Randomized Controlled Trial of Ketamine and Moderate Sedation for Outpatient Endoscopy in Adults.

INTRODUCTION: Ketamine is an effective sedative agent in a variety of settings due to its desirable properties including preservation of laryngeal reflexes and lack of cardiovascular depression. We hypothesized that ketamine is an effective alternative to standard moderate sedation (SMS) regimens for patients undergoing endoscopy. MATERIALS AND METHODS: We conducted a randomized controlled trial comparing ketamine to SMS for outpatient colonoscopy or esophagogastroduodenoscopy at Brooke Army Medical Center. The ketamine group received a 1-mg dose of midazolam along with ketamine, whereas the SMS group received midazolam/fentanyl. The primary outcome was patient satisfaction measured using the Patient Satisfaction in Sedation Instrument, and secondary outcomes included changes in hemodynamics, time to sedation onset and recovery, and total medication doses. RESULTS: Thirty-three subjects were enrolled in each group. Baseline characteristics were similar. Endoscopies were performed for both diagnostic and screening purposes. Ketamine was superior in the overall sedation experience and in all analyzed categories compared to the SMS group (P = .0096). Sedation onset times and procedure times were similar among groups. The median ketamine dose was 75 mg. The median fentanyl and midazolam doses were 150 mcg and 5 mg, respectively, in SMS. Vital signs remained significantly closer to the physiological baseline in the ketamine group (P = .004). Recovery times were no different between the groups, and no adverse reactions were encountered. CONCLUSIONS: Ketamine is preferred by patients, preserves hemodynamics better than SMS, and can be safely administered by endoscopists. Data suggest that ketamine is a safe and effective sedation option for patients undergoing esophagogastroduodenoscopy or colonoscopy (clinicaltrials.gov NCT03461718).

CMV Ileitis: To Treat or Not to Treat? Implications of Initiating Biologic Therapy for Concurrent Crohn's Disease.

Cytomegalovirus (CMV) enteritis is traditionally thought to be a self-limited infection in immunocompetent individuals. Consequently, current guidelines recommend against treating nonimmunocompromised patients with antiviral therapy. Conversely, recent data suggests that spontaneous resolution occurs less frequently than previously believed; furthermore, mortality rate in immunocompetent individuals is similar to that of the immunosuppressed. We present a case of a 43-year-old male who was simultaneously diagnosed with CMV ileitis and Crohn's Disease. When discovered concomitantly, there is no guidance in the current medical literature regarding the benefit of antiviral treatment of the CMV infection prior to initiating biologic therapy versus the risks of withholding treatment, as is currently recommended for nonimmunosuppressed individuals.

Arterial Phase CTA Replacement by a Virtual Arterial Phase Reconstruction from a Venous Phase CTA: Preliminary Results Using Detector-Based Spectral CT.

OBJECTIVE: To assess the feasibility of creating virtual monoenergetic arterial images from venous phase CTA obtained on a detector-based spectral CT scanner and quantitatively compare the signal-to-noise (SNR) and contrast-to-noise (CNR) ratios of the major arteries to those on polyenergetic true arterial phase images. METHODS: In this retrospective study, 23 patients (15 men and 8 women, median age 68 years) who underwent triple-phase CTA on a spectral CT scanner for aortic endograft surveillance were included. The venous phase CTA of each study was reconstructed to generate virtual monoenergetic images at various keV, which were compared to true arterial phase CTA images. SNR and CNR of the aortoiliac arteries were evaluated by testing the differences in means and non-inferiority of virtual arterial images to true arterial images. Effective radiation dose was calculated for standard triple-phase studies in comparison with dual-phase and single-phase spectral CT examinations. RESULTS: Virtual monoenergetic images demonstrated non-inferior (P < 0.05) arterial SNR and CNR compared to true arterial images at 40 keV for all arteries, at 45-50 keV for the thoracic and suprarenal aorta, and at 45-55 keV for the infrarenal aorta and iliac arteries. Significantly higher (P < 0.05) arterial attenuation was obtained at 40 keV for the aortoiliac arteries. Mean effective dose for conventional triple-phase studies was 32.5 mSv in comparison with 21.3 mSv for dual-phase non-contrast/venous scans and 11.3 mSv for single-phase venous scans. CONCLUSIONS: Detector-based spectral CT enables creation of virtual monoenergetic arterial images from venous phase CTA with equivalent and in some cases significantly higher SNR/CNR of major arteries compared to images from true arterial phase polyenergetic CTA.

Nitrous oxide cryotherapy ablation for refractory gastric antral vascular ectasia.

BACKGROUND: Argon plasma coagulation (APC) is typically the first-line therapy for gastric antral vascular ectasia (GAVE). However, many patients are refractory to APC ablation. OBJECTIVE: We examined the safety and efficacy of nitrous oxide CryoBalloon cryotherapy ablation for GAVE refractory to APC. METHODS: This is a retrospective review of patients with refractory GAVE treated with the CryoBalloon system. Technical success was defined as successful ablation of the visualized GAVE. Clinical success was defined by transfusion independence and percentage of GAVE that was eradicated. RESULTS: Twenty-three patients with GAVE were included, of whom 16 patients (70%) had two treatments with the CryoBalloon and seven patients (30%) had one treatment. Technical success was achieved in all patients. At six months, 19/23 (83%) were transfusion independent, while 20/23 (87%) had more than 75% of the GAVE eradicated. Patients were transfused an average of 1.8 units/month one year prior to cryotherapy and an average of 0.3 units/month up to six months post-cryotherapy (p < 0.001). The average increase in mean hemoglobin at six months was 2.55 g/dl. No acute or late adverse events were reported. CONCLUSIONS: CryoBalloon ablation is an efficacious and safe modality for the treatment of GAVE. Prospective studies need to be conducted to determine comparative results to standard therapies.

Gastroduodenal Cryptococcus in an AIDS Patient Presenting With Melena.

Gastrointestinal cryptococcosis is extremely rare with only a few case reports found in the literature and involvement primarily identified post-mortem. This is a case of 54-year-old man with a 20-year history of poorly controlled human immunodeficiency virus presented with constitutional symptoms along with melena. Diagnostic work up with esophagogastroduodenoscopy showed 4 irregular ulcers in the stomach notable for red-pigmented lesions within the ulcers, erythematous mucosa in the antrum and patchy friable mucosa in the duodenum. H&E staining and Mucicarmine staining showed findings consistent with C. neoformans. Blood culture and cerebrospinal fluid studies also revealed C. neoformans. Cryptococcus neoformans is an AIDS defining illness that most commonly presents as meningoencephalitis and pneumonitis. Key management principles includes: induction of antifungal therapy followed by consolidation and maintenance; management of elevated intracranial pressure and immune reconstitution inflammatory syndrome. Although the organism can infect nearly all organs, gastrointestinal involvement is rarely described. Our case highlights the fact that gastrointestinal C. neoformans infection can be associated with upper gastrointestinal symptoms and may be the initial presentation of disseminated cryptococcosis.

Effect of weight loss on nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) has become one of the most common causes of liver disease worldwide and has grown proportionately with the rise in obesity. The prevalence of NAFLD is now thought to be around 20% to 40% of the entire population in industrialized Western countries. Insulin resistance, a product of obesity, is central to the pathogenesis of NAFLD, and is improved with weight loss, making this modality the primary goal of therapy. A combination of dietary modifications and increased physical activity, although hard to maintain, is thought to have significant long-term benefits, although further study is required to determine the best and most effective approaches to lifestyle modification. Alternatively, for those individuals who are unable to lose weight despite aggressive efforts, bariatric surgery, which has been shown rather convincingly to improve underlying fatty liver disease, may offer a solution. This review discusses dietary modification, exercise, weight loss pharmacotherapy, and surgical intervention as potential options for patients with NAFLD.