Capsule Endoscopy in the Diagnosis, Disease Mapping, and Monitoring of Treatment Response in Gastrointestinal Whipple's Disease.

Whipple's disease is a rare systemic infection causing malabsorption. Affected patients often undergo extensive investigation until final diagnosis with periodic acid-Schiff-positive histology. We present the case of a 73-year-old man diagnosed with Whipple's disease after a prolonged history, with a focus on capsule endoscopy (CE) in both mapping the extent of the pathology and follow-up. We demonstrate pre-treatment and post-treatment CE images, allowing visualization of resolved small bowel pathology, and demonstrate histological resolution. The early use of CE in the investigation of Whipple's disease may expedite diagnosis in patients with more distal bowel pathology and help assess disease severity.

Hypothesis: Pentoxifylline is a potential cytokine modulator therapeutic in COVID-19 patients.

We propose a new hypothesis that the established drug pentoxifylline deserves attention as a potential repurposed therapeutic for COVID-19. Pentoxifylline is an immunomodulator with anti-inflammatory properties. It is a nonselective phosphodiesterase inhibitor and through Adenosine A2A Receptor-mediated pathways reduces tumor necrosis factor alpha, interleukin 1, interleukin 6, and interferon gamma and may act to reduce tissue damage during the cytokine storm host response to SARS-CoV-2 infection. This agent has been used clinically for many years and has a favorable profile of safety and tolerability. Pre-clinical data support pentoxifylline as effective in cytokine-driven lung damage. Clinical studies of pentoxifylline in radiation and cytokine-induced lung damage in humans are positive and consistent with anti-inflammatory efficacy. Pentoxifylline is a readily available, off-patent and inexpensive drug, suitable for large-scale use including in resource-limited countries. Current trials of therapeutics are largely focused on the inhibition of viral processes. We advocate urgent randomized trials of pentoxifylline for COVID-19 as a complementary approach to target the host responses.

Combination therapy for systemic sclerosis-associated pneumatosis intestinalis.

We present a case of a patient with pneumatosis intestinalis and pneumoperitoneum secondary to gastrointestinal systemic sclerosis, who presented following recurrent accident and emergency attendances with abdominal pain. Pneumatosis intestinalis is a rare complication of systemic sclerosis; management approaches focus largely on exclusion of life-threatening surgical pathologies and subsequent symptom control. To date, there are still no established gold-standard treatment strategy and no large-scale trial data to support a specific management strategy. We describe a case of successful medical management with a combination of antimicrobial, elemental diet and high-flow inhalation oxygen therapy, with supporting evidence of CT image confirming resolution. This case therefore contributes to the literature, being the first to report both symptomatic and radiological improvement following combination therapy without the need for surgical intervention.

Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors.

Spontaneous bacterial peritonitis (SBP) in cirrhotic patients is a serious complication associated with a high mortality rate. A baseline audit of the acute medical take (AMT) at Northwick Park suggested a lack of awareness regarding management. A questionnaire based on contemporary SBP guidelines was circulated to all trainee doctors (FY1 to SpR). Ascitic fluid testing requests were analysed over a six-month period. The electronic requesting system was updated to include prompts and direct links to Trust SBP guidelines, and a one-hour lecture to all members of the AMT, supported by an educational booklet on SBP, was performed. Re-audit was carried out six months post-intervention, the AMT completed a second questionnaire and ascitic fluid testing requests were re-audited. In comparable pre- and post-intervention AMT cohorts, a clinical and educational intervention led to a significant improvement in understanding of when to investigate (p≤0.001), samples (p = 0.002) and containers (p≤0.001) required, urgency of obtaining results (p≤0.001), and initiation of treatment for suspected SBP (p = 0.007). Significantly more ascitic samples were sent, with specific suspicion of SBP more readily documented, crucial to expediting laboratory processing. Targeted education and production of a clinical algorithm has significantly improved the management of patients with SBP.

Development of an accurate oscillometric blood pressure device for low resource settings.

OBJECTIVE: To assess and develop an accurate blood pressure measurement device for use in low resource settings and by untrained staff, according to the World Health Organisation guidelines. METHODS: Ninety-nine adults were recruited to validate the device according to the International Protocol of the European Society of Hypertension. All participants provided written informed consent. Patients with an arrhythmia or unclear Korotkoff sounds were excluded. Nine sequential same-arm measurements were taken from each participant alternating between the test device and mercury sphygmomanometry. Differences between the test device and observers were evaluated according to the criteria of the International Protocol and the Association for the Advancement of Medical Instrumentation. RESULTS: The device failed the first assessment of the oscillometric function and required modification to both the deflation rate and the algorithm to fulfil the International Protocol criteria. It then achieved an acceptable mean difference of -0.7 (4.7) mmHg for systolic and -2.0 (4.6) mmHg for diastolic pressure (oscillometric function) and -1.9 (3.8) mmHg and -0.9 (3.3) mmHg for systolic and diastolic pressures, respectively (auscultatory function). CONCLUSION: The Microlife 3AS1-2 is a semi-automated upper arm device with features consistent with low resource requirements. We successfully developed this device for accurate blood pressure measurement in adults according to the International Protocol, through adjustment of the deflation rate and algorithm. The accuracy and user-friendly design of this low-cost device makes it a highly valuable monitor in clinical practice, particularly in low resource settings and for use by untrained staff.