Rare Association of Autoimmune Limbic Encephalitis and Stiff Person Syndrome.

Antibodies to Glutamic Acid Decarboxylase (GAD) have been implicated in the pathogenesis of both autoimmune Limbic Encephalitis (LE) and Stiff Person Syndrome (SPS). However, their association is quite rare. We present a case of a 48-year-old Caucasian female who presented with symptoms of recurrent severe headaches, behavioral and cognitive dysfunction, and an episode of seizure. She was found to have high titers of anti-GAD65 antibodies in both cerebrospinal fluid and serum. She was diagnosed with LE and SPS, and was started on immunosuppressive therapy with steroids and intravenous immunoglobulins (IVIG). The patient responded well to treatment with improvement in her symptoms.

Cannabis Use in Patients with Gastroparesis.

Aim: The primary aim was to determine the prevalence of cannabis use among patients hospitalized for gastroparesis. The secondary aim was to identify independent variables associated with cannabis use compared with noncannabis-related gastroparesis hospitalization. Methods: We use the nationwide inpatient sample database from January 2012 to December 2014. The patients included in this study were the ones with primary diagnosis of gastroparesis and cannabis use. The analysis was performed using the Statistical Package for the Social Sciences 27 (SPSS) and a multivariable regression was conducted to identify independent variables. Results: We found 50,170 patients with a primary diagnosis of gastroparesis. The prevalence of cannabis use among patients hospitalized for gastroparesis was 4.2%. Multivariate regression analysis was performed, adjusting for confounders. The variables found to increase the odds of cannabis use in gastroparesis populations independently were age interval of 18-35 and 36-50 years, male, Black and Asian, median household income 1-25th percentile, Medicaid insurance, no charge hospitalization, and smoking. Cannabis use was associated with lower odds of vomiting. Conclusion: Patients who used cannabis were younger and of African American, Asian, or Pacific Islander descent. They had Medicaid insurance and a lower median household income.

Adequacy Rate of Magnesium Citrate Bowel Preparation in a Large Retrospective Cohort.

INTRODUCTION: Magnesium Citrate (MC) is not FDA approved as a colonoscopy preparation. Advantages include low cost, small volume and accessibility without prescription. We retrospectively evaluated bowel preparations used in a private gastroenterology practice. The sample size is the largest for any similar studies (n =19,173). METHODS: Electronic Medical Records were queried for colonoscopies between 2010-2016. Bowel preps, indications (screening vs. other) and preparation adequacy were all recorded. Adequacy rates were calculated and compared using generalized linear modeling. Data were analyzed using SAS. RESULTS: The most common prep used was MC 2 bottles; screening (n=6,064, with 98.94% adequacy) and non-screening (n=3,251, with 99.29% adequacy), followed by MC 3 bottles; screening (n=2,757 with 90.35% adequacy), and non-screening (n=1,925 with 92.92% adequacy). CONCLUSION: MC bowel preparation is adequate, well tolerated, and inexpensive. In a large retrospective analysis, it compares favorably to other preparations.

Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions.

BACKGROUND: Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC. AIM: To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC. METHODS: This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality. RESULTS: Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001]. CONCLUSION: The prevalence of GIH in patients with GIC varies significantly based on the tumor's anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.

Five-year outcomes of transoral outlet reduction for the treatment of weight regain after Roux-en-Y gastric bypass.

BACKGROUND AND AIMS: Transoral outlet reduction (TORe) is a common endoscopic treatment for patients with weight regain after Roux-en-Y gastric bypass (RYGB) with a dilated gastrojejunal anastomosis (GJA). This study aims to assess long-term efficacy of TORe. METHODS: This was a retrospective review of prospectively collected data on RYGB patients who underwent TORe for weight regain or inadequate weight loss. The primary outcome was efficacy of TORe at 1, 3, and 5 years. Secondary outcomes were procedure details, safety profile, and predictors of long-term weight loss after TORe. RESULTS: Three hundred thirty-one RYGB patients underwent 342 TORe procedures and met inclusion criteria. Of these, 331, 258, and 123 patients were eligible for 1-, 3- and 5-year follow-ups, respectively. Mean body mass index was 40 ± 9 kg/m2. Pre-TORe GJA size was 23.4 ± 6.0 mm, which decreased to 8.4 ± 1.6 mm after TORe. Patients experienced 8.5% ± 8.5%, 6.9% ± 10.1%, and 8.8% ± 12.5% total weight loss (TWL) at 1, 3, and 5 years with follow-up rates of 83.3%, 81.8%, and 82.9%, respectively. Of 342 TORe procedures, 76%, 17.5%, 4.4%, and 2.1% were performed using single purse-string, interrupted, double purse-string, and running suture patterns, respectively, with an average of 9 ± 4 stitches per GJA. Pouch reinforcement suturing was performed in 57.3%, with an average of 3 ± 2 stitches per pouch. There were no severe adverse events. Some patients (39.3%) had additional weight loss therapy (pharmacotherapy or procedure), with 3.6% getting repeat TORe. Amount of weight loss at 1 year (ß = .43, P = .01) and an additional endoscopic weight loss procedure (ß = 8.52, P = .01) were predictors of percentage of TWL at 5 years. CONCLUSIONS: TORe appears to be safe, effective, and durable at treating weight regain after RYGB.

