In recurrent C difficile infection, oral FMT capsules have a pooled cure rate of 82% (low-quality evidence).

SOURCE CITATION: Du C, Luo Y, Walsh S, Grinspan A. Oral fecal microbiota transplant capsules are safe and effective for recurrent Clostridioides difficile infection: a systematic review and meta-analysis. J Clin Gastroenterol. 2021;55:300-8. 33471490.

In adults with severe acute GI bleeding, tranexamic acid did not reduce death due to bleeding at 5 days.

SOURCE CITATION: The HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395:1927-36. 32563378.

Effect of Aspiration Therapy on Obesity-Related Comorbidities: Systematic Review and Meta-Analysis.

BACKGROUND/AIMS: Aspiration therapy (AT) involves endoscopic placement of a gastrostomy tube with an external device that allows patients to drain 30% of ingested calories after meals. Its efficacy for inducing weight loss has been shown. This study aimed to assess the effect of AT on obesity-related comorbidities. METHODS: A meta-analysis of studies that assessed AT outcomes was conducted through December 2018. Primary outcomes were changes in comorbidities at 1 year following AT. Secondary outcomes were the amount of weight loss at up to 4 years and pooled serious adverse events (SAEs). RESULTS: Five studies with 590 patients were included. At 1 year, there were improvements in metabolic conditions: mean difference (MD) in systolic blood pressure: -7.8 (-10.7 - -4.9) mm Hg; MD in diastolic blood pressure: -5.1 (-7.0 - 3.2) mm Hg; MD in triglycerides: -15.8 (-24.0 - -7.6) mg/dL; MD in high-density lipoprotein: 3.6 (0.7-6.6) mg/dL; MD in hemoglobin A1c (HbA1c): -1.3 (-1.8 - -0.8) %; MD in aspartate transaminase: -2.7 (-4.1 - -1.3) U/L; MD in alanine transaminase: -7.5 (-9.8 - -5.2) U/L. At 1 (n=218), 2 (n=125), 3 (n=46), and 4 (n=27) years, the patients experienced 17.8%, 18.3%, 19.1%, and 18.6% total weight loss (TWL), corresponding to 46.3%, 46.2%, 48.0%, and 48.7% excess weight loss (EWL) (p<0.0001 for all). Subgroup analysis of 2 randomized controlled trials (n=225) showed that AT patients lost more weight than did controls by 11.6 (6.5-16.7) %TWL and 25.6 (16.0-35.3) %EWL and experienced greater improvement in HbA1c and alanine transaminase by 1.3 (0.8-1.8) % and 9.0 (3.9-14.0) U/L. The pooled SAE rate was 4.1%. CONCLUSION: Obesity-related comorbidities significantly improved at 1 year following AT. Additionally, a subgroup of patients who continued to use AT appeared to experience significant weight loss that persisted up to at least 4 years.

Successful endoscopic treatment of an intraductal papillary neoplasm of the bile duct.

We present a case of a 76-year-old man with right upper quadrant abdominal pain and weight loss, who was found to have an intraductal papillary neoplasm of the bile duct (IPNB) of the pancreaticobiliary subtype, deemed curatively resectable. The patient declined surgery and opted for endoscopic therapy. He underwent two sessions of endoscopic retrograde cholangiopancreatography (ERCP)-guided radiofrequency ablation (RFA). Ten months later, no evidence of recurrence was identified on repeat ERCP. To our knowledge, this is the first reported case of successful use of RFA as a primary treatment modality for resectable IPNB.

A comparison of an opioid abuse screening tool and prescription drug monitoring data in the emergency department.

OBJECTIVES: This study aimed to: (a) determine the percentage of ED patients receiving prescriptions for opioid pain medications that meet the criteria for "high-risk for abuse potential" on the Screener and Opioid Assessment for Patients with Pain (SOAPP(®)-R), (b) determine the percentage of patients with high-risk behavior on the state prescription drug monitoring program (PDMP) database, (c) compare the SOAPP-R with data from the PDMP, and (d) determine psychometric properties of SOAPP-R for ED patients METHODS: Convenience sample of ED patients who were being considered for discharge with a prescription for an opioid pain medication. Subjects completed SOAPP-R on an electronic tablet and PDMP data was obtained. Scores on SOAPP-R ≥ 18 were defined as "at-risk", and PDMP data showing both ≥ 4 opioid prescriptions and ≥ 4 providers in 12 months was considered the criterion standard for high-risk behavior. RESULTS: 82 patients (88.2%) provided consent. 32.9% (n=27) were determined to be "at-risk" (score ≥ 18) by SOAPP-R. 15.9% (n=13) subjects met PDMP criteria and 53.9% (n=7) of those had SOAPP-R scores ≥ 18 (sensitivity 54%, specificity 71%, positive predictive value 26%, negative predictive value 89%). The association of an at-risk SOAPP-R score and PDMP high-risk criteria was an adjusted odds ratio of 1.39 (95% confidence interval 0.73-3.68). CONCLUSIONS: In our population, about one-third of patients being considered for discharge with an opioid prescription scored "at-risk" on SOAPP-R and 15.9% met the PDMP high-risk criteria. The high negative predictive value of SOAPP-R indicates it may be a useful screening tool for the ED patient population.

Feasibility of tablet computer screening for opioid abuse in the emergency department.

INTRODUCTION: Tablet computer-based screening may have the potential for detecting patients at risk for opioid abuse in the emergency department (ED). Study objectives were a) to determine if the revised Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), a 24-question previously paper-based screening tool for opioid abuse potential, could be administered on a tablet computer to an ED patient population; b) to demonstrate that >90% of patients can complete the electronic screener without assistance in <5 minutes and; c) to determine patient ease of use with screening on a tablet computer. METHODS: This was a cross-sectional convenience sample study of patients seen in an urban academic ED. SOAPP®-R was programmed on a tablet computer by study investigators. Inclusion criteria were patients ages ≥18 years who were being considered for discharge with a prescription for an opioid analgesic. Exclusion criteria included inability to understand English or physical disability preventing use of the tablet. RESULTS: 93 patients were approached for inclusion and 82 (88%) provided consent. Fifty-two percent (n=43) of subjects were male; 46% (n=38) of subjects were between 18-35 years, and 54% (n=44) were >35 years. One hundred percent of subjects completed the screener. Median time to completion was 148 (interquartile range 117.5-184.3) seconds, and 95% (n=78) completed in <5 minutes. 93% (n=76) rated ease of completion as very easy. CONCLUSIONS: It is feasible to administer a screening tool to a cohort of ED patients on a tablet computer. The screener administration time is minimal and patient ease of use with this modality is high.

Spinocerebellar ataxia type 7: clinical course, phenotype-genotype correlations, and neuropathology.

Spinocerebellar ataxia type 7 is a neurodegenerative polyglutamine disease characterized by ataxia and retinal degeneration. The longitudinal course is unknown, and relationships between repeat expansion, clinical manifestations, and neuropathology remain uncertain. We followed 16 affected individuals of a 61-member kindred over 27 years with electroretinograms, neurological examinations including the Brief Ataxia Rating Scale, neuroimaging in five, and autopsy in four cases. We identified four stages of the illness: Stage 0, gene-positive but phenotypically silent; Stage 1, no symptoms, but hyperreflexia and/or abnormal electroretinograms; Stage 2, symptoms and signs progress modestly; and Stage 3, rapid clinical progression. CAG repeat length correlated inversely with age of onset of visual or motor signs (r = -0.74, p = 0.002). Stage 3 rate of progression did not differ between cases (p = 0.18). Electroretinograms correlated with Brief Ataxia Rating Scale score and were a biomarker of disease onset and progression. All symptomatic patients developed gait ataxia, extremity dysmetria, dysarthria, dysrhythmia, and oculomotor abnormalities. Funduscopy revealed pale optic discs and pigmentary disturbances. Visual acuity declined to blindness in those with longer CAG expansions. Hyperreflexia was present from Stage 1 onwards. Restless legs syndrome and sensory impairment were common. Neuropathological hallmarks were neuronal loss in cerebellar cortex, deep cerebellar nuclei, inferior olive, and anterior horns of the spinal cord, and axonal loss in spinocerebellar tracts, dorsal nerve roots, and posterior columns. Retinal pathology included photoreceptor degeneration and disruption of retinal pigment epithelium. Spinocerebellar ataxia type 7 evolves through four clinical stages; neuropathological findings underlie the clinical presentation; electroretinograms are a potential biomarker of disease progression.

Atypical case of Wolfram syndrome revealed through targeted exome sequencing in a patient with suspected mitochondrial disease.

BACKGROUND: Mitochondrial diseases comprise a diverse set of clinical disorders that affect multiple organ systems with varying severity and age of onset. Due to their clinical and genetic heterogeneity, these diseases are difficult to diagnose. We have developed a targeted exome sequencing approach to improve our ability to properly diagnose mitochondrial diseases and apply it here to an individual patient. Our method targets mitochondrial DNA (mtDNA) and the exons of 1,600 nuclear genes involved in mitochondrial biology or Mendelian disorders with multi-system phenotypes, thereby allowing for simultaneous evaluation of multiple disease loci. CASE PRESENTATION: Targeted exome sequencing was performed on a patient initially suspected to have a mitochondrial disorder. The patient presented with diabetes mellitus, diffuse brain atrophy, autonomic neuropathy, optic nerve atrophy, and a severe amnestic syndrome. Further work-up revealed multiple heteroplasmic mtDNA deletions as well as profound thiamine deficiency without a clear nutritional cause. Targeted exome sequencing revealed a homozygous c.1672C > T (p.R558C) missense mutation in exon 8 of WFS1 that has previously been reported in a patient with Wolfram syndrome. CONCLUSION: This case demonstrates how clinical application of next-generation sequencing technology can enhance the diagnosis of patients suspected to have rare genetic disorders. Furthermore, the finding of unexplained thiamine deficiency in a patient with Wolfram syndrome suggests a potential link between WFS1 biology and thiamine metabolism that has implications for the clinical management of Wolfram syndrome patients.