Low-Dose Cannabidiol Is Safe but Not Effective in the Treatment for Crohn's Disease, a Randomized Controlled Trial

BACKGROUND

Cannabidiol (CBD) is an anti-inflammatory cannabinoid shown to be beneficial in a mouse model of IBD. Lacking any central effect, cannabidiol is an attractive option for treating inflammatory diseases.

AIM

To assess the effects of cannabidiol on Crohn's disease in a randomized placebo-controlled trial.

PATIENTS AND METHODS

Twenty patients aged 18-75 years with a Crohn's disease activity index (CDAI) >200 were randomized to receive oral (10 mg) CBD or placebo twice daily. Patients did not respond to standard treatment with steroids (11 patients), thiopurines (14), or TNF antagonists (11). Disease activity and laboratory parameters were assessed during 8 weeks of treatment and 2 weeks thereafter. Other medical treatment remained unchanged.

RESULTS

Of 20 patients recruited 19 completed the study. Their mean age was 39 ± 15, and 11 were males. The average CDAI before cannabidiol consumption was 337 ± 108 and 308 ± 96 (p = NS) in the CBD and placebo groups, respectively. After 8 weeks of treatment, the index was 220 ± 122 and 216 ± 121 in the CBD and placebo groups, respectively (p = NS). Hemoglobin, albumin, and kidney and liver function tests remained unchanged. No side effects were observed.

CONCLUSION

In this study of moderately active Crohn's disease, CBD was safe but had no beneficial effects. This could be due to lack of effect of CBD on Crohn's disease, but could also be due to the small dose of CBD, the small number of patients in the study, or the lack of the necessary synergism with other cannabinoids. Further investigation is warranted. CLINICALTRIALS.GOV: NCT01037322.

Adherence with a low-FODMAP diet in irritable bowel syndrome: are eating disorders the missing link?

OBJECTIVES

The low-FODMAP diet has emerged as an option for the treatment of irritable bowel syndrome (IBS). This diet is very restrictive, and compliance is usually low. Preliminary findings suggest an association between eating disorders (EDs) and the risk of developing IBS. The aim of this study was to assess the correlation between compliance with a low-FODMAP diet and the risk of ED behaviours among patients with IBS.

PATIENTS AND METHODS

A single-centre prospective study was carried out among 233 IBS patients (79.8% females) at University College London Hospital, who commenced a low FODMAPs group programme for IBS (Rome III or IV). Self-reported diet adherence at the end of the 6-week programme was measured. At baseline, and at the 6-week follow-up visit, participants completed the validated IBS-Symptom Severity Score, the SCOFF ED screening questionnaire and the Hospital Anxiety and Depression Scale.

RESULTS

Adherence with a low-FODMAP diet was found in 95 (41%) patients. Overall, 54 (23%) patients were classified to be at risk for ED behaviour. Adherence was 57% in the ED group (31/54) versus 35% in the non-ED group (64/179); P<0.05. Adherence with a low-FODMAP diet was highest (51%) in the IBS with diarrhoea subtype and lowest (10%) in IBS with constipation. There was no significant correlation between IBS-Symptom Severity Score and either adherence (P=0.39) or ED behaviour (P=0.28).

CONCLUSION

In this IBS cohort, greater adherence to a low-FODMAP diet is associated with ED behaviour. The implications of our study are important in clinical practice for a clinician to have a high index of suspicion of EDs in IBS patients when a high level of low-FODMAP diet achieved.

The Evolving Role of Gut Microbiota in the Management of Irritable Bowel Syndrome: An Overview of the Current Knowledge

The intestinal microbiota is one of the most rapidly evolving areas in biology and medicine. Extensive research in the last decade has escalated our understanding of the role of the microbiota in the pathogenesis of several intestinal and extra-intestinal disorders. Marked by high prevalence, substantial morbidity, and enormous costs, irritable bowel syndrome (IBS) is an important chronic gastrointestinal disorder that is widely encountered by gastroenterologists. Despite advances in our understanding of its pathophysiology, curative interventions have yet to be discovered, and therapeutic approaches remain symptom-driven. Recently, accumulating evidence has enlightened the possible impact of an imbalanced gut microbiome in the pathogenesis of IBS. In fact, several studies have documented altered microbiota in patients, while others have shown that IBS severity was associated with a distinct microbiota signature. These findings may pave the way for the use of microbiota manipulation strategies as an attractive option for IBS management, and may have an essential role in efforts to reduce the societal and economic effects of this ever-growing disorder. In this review, we have outlined the results of the latest research on the association between microbiota and IBS and their implications for the clinical management of affected patients.

Predictors and colonoscopy outcomes of inadequate bowel cleansing: a 10-year experience in 28,725 patients

Background:

Inadequate bowel preparation is still the main obstacle to a complete colonoscopy in many patients and necessitates many repeated procedures. We aimed to identify risk factors associated with inadequate bowel preparation and to better characterize these patients.

Methods:

This was a retrospective study that reviewed electronic reports of colonoscopy procedures over a 10-year period. Patients were divided into 2 groups: adequate vs. non-adequate bowel preparation. A multivariate analysis was performed to identify variables associated with inadequate bowel preparation, including age, sex, setting (inpatient/outpatient), preparation regimen and procedures’ indications. We examined the effect of inadequate preparation on colonoscopy quality indicators.

Results:

Of the 28,725 patients included in the study, 6,702 (23.3%) had inadequate bowel preparation. In the multivariate analysis, advanced age (odds ratio [OR] 1.015, 95% confidence interval [CI] 1.013-1.017; P<0.01), male sex (OR 1.353, 95%CI 1.286-1.423; P<0.01) and a minority population (OR 1.635, 95%CI 1.531-1.746; P<0.01) were significantly associated with inadequate bowel preparation. The inpatient setting was among the most prominent factors associated with inadequate bowel preparation (OR 2.018, 95%CI 1.884-2.163; P<0.01). Adequate bowel preparation was associated with a higher polyp detection rate (26.8% vs. 23.6%; OR 1.22, 95%CI 1.109-1.347; P<0.01) and colorectal cancer (2.8% vs. 2.4%; OR 1.402, 95%CI 1.146-1.716; P<0.01), and higher frequencies of cecal (96.4% vs. 73.5%; OR 2.243, 95%CI 2.095-2.403; P<0.01) and terminal ileum intubation (8.1% vs. 5.4%; OR 1.243, 95%CI 1.088-1.434; P<0.01).

Conclusion:

We outlined various factors associated with inadequate bowel preparation and confirmed its adverse effect on colonoscopy quality indicators.

Diagnosis and Management of Achalasia: Updates of the Last Two Years

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Diagnostic approach to faecal incontinence: What test and when to perform?

Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.

A State-of-the-Art Review on the Evolving Utility of Endoscopic Ultrasound in Liver Diseases Diagnosis

Liver diseases are amongst the most common diseases worