Use of Proton Pump Inhibitors With Dexamethasone in Patients With COVID-19 Pneumonia: Contributions to Long-Term Polypharmacy.

Introduction  Proton pump inhibitors have been used in conjunction with dexamethasone to treat patients with COVID-19. This is given prophylactically to anticipate possible complications while on steroids, including abdominal pain, gastric ulcers, or gastrointestinal bleeding. Proton pump inhibitors have complications, including Clostridium difficile infection, pneumonia, osteoporosis, and vitamin deficiency. The goal of the following project is to assess if there are any subjective and objective benefits to be treated with this regimen instead of dexamethasone on its own. Another inquiry that will be investigated is if this combination results in more patients being prescribed a proton pump inhibitor on discharge.  Materials and methods The following is a retrospective study involving two groups, the first group taking the aforementioned regimen and the second group on dexamethasone only. Objective findings that will be compared include the change in hemoglobin, blood urea nitrogen, and creatinine levels from admission to discharge between the two groups. Subjective findings include complaints of abdominal pain and reported bloody bowel movements. Medication reconciliation on discharge will also be assessed to observe if patients were discharged with a proton pump inhibitor and how long were they taking this medication as an outpatient.  Results The difference between hemoglobin, blood urea nitrogen, and creatinine between the two groups was not significant as the p-values were .14, .43. and .10, respectively. Therefore, the null hypothesis was accepted that there was no difference in these objective findings between the two populations. In addition, neither set had complaints of abdominal pain. For the investigated population on a proton pump inhibitor, it was found that 53% of these patients were discharged with this medication. This subset was on this medication for an average of three months, with the maximum duration being seven months for one patient. The data supported the hypothesis that there was no subjective or objective benefit to being on this drug combination, and consequentially, most patients continue to take this medication for months after discharge.  Conclusion The data affirms the hypothesis that most patients can tolerate dexamethasone without the need for a proton pump inhibitor. This study was limited to patients without any history of gastritis, peptic ulcer disease, or gastrointestinal bleeding; a separate study would need to be done to investigate the need for prophylaxis for patients with these comorbidities. The concerning finding was that patients are being discharged with a medication that they do not need, some patients are taking proton pump inhibitors for more than half the year. There should be further screening to determine if a patient needs to be on a proton pump inhibitor other than steroids.

Leptospirosis as an unusual culprit of acute pancreatitis and portal vein thrombosis in a New Yorker.

Leptospirosis often takes clinicians by surprise when presenting in urban locations with unusual manifestations. This delays diagnosis and treatment which increases mortality rate. Our case illustrates the importance of taking into account the socioeconomic backgrounds, environmental exposures, and clinical presentations of patients to create a good differential diagnosis.

Patient considerations in the management of ulcerative colitis - role of vedolizumab.

Ulcerative colitis (UC) is a subtype of inflammatory bowel disease which causes inflammation of the large intestine and affects approximately 7.6-24.6 per 100,000 persons. The therapeutic goal for UC patients is inducing remission, maintaining remission, and ideally, obtaining mucosal healing. Vedolizumab, approved by the US Food and Drug Administration in May 2014 for the treatment of moderate-to-severe UC and Crohn's disease, is a newly developed anti-integrin therapy. This review focuses on the preclinical development of vedolizumab and data from early trials, and details the results of the landmark trails that led to its approval in the USA with a specific focus on the management of UC. Additionally, data on safety and the current UC management protocols are also discussed.

Histological healing favors lower risk of colon carcinoma in extensive ulcerative colitis.

AIM: To search for the answer in extensive ulcerative colitis as to whether histological inflammation persisting despite endoscopic mucosal healing serves to increase the risk of colon cancer (CC) or high grade dysplasia (HGD). METHODS: This is a single center (Lenox Hill Hospital) retrospective cohort and descriptive study of extensive ulcerative colitis (UC) for 20 years or more with a minimum of 3 surveillance colonoscopies and biopsies performed after the first 10 years of UC diagnosis. Data analyzed included: duration of UC, date of diagnosis of (CC) or (HGD), number of surveillance colonoscopies, and biopsies showing histological inflammation and its severity in each of 6 segments when endoscopic appearance is normal. Two subgroups of patients were compared: group 1 patients who developed CC/HGD and group 2 patients who did not develop CC/HGD. RESULTS: Of 115 patients with longstanding UC reviewed, 68 patients met the inclusion criteria. Twenty patients were in group 1 and 48 in group 2. We identified the number of times for each patient when the endoscopic appearance was normal but biopsies nevertheless showed inflammation. Overall, histological disease activity in the absence of gross/endoscopic disease was found in 31.2% (95%CI: 28%-35%) of colonoscopies performed on the entire cohort of 68 patients. Histological disease activity when the colonoscopy showed an absence of gross disease activity was more common in group 1 than group 2 patients, 88% (95%CI: 72%-97%) vs 59% (95%CI: 53%-64%). Only 3/20 (15%) of patients in group 1 ever had a colonoscopy completely without demonstrated disease activity (i.e., no endoscopic or histological activity) as compared to 37/48 (77%) of patients in group 2, and only 3.3% (95%CI: 0.09%-8.3%) of colonoscopies in group 1 had no histological inflammation compared to 23% (95%CI: 20%-27%) in group 2. CONCLUSION: Progression to HGD or CC in extensive ulcerative colitis of long standing was more frequently encountered among those patients who demonstrate persistent histological inflammation in the absence of gross mucosal disease. Our findings support including the elimination of histological inflammation in the definition of mucosal healing, and support this endpoint as an appropriate goal of therapy because of its risk of increasing dysplasia and colon cancer.