Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis.

Background and Aim: Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. Methods: We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test. Results: A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009). Conclusion: Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Hepatitis C Treatment in Patients With Porphyria Cutanea Tarda.

BACKGROUND: Hepatitis C virus (HCV) infection is a common susceptibility factor for porphyria cutanea tarda (PCT). Experience on HCV treatment in patients with PCT is limited. Recently, HCV treatment has improved with direct-acting antivirals (DAA). We review our experience on HCV treatment in patients with PCT with older and newer regimens. MATERIALS AND METHODS: A retrospective chart review was conducted. HCV treatment was attempted 22 times in 13 patients with PCT (5 attempts in 1, 2 in 5 and 1 in the other 7 patients). RESULTS: Before starting HCV treatment, PCT was in complete remission in 16, partial remission in 2, unknown status in 2 and active in 2 instances. PCT relapsed during therapy 6 times (all interferon-based regimens and 2 including telaprevir), 4 requiring treatment interruption. Treatment was interrupted for reasons other than PCT relapse in 2 patients treated with interferon-based regimens. To prevent PCT recurrence, hydroxychloroquine was continued during HCV therapy 6 times (3 interferon regimens, 2 ribavirin regimens without interferon and 1 DAA alone). Twelve patients achieved sustained viral response, 3 with interferon regimens and 9 with DAA. Two patients with active PCT were treated with DAA, with reduction of plasma porphyrins in 1 and normalization in the other at the end of HCV therapy. CONCLUSIONS: HCV treatment regimens including interferon or ribavirin may precipitate PCT relapse. Hydroxychloroquine may be useful to prevent such relapses. In this limited experience, DAA were not associated with PCT relapse. Studies are needed to examine DAA as a primary PCT treatment in HCV-infected patients.

Impact of vitamin D on the hospitalization rate of Crohn's disease patients seen at a tertiary care center.

AIM: To study the association between vitamin D level and hospitalization rate in Crohn's disease (CD) patients. METHODS: We designed a retrospective cohort study using adult patients (> 19 years) with CD followed for at least one year at our inflammatory bowel disease center. Vitamin D levels were divided into: low mean vitamin D level (< 30 ng/mL) vs appropriate mean vitamin D level (30-100 ng/mL). Generalized Poisson Regression Models (GPR) for Rate Data were used to estimate partially adjusted and fully adjusted incidence rate ratios (IRR) of hospitalization among CD patients. We also examined IRRs for vitamin D level as a continuous variable. RESULTS: Of the 880 CD patients, 196 patients with vitamin D level during the observation period were included. Partially adjusted model demonstrated that CD patients with a low mean vitamin D level were almost twice more likely to be admitted (IRR = 1.76, 95%CI: 1.38-2.24) compared to those with an appropriate vitamin D level. The fully adjusted model confirmed this association (IRR = 1.44, 95%CI: 1.11-1.87). Partially adjusted model with vitamin D level as a continuous variable demonstrated, higher mean vitamin D level was associated with a 3% lower likelihood of admission with every unit (ng/mL) rise in mean vitamin D level (IRR = 0.97, 95%CI: 0.96-0.98). The fully adjusted model confirmed this association (IRR = 0.98, 95%CI: 0.97-0.99). CONCLUSION: Normal or adequate vitamin D stores may be protective in the clinical course of CD. However, this role needs to be further characterized and understood.

Budesonide Use and Hospitalization Rate in Crohn's Disease: Results From a Cohort at a Tertiary Care IBD Referral Center.

BACKGROUND: Budesonide is generally not used for periods > 90 days in Crohn's disease (CD). We sought to study the association between cumulative outpatient budesonide use in days and hospitalization rate in CD patients seen at our institution. METHODS: Using a retrospective cohort study design, we selected CD patients > 19 years old and followed for at least 1 year. Days of outpatient budesonide use were calculated by reviewing outpatient clinic notes. Treatment groups included patients who were not given budesonide, received budesonide from 1 to 90 days, and received budesonide > 90 days. We performed univariate analyses and developed generalized Poisson regression models for rate data to estimate incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) for CD-related hospitalization. RESULTS: Of 767 CD patients, 664 did not receive budesonide, 45 received budesonide from 1 to 90 days, and 58 received budesonide for > 90 days. Incidence rates of hospitalization in patients who received no budesonide vs. 1 - 90 days of budesonide vs. > 90 days of budesonide were 31, 26, and 19 per 100 person-years, respectively. Adjusted models demonstrated that receiving outpatient budesonide from 1 to 90 days and for > 90 days was associated with a lower likelihood of being admitted for a CD exacerbation (1 - 90 days: IRR 0.85; 95% CI 0.65 - 1.10; > 90 days: IRR 0.71; 95% CI 0.56 - 0.91). CONCLUSIONS: Outpatient budesonide use appears to be associated with a lower likelihood of a CD-related hospitalization, notably when used for > 90 days. This association needs to be further assessed before recommending this agent for routine use for > 90 days.

Vitamin E-deficient diets enriched with fish oil suppress lethal Plasmodium yoelii infections in athymic and scid/bg mice.

Mice fed vitamin E-deficient diets containing omega-3 fatty acids survive infection with lethal Plasmodium yoelii. The current study sought to determine if antimalarial T- and B-cell responses were required for such dietary-mediated protection. In the first set of experiments, nu/nu mice (which lack alphabeta T-cell-receptor-positive T cells and do not produce antimalarial antibody) and nu/+ mice were fed casein-based diets containing 4% menhaden oil, with or without vitamin E supplementation, for 4 weeks prior to infection with lethal P. yoelii. All mice fed diets containing vitamin E developed fulminating parasitemias and quickly died, whereas both nu/nu and nu/+ mice fed diets deficient in vitamin E controlled their parasitemias for the first 18 days of infection. Thereafter, the nu/nu mice became anemic and died, whereas the nu/+ mice produced antimalarial antibodies and survived. In the second set of experiments, scid/scid.bg/bg mice (which lack B cells and alphabeta and gammadelta T cells and have reduced NK-cell activity) were fed the experimental diet for 6 weeks and then infected with the less virulent 17XNL strain of P. yoelii. Mice fed vitamin E-containing diets quickly died, whereas those fed the vitamin E-deficient diet survived without developing detectable parasitemias. Results from these experiments show that under prooxidant dietary conditions, mice were able to control and even survive malaria in the absence of malaria-primed T cells and antimalarial antibody. These results emphasize the importance of cellular oxidative processes in parasite elimination.

Effects of pyran copolymer on host resistance of mice to Plasmodium yoelii.

Female B6C3F1 mice treated with 25 mg/kg pyran intravenously (i.v.) on days -4 and -3 were more susceptible to nonlethal Plasmodium yoelii 17XNL or lethal Plasmodium berghei ATCC-30090 than untreated mice or mice treated intraperitoneally (i.p.). Female B6C3F1 mice treated with pyran i.p. displayed enhanced resistance to Listeria monocytogenes as compared to untreated mice or mice given pyran i.v. Peritoneal exudate cells (PEC) primed by pyran i.p. possessed enhanced ability to kill Listeria but impaired ability to destroy Plasmodium. Phagocytosis of Covaspheres by PEC was greater for mice given pyran i.p. than those given pyran i.v. Chemiluminescence evoked by zymosan was less for PEC from mice given pyran i.v. than for those from untreated mice or those given pyran i.p. Chemiluminescence was greater for adherent splenocytes from mice treated with pyran i.p. than for those from untreated mice or those from mice treated i.v. Pyran administered i.v. is less effective in modulating the host immune response than pyran administered i.p. Immunomodulatory agents such as pyran have adverse as well as beneficial effects depending upon the route of administration.

A study of Giardia infection in irradiated and thymectomized mice.

Thymectomized and irradiated mice were infected with Giardia cysts obtained from a human source. The animals were killed on the third, sixth, ninth, 12th and 15th days post-infection. The intestinal contents were collected and a count of motile trophozoites was made. The results were compared with an infected control group of animals which were similar to the experimental group in age, sex, weight and species. There was a considerable increase in the trophozoites counts in the experimental group on the third, sixth, ninth and 12th days of the experiment with the differences from the control group being highly significant (P less than 0.001) on each comparable day of study. However, no such difference was observed on the 15th day post-infection. Both groups of animals showed an initial rise in the trophozoite counts with the peak on the 9th day post-infection followed by a fall in the counts on the 12th and 15th day. The difference on each successive day of experiment was highly significant. Six out of 30 (20%) mice in the experimental group died, with all the deaths occurring within the first 6 days post-infection. On the other hand, there were no deaths in the control group and in the uninfected thymectomized and irradiated group. These observations were further substantiated by the more severe histological changes in the villi and lymphocyte infiltration in the experimental group than in the control group. Therefore it is surmised that the intensity of Giardia infection in mice with depressed cell mediated immunity is considerably increased. However, it is interesting to note that these animals show a definite trend towards recovery as do normal animals with Giardia infection.