Critical Care Utilization in Patients with Diabetic Ketoacidosis, Stroke, and Gastrointestinal Bleed: Two Hospitals Experience.

INTRODUCTION: Intensive Care Units (ICUs) are among the most expensive components of hospital care. Experts believe that ICUs are overused; however, hospitals vary in their ICU admission rate. Our hypothesis is based on clinical observations that many patients with diabetic ketoacidosis (DKA), stroke, and gastrointestinal (GI) bleeding admitted to the ICU don't really need it and could be managed safely in a non-ICU level of care. Reducing inappropriate admissions would reduce healthcare costs and improve outcomes. Our primary objective was to determine the frequency of inappropriate ICU admissions. Secondary objectives were to evaluate which diagnoses were more unnecessarily admitted to the ICU, evaluate different variables and comorbidities, and determine the mortality rates during ICU admissions. METHODS:  Patients admitted to the ICU, from the Emergency Department (ED) or transferred from the floor, during a one-year period were evaluated in this retrospective study. Patients 18-years old and above who had an admitting diagnosis of DKA, GI bleed, ischemic stroke, or hemorrhagic stroke were included. Patients in a comatose state, intubated, on vasopressors, hemodynamically unstable or had an unstable comorbid disease, subarachnoid hemorrhage, surgery during hospitalization prior to the ICU admission were excluded. Patients were categorized as having an appropriate or inappropriate ICU admission based on our institutional ICU admission criteria and data from available literature and guidelines. RESULTS: A total of 95 patients were included in our cohort. Seventy-two out of 95 (76%) were considered as inappropriate ICU admissions. When comparing each of the four admitting diagnoses, a significantly higher proportion of DKA patients were considered inappropriate ICU admissions when compared to the other diagnoses (P = 0.001). The overall mortality rate of ICU admissions was 16%, 15 patients out of 95 study population. When comparing each of the four admitting diagnoses, there was a significant difference in mortality rate with DKA having the lowest mortality (3%) and GI bleed having the highest mortality (43%). Out of the 15 patients who died, only 1 patient was categorized as an inappropriate ICU admission. CONCLUSIONS:  More than three-quarters of our study population was admitted to the ICU inappropriately. Incorporating severity scores in ICU admission criteria could improve the appropriateness of ICU admission and financial feasibility. This article is based on a poster: Alsamman S, Alsamman MA, Castro M, Koselka H, Steinbrunner J: ICU admission patterns in patients with DKA, stroke and GI bleed: do they all need ICU? J Hosp Med. March 2015.

Retrospective Analysis Confirms Tetracycline Quadruple as Best Helicobacter pylori Regimen in the USA.

BACKGROUND: Declining Helicobacter pylori (H. pylori) eradication rates have prompted a switch in first-line therapy from standard triple (PPI, clarithromycin, and amoxicillin) to bismuth-based quadruple therapy. A caveat of the ACG 2017 H. pylori treatment guidelines was a paucity of recent US eradication data. AIM: To determine Rhode Island H. pylori eradication data, in the largest US study from the last two decades. METHODS: Electronic records were queried for patients with H. pylori infection diagnosed by pathology, urea breath test, or stool antigen from 2015 to 2017. Demographics, diagnostic test, treatment regimen, and test of cure were extracted. Eradication rates were calculated, and treatment regimens were compared. RESULTS: A total of 1710 patients were identified (64% female): 825 (46%) diagnosed by breath test, 755 (42%) by biopsy, and 191 (12%) by stool antigen. Full data were obtained on 1101 patients. Seven regimens were used: quadruple (64%), triple (25%), doxycycline quadruple (5%), and miscellaneous (6%). Quadruple was superior to triple: (85% vs. 75%, P = 0.002), quadruple 14 days versus triple 14 days (87% vs. 79%, P = 0.0052), quadruple 10 days versus triple 10 days (77% vs. 67%, P = 0.33). Increased therapy length improved eradication (quadruple 14 days  vs. 10 days, 87% vs. 77%, P = 0.002; triple 14 days  versus 10 days 79% vs. 67%, P = 0.13). Finally, substituting doxycycline for tetracycline yielded lower eradication (85% vs. 67%, P = 0.006). CONCLUSION: Quadruple therapy is superior to triple therapy within the Rhode Island population. Fourteen-day therapy achieves superior eradication compared to 10-day therapy, and doxycycline is inferior to tetracycline for quadruple therapy. Our findings support adherence to ACG and international guidelines advising 14-day quadruple therapy.

Efficacy and Safety of Intragastric Balloon Placements in 1600 Case, an Experience from the Middle East.

BACKGROUND AND PURPOSE: Intragastric balloons are used as a treatment for obesity. Much of the data collected on balloons had been in the context of clinical trials in academic medical centers or as a bridge to bariatric surgery in obesity centers. The aim of this study was to investigate the efficacy and safety of balloon treatment in private practice. STUDY DESIGN: This is an interventional study. SUBJECTS: The study included 1600 patients. PLACE: The study was conducted at the ElKatib Hospital. METHOD: This was a retrospective analysis of 6-month weight loss data and balloon-related complications of patients referred to a private center for obesity treatment. ASSESSMENT: The assessment was carried out by obtaining full patients' history (personal history, present illness, and previous drug history and operations). Laboratory work was done in the form of CBC, blood sugar, and viral markers. Bioenterics Intragastric Balloon (BIB) silicone balloon was used, filled with saline plus methylene blue dye with a volume ranging from 400 to 700 ml. The gained measures were analyzed by using SPSS program, and paired t test and chi-square test were used to compare between groups. RESULTS: A total of 1600 patients were included (368 male (23%) and 1232 female (77%)) with mean age 34.1 ± 10.354, mean body weight 112.45 ± 26.24, and mean body mass index (BMI) 40.32 ± 8.17. There were 46 patients younger than 18 years and 12 patients older than 60 years. There were 109 patients with a BMI ranging from 25 to < 35 and 737 patients with a BMI ≥ 40 kg/m2. A total of 1567 patients who attended weight consultation had a mean weight loss 17.35 ± 11.07 from intragastric balloon implantation. Thirty-three patients from the total sample were not weighted after the removal of the balloon (dropped out). Percentage excess weight loss (% EWL) = 100% × (baseline absolute weight (AW)-last weight)/(baseline AW-initial body weight (IBW)) was found, and weight loss of more than 10% was considered significant. About 49.3% of patients showed significant weight loss > 10%, 24.7% of patients showed weight loss > 20%, while 26% of patients showed no significant weight loss < 10%. CONCLUSION: Intragastric balloons on their own, with an intensive lifestyle program and supportive consultations, resulted in safe and short-term substantial weight loss, and may fill the therapeutic gap between pharmacotherapy and surgery.

Successful Endoscopic Reduction of an Ileocolonic Intussusception in an Adult With Peutz-Jeghers Syndrome.

Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant disorder characterized by hamartomatous polyps throughout the gastrointestinal tract, mostly causing gastrointestinal bleeding and recurrent intestinal obstructions. Few intussusception related to PJS occurs reportedly in adults. Unlike pediatric cases almost all reported cases end up with surgical resection. Here we present a case of PSJ-related intussusception in an adult patient treated successfully with endoscopic approach, with no surgical intervention required.

Nonmetastatic renal cell carcinoma presenting with persistent cough: Case report with literature review.

Renal cell carcinomas (RCC), constitute 80- 85% of primary renal neoplasms. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in approximately 9% of patients; it strongly suggests locally advanced disease. RCC may also be associated with a number of paraneoplastic syndromes. These are typically due to ectopic production of various hormones. We present a 69-year-old male patient previously healthy presented to the emergency department with recurrent persistent cough. A non-metastatic RCC was incidentally discovered. Eventually, he underwent left radical nephrectomy. One year has passed with no cough. This is a rare and unusual presentation of RCC that falls under the category of paraneoplastic syndrome with review of similar reported cases and summary of all paraneoplastic syndromes associated with RCC in literature.