.4-90.5%; I2 0%), and NGT/NDT 78.1% (CI 71.6-84.1%; I2 0%). On subgroup analysis of colonoscopy FMT, sample preparation methods had comparable cure rates: fresh 94.9% compared to 94.5%. Similarly, cure rates were unaffected by donor relationship: mixed 94.5% compared to unrelated donor 95.7%. CONCLUSION: CDI cure rates with FMT performed with colonoscopy are superior to enema and NGT FMT, while those with FMT with colonoscopy and capsule are comparable.

When Thirst Ceases to Exist: A Case Report and Literature Review of Adipsic Diabetes Insipidus Following Coil Embolization of a Ruptured Anterior Communicating Artery Aneurysm.

Diabetes insipidus is a condition characterized by inappropriately dilute urine in the setting of serum hyperosmolality. The two predominant subtypes include central (from lack of vasopressin production) and nephrogenic diabetes insipidus (from renal resistance to circulating vasopressin). A common manifestation is the significant pursuant thirst from excessive polyuria. We present a case report and literature review of an infrequent variation of central diabetes insipidus known as adipsic (hypothalamic) diabetes insipidus, characterized by the absence of thirst, secondary to coiling of a ruptured anterior communicating artery aneurysm. Due to the loss of thirst, patients are at a heightened risk for hypernatremia and complications secondary to dehydration. Our patient's course was complicated by recurrent polyuria and hypernatremia, requiring a fixed-dose desmopressin regimen. On follow-up, only partial thirst sensation was restored. We provide a literature review to compare our case report to the scant literature available to broaden the awareness of this infrequent, perilous, manifestation.

A Rare Case of Levetiracetam-Induced Refractory Hypokalemia.

Levetiracetam is a Food and Drug Administration (FDA)-approved drug for partial, generalized, and myoclonic seizures. Its mechanism of action as an antiepileptic involves the release of neurotransmitters from synaptic vesicles. The common side effects of levetiracetam include sleepiness, weakness, dizziness, and infection. We present a case of levetiracetam-induced hypokalemia, which was refractory to multiple repletion attempts. A 73-year-old woman with a history of seizures, heart failure, and previous stroke was admitted to the hospital due to witnessed seizure-like activity as a result of medication non-compliance. Her serum potassium prior to the start of antiepileptic medication was 4.5 mmol/L. She was restarted on her home dose of levetiracetam 1000 mg twice daily. Twenty-four hours after starting levetiracetam, the patient was found to have hypokalemia, and the patient's potassium levels failed to correct, dropping as low as 2.0 mmol/L despite continued repletion and normalized magnesium levels. A decision was made to switch the levetiracetam to lacosamide. Thirty-six hours after this change was made, the patient's potassium level corrected to 3.3 mmol/L and then corrected to 3.9 mmol/L five days later without requiring further repletion. Based on her clinical course, a diagnosis of levetiracetam-induced refractory hypokalemia was made. She was discharged home on lacosamide as her new antiepileptic medication, along with a close follow-up with neurology. Our case highlights the importance of considering Levetiracetam as a cause of refractory hypokalemia. Cases of levetiracetam-induced hypokalemia and hypomagnesemia are rarely reported in the literature, and those that have been reported vary greatly in onset and the resolution of electrolyte derangements. Given that levetiracetam is a widely used antiepileptic medication, we suggest that in cases of refractory hypokalemia, a change in antiepileptic medication should be considered.

Atezolizumab-induced autoimmune diabetes mellitus presenting as diabetic ketoacidosis and Takotsubo cardiomyopathy.

Atezolizumab is a humanised monoclonal IgG1 antibody that is used in treating many solid malignancies. Endocrinopathies are known but a rare adverse event of these immunotherapeutic drugs. Autoimmune diabetes induced by atezolizumab has been rarely reported in the literature. We report the case of a woman in her eighth decade with no known history of diabetes who developed new-onset autoimmune diabetes and Takotsubo cardiomyopathy due to the adverse effects of atezolizumab therapy for hepatocellular carcinoma. We also review the characteristics and outcomes of cases previously reported in the literature.

Impact of the COVID-19 Pandemic on the Overall Health of Patients With Pre-diabetes and Diabetes.

Coronavirus disease 2019 (COVID-19) impacted those with chronic diseases worldwide, especially those with diabetes. Very few studies have explored the effect of COVID-19 on diabetic patients' health markers. The present retrospective study compared various health markers of diabetic patients before and during the COVID-19 pandemic. Patients (N = 511) displayed a significant increase in systolic blood pressure, hemoglobin A1c (HbA1c), diabetic medications, and dose of insulin (p < 0.05) as well as a decrease in low density lipoprotein (LDL) levels (p = 0.04). When patients were stratified by body mass index (BMI), those in higher BMI categories were more negatively impacted during the pandemic than those in lower categories. Results display the impact that COVID-19 had on the general well-being of diabetic patients, and should encourage providers to increase telehealth visits when in-person visits are not possible.

Grade 3 Neuroendocrine Tumor (G3NET): An Unusual Tumor With A Histochemical Surprise.

Given the rare occurrence and the indolent course of Neuroendocrine tumors (NETs), few epidemiological studies exist on these cancers. A small but interesting subset of these tumors are G3- Neuroendocrine Tumors. Grade 3 Neuroendocrine tumors (or G3-NETs) are unique in their intermediate prognosis. These grade discordant tumors lie in between high-grade poorly differentiated neuroendocrine carcinomas and grade 2 well-differentiated NETs, which have a worse and better prognosis than this rare entity, respectively. In this case report, we present a case of Grade 3 NET with an unusually high Ki67 index, diagnosed upon biopsy of metastasis visualized on imaging. Additionally, we review existing literature for characteristics, immunohistochemical markers, prognosis, and treatment modalities for the same.