Keeping the cecum clean: a randomized, prospective, placebo-controlled trial of loperamide as part of preparation for colonoscopy.

BACKGROUND: Coating of the cecum with sticky bile causes a problem with inspection of the mucosa during colonoscopy. PURPOSE: This study aimed to see whether 4 mg of loperamide taken after colonoscopy preparation would delay the passage of bile and improve the quality of cecal preparation. PATIENTS: Patients undergoing office colonoscopy were included. Patients with incomplete colonoscopies or right colectomy were excluded. STUDY DESIGN: This study was a prospective, randomized, double-blinded, and placebo-controlled trial. INTERVENTION: Either 2 placebo capsules or 2 loperamide capsules were taken after gut lavage, as soon as the passage of liquid stool ceased. Cecal photographs were scored in a blinded fashion. MAIN OUTCOME MEASURES: The primary outcomes measured were the quality of cecal preparation on a scale of 1 to 5 and overall preparation on a scale of 1 to 4. RESULTS: Ninety-eight patients took loperamide (50 men, 48 women) and 102 took placebo (57 men, 45 women). Mean ages of the loperamide group were: men, 61.9 ± 11.9 years, and women, 61.8 ± 10.0 years; and mean ages of the placebo group were: men, 62.5 ± 12.1 years, and women, 58.6 ± 9.8 years. Over 90% of patients used a polyethylene glycol-based preparation. Thirteen of 102 (12.7%) placebo cases had a dirty or coated cecum (score 4 or 5). In the loperamide group, this number was 2 of 98 (2.0%; p = 0.0041). Nineteen placebo cases (18.6%) had an overall fair/poor preparation in comparison with 9 of the loperamide group (9.2%; p = 0.0543). Days to first bowel movement were 2.4 ± 1.1 for loperamide and 2.5 ± 1.7 for placebo (p = 0.7224). Fifty-eight percent of loperamide patients had polyps, and 74% of these patients had multiple polyps; 67% of placebo patients had polyps, but only 54% of these patients had multiple polyps (vs loperamide, p = 0.0183). CONCLUSION: Judicious use of loperamide can significantly improve the quality of cecal preparation and may increase polyp yield.

Randomized trial comparing the effectiveness of internal (through implantable cardioverter defibrillator) versus external cardioversion of atrial fibrillation.

PURPOSE: When patients with implantable cardioverter defibrillators (ICD) develop symptomatic atrial fibrillation (AF), external direct current cardioversion (EDCCV), as well as internal cardioversion using their ICD, are the options available. It is currently unknown which of these two methods are more effective. We compared the effectiveness of EDCCV versus internal cardioversion to terminate AF in patients with a single-coil ICD. METHODS: This randomized controlled trial (clinicaltrial.gov NCT03164395) enrolled consecutive patients with a single-coil ICD that presented with symptomatic AF of less than 1-year duration. They received either the maximum energy internal shock through the ICD or an EDCCV using transcutaneous pads of 200 J. The primary endpoint was a successful conversion to sinus rhythm after one shock. Crossover was permitted if the first shock was unsuccessful. RESULTS: Thirty-one patients were enrolled in the study, including 16 in the internal ICD cardioversion group. The study included patients with a mean age of 59.5 ± 16.0 years, 41.9% females, median AF duration 1 month (interquartile range 1-3), 45.2% non-ischemic cardiomyopathies, mean EF 28.6 ± 16.0%, and 45.2% biventricular ICD. There were no significant differences in baseline clinical characteristics between the two groups. In the internal cardioversion group, 5/16 patients (31.3%) met the primary endpoint versus 14/15 (93.3%) in the EDCCV group, p < 0.001. All patients that failed the first shock were subsequently cardioverted externally. CONCLUSION: Among patients with a single-coil ICD and symptomatic AF of less than 1 year, external direct current cardioversion is much more effective than internal shock through the ICD.

Polishing the crystal ball: knowing genotype improves ability to predict desmoid disease in patients with familial adenomatous polyposis.

INTRODUCTION: Desmoid disease occurs in one third of patients with familial adenomatous polyposis. Patients may be protected by changing surgical strategy. We designed a formula to predict desmoid risk and tested the value of adding genotype to the formula. METHODS: A desmoid risk factor was calculated by summing points awarded for gender (male = 1, female = 3), extracolonic manifestations (nil = 1, one = 2, >one = 3), and family history of desmoids (negative = 1, one relative = 2, more than one relative = 3). Performance of the score with and without genotype (5' 1309 = 1, 1309-1900 = 2, 3' 1900 = 3) was analyzed. RESULTS: There were 839 patients (138 desmoids) without genotype and 154 (30 desmoids) with genotype. The mean desmoid risk factor score of patients without desmoids (no genotype) was 4.7 (+/-1.4 SD) and for patients with desmoid the desmoid risk factor was 6.0 (+/-1.7, P < 0.001). Corresponding data for patients with genotype was 6.1 +/- 1.3 (no desmoids) and 8.4 +/- 1.8 with desmoids (P < 0.001). Of patients without genotype, 648 patients were at low risk and 9.9% had desmoid disease, 178 patients were at medium risk and 34% had desmoids, and 10 patients were at high risk and all had desmoids. Of those with genotype information, 83 patients were at low risk and 5% had desmoids, 52 patients were at medium risk and 21% had desmoids, and 18 patients were at high risk and 83% had desmoids. CONCLUSION: The desmoid risk factor identifies patients with various levels of risk for developing desmoid disease, and can be used to plan surgical strategies designed to minimize desmoid risk.

A desmoid tumor-staging system separates patients with intra-abdominal, familial adenomatous polyposis-associated desmoid disease by behavior and prognosis.

PURPOSE: Intra-abdominal desmoid tumors associated with familial adenomatous polyposis are heterogeneous. A recent staging system categorizes desmoids according to size, symptoms, and complications. We applied the staging system to determine whether it separates patients into clinically significant groups. METHODS: The staging system was applied to 101 patients with familial adenomatous polyposis. RESULTS: There were 21 patients with Stage I tumors, 36 with Stage II, 26 with Stage III, and 18 with Stage IV. Twelve patients with Stage I and five with Stage II tumors needed no treatment. Eight patients with Stage I disease received medical treatment, as did 26 with Stage II, 16 with Stage III, and 15 with Stage IV. Six Stage I tumors had surgery, as did 20 Stage II, 12 Stage III, and 13 Stage IV. Chemotherapy was given to 1 Stage II tumor, 7 Stage III, and 5 Stage IV. No patient with Stages I or II disease died. Four Stage III patients (15 percent) and 8 Stage IV patients (44 percent) died from desmoids. Finally 89 percent with Stage I, 65 percent with Stage II, 59 percent with Stage III, and 50 percent with Stage IV disease were asymptomatic; 81 percent of Stage I desmoids, 78 percent of Stage II, 42 percent of Stage III, and 28 percent of Stage IV were stable or disappeared. CONCLUSION: Desmoid staging identifies tumors by prognosis and its use for designing prospective treatment studies is reasonable.