Real-world efficacy of bezlotoxumab for prevention of recurrent Clostridium difficile infection: a retrospective study of 46 patients in five university hospitals in Finland.

Reports on real-world experience on efficacy of bezlotoxumab (BEZ) has been lacking thus far. We retrospectively studied the efficacy and safety of BEZ in preventing the recurrence of Clostridium difficile infection (CDI) in five university hospitals in Finland. Seventy-three percent of our 46 patients remained free of recurrence in the following 3 months and the performance remained as 71% effective also among immunocompromised patients. In severe CDI, BEZ prevented recurrence in 63% of cases. From our study patients, 78% had three or more known risk factors for recurrence of CDI. Eight of our patients were waiting for fecal microbiota transplantation but after stopping the antibiotics that were continued to prevent recurrence of CDI and after receiving BEZ, all remained free of recurrence and did not need the procedure. Success with BEZ as an adjunctive treatment in preventing recurrence of CDI in high-risk patients may be rated as high. Among a subgroup of our patients, those already evaluated to be in need of fecal microbiota transplantation, BEZ seems to be an alternative option.

Metformin treatment significantly enhances intestinal glucose uptake in patients with type 2 diabetes: Results from a randomized clinical trial.

AIMS: Metformin therapy is associated with diffuse intestinal 18F-fluoro-deoxyglucose (FDG) accumulation in clinical diagnostics using routine FDG-PET imaging. We aimed to study whether metformin induced glucose uptake in intestine is associated with the improved glycaemic control in patients with type 2 diabetes. Therefore, we compared the effects of metformin and rosiglitazone on intestinal glucose metabolism in patients with type 2 diabetes in a randomized placebo controlled clinical trial, and further, to understand the underlying mechanism, evaluated the effect of metformin in rats. METHODS: Forty-one patients with newly diagnosed type 2 diabetes were randomized to metformin (1g, b.i.d), rosiglitazone (4mg, b.i.d), or placebo in a 26-week double-blind trial. Tissue specific intestinal glucose uptake was measured before and after the treatment period using FDG-PET during euglycemic hyperinsulinemia. In addition, rats were treated with metformin or vehicle for 12weeks, and intestinal FDG uptake was measured in vivo and with autoradiography. RESULTS: Glucose uptake increased 2-fold in the small intestine and 3-fold in the colon for the metformin group and associated with improved glycemic control. Rosiglitazone increased only slightly intestinal glucose uptake. In rodents, metformin treatment enhanced intestinal FDG retention (P=0.002), which was localized in the mucosal enterocytes of the small intestine. CONCLUSIONS: Metformin treatment significantly enhances intestinal glucose uptake from the circulation of patients with type 2 diabetes. This intestine-specific effect is associated with improved glycemic control and localized to mucosal layer. These human findings demonstrate directs effect of metformin on intestinal metabolism and elucidate the actions of metformin. Clinical trial number NCT02526615.

Inferior vena cava filter migration to the right ventricle.

Inferior vena cava (IVC) filter placement is recommended for acute proximal deep venous thrombosis if anticoagulation is contraindicated. A 52-year-old man presented with weakness, dyspnea, syncope, and renal failure 8 months after IVC filter placement. Imaging revealed migration of the IVC filter to the right ventricle. Endovascular retrieval was not feasible, thus surgical extraction and tricuspid valve repair was performed. IVC filter migration to the heart is a rare, but a potentially life-threatening complication. Retrieval can be accomplished using endovascular or open surgical technique.

[(18)F]Fluorodeoxyglucose positron emission tomography-computerized tomography and lung cancer: a significant referral bias exists.

OBJECTIVE: [(18)F]Fluorodeoxyglucose positron emission tomography-computerized tomography (PET-CT) scan is a tool widely used in the diagnosis and staging of lung cancer. Referral bias is present when the results of a diagnostic study affect the decision to proceed with definitive testing. This bias artificially increases the sensitivity and decreases the specificity, and may inappropriately alter the decision to undergo definitive testing. The accuracy of PET-CT scan in suspected lung cancer and the role of referral bias were investigated. METHODS: From January 2005 through June 2007, 584 consecutive patients undergoing PET-CT scan for suspected lung cancer were studied. Endpoints measured included qualitative and quantitative results of PET-CT scans and pathologic results from patients, who underwent invasive procedures for diagnosis, staging and/or therapy. A positive PET scan was defined as one in which the standard uptake value (SUV) was greater than 2.5. A standard mathematical model, based on overall results of PET-CT scan in all patients, was used to create adjustments to account for the effect of referral bias. RESULTS: A total of 414 (71%) of PET-CT scans were reported as positive, while 170 (29%) were negative. Attempt at tissue diagnosis occurred in 417 patients (71%); surgical intervention was performed in 246 (42%). Whereas 86% (355/414) of patients with a positive PET-CT scan underwent tissue sampling, only 36% (62/170) with a negative PET-CT scan had an attempt (p<.001). In patients with a positive study, a higher SUV was associated with an attempt at tissue diagnosis (p<.001). Before adjustment, the sensitivity and specificity of the PET-CT scan for any cancer were 87% and 43%. After adjustment, sensitivity fell to 75%, while specificity rose to 64%. The unadjusted sensitivity of PET-CT scan for detecting mediastinal disease was only 79%. CONCLUSIONS: The estimate of the accuracy of PET-CT scan is significantly influenced by referral bias, and a strong reliance is placed on its results. Furthermore, patients with a positive PET-CT scan are more likely to undergo tissue sampling as the SUV increases. Given the relatively low sensitivity of the PET-CT scan in detecting disease and its poor performance in the mediastinum, the PET-CT scan may have too high an impact on the decision to undergo further invasive diagnostic procedures. Patients should not be deferred from tissue sampling based solely on a negative PET-CT scan.

Special situations: air leak after lung volume reduction surgery and in ventilated patients.

Patients undergoing lung volume reduction surgery and those supported by mechanical ventilation are among our most vulnerable patients. Prolonged air leak in these fragile patients can have dire, even fatal, consequences. This article describes the incidence of prolonged air leak in these populations, the causes ascribed to their development, and strategies that may be applied to their prevention and treatment.

Bronchopulmonary carcinoid tumor presenting with polymyositis.

We present a patient with a typical bronchopulmonary carcinoid tumor who presented with proximal muscle weakness. Laboratory analysis and a muscle biopsy specimen led to the diagnosis of polymyositis. Chest imaging revealed a bronchopulmonary carcinoid tumor. Symptoms and laboratory derangements remitted after removal of the tumor. This case represents a rare report of a typical carcinoid tumor presenting with the paraneoplastic syndrome of polymyositis.

A prospective diagnostic accuracy study of 18F-fluorodeoxyglucose positron emission tomography/computed tomography, multidetector row computed tomography, and magnetic resonance imaging in primary diagnosis and staging of pancreatic cancer.

OBJECTIVE: To prospectively compare the accuracy of combined positron emission tomography/computed tomography using F-fluorodeoxyglucose (FDG-PET/CT), multidetector row computed tomography (MDCT), and magnetic resonance imaging (MRI) in the evaluation of patients with suspected pancreatic malignancy. SUMMARY BACKGROUND DATA: FDG-PET/CT imaging is increasingly used for staging of pancreatic cancer. Preliminary data suggest a significant influence of FDG-PET/CT on treatment planning, although its role is still evolving. METHODS: Thirty-eight consecutive patients with suspicion of pancreatic malignancy were enrolled. Patients underwent a protocol including FDG-PET/CT, MDCT, and MRI combined with magnetic resonance cholangiopancreatography, all of which were blindly evaluated. The findings were confirmed macroscopically at operation and/or by histopathologic analysis (n = 29) or follow-up (n = 9). Results of TNM classification of different imaging methods were compared with clinical TNM classification. RESULTS: Pancreatic adenocarcinoma was diagnosed in 17 patients, neuroendocrine tumor in 3, mass-forming pancreatitis in 4, cystic lesion in 6, and fibrosis in 2. Six patients had a finding of a normal pancreas. The diagnostic accuracy of FDG-PET/CT for pancreatic malignancy was 89%, compared with 76% and 79% for MDCT and MRI, respectively. In the differential diagnosis of suspected malignant biliary stricture at endoscopic retrograde cholangiopancreaticography (n = 21), FDG-PET/CT had a positive predictive value of 92%. In 17 patients with advanced pancreatic adenocarcinoma, FDG-PET/CT had a sensitivity of 30% for N- and 88% for M-staging. Both MDCT and MRI had sensitivities of 30% for N- and 38% for M-staging. Furthermore, the clinical management of 10 patients (26%) was altered after FDG-PET/CT. CONCLUSION: FDG-PET/CT was more sensitive than conventional imaging in the diagnosis of both primary pancreatic adenocarcinoma and associated distant metastases. In contrast, the sensitivity of FDG-PET/CT was poor in detecting local lymph node metastasis, which would have been important for an assessment of resectability. We recommend the use of FDG-PET/CT in the evaluation of diagnostically challenging cases, especially in patients with biliary strictures without evidence of malignancy in conventional imaging.

Standard uptake value predicts survival in non-small cell lung cancer.

BACKGROUND: Integrated [(18)F]fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) scan is a widely used modality in the evaluation of lung cancer. Our goal was to determine the ability of the standard uptake value (SUV) of the primary tumor (SUV-T) and regional lymph nodes (SUV-N) to predict survival. METHODS: From January 2005 through June 2007, 584 consecutive patients undergoing integrated PET-CT scan for suspected lung cancer were studied. Results of integrated PET-CT scans, including the maximum SUV-T and SUV-N, were recorded. A patient was defined as having a positive PET scan if the maximum SUV (T or N) was greater than 2.5. Overall survival was documented from clinical records and the Social Security Death Index. Cox regression analysis was used to evaluate the correlation between SUV and survival. RESULTS: Among patients with a positive PET scan (n = 329), both SUV-T and SUV-N were predictors of survival. As maximum SUV of the primary mass increased, survival decreased (hazard ratio, 1.05; p < 0.001). As maximum SUV of locoregional lymph nodes increased, survival also decreased (hazard ratio, 1.06; p < 0.001). Furthermore, among patients with no mediastinal disease identified by PET-CT scan, increased SUV-T continued to predict poor survival (hazard ratio, 1.06; p = 0.001). CONCLUSIONS: Local and regional maximum SUVs defined by integrated PET-CT scanning have a strong correlation with survival in patients with non-small cell lung cancer. An elevated SUV is known preoperatively and may assist clinicians in stratifying patients at increased overall risk preoperatively.

Postoperative outcomes in intimal aortic angiosarcoma: a case report and review of the literature.

Intimal angiosarcoma is a most unexpected cause of aortic occlusion. We present the case of a 74-year-old woman with intimal angiosarcoma that manifested with the triad of congestive heart failure, acute renal failure, and abdominal angina. A review of the literature and discussion of postoperative outcomes follows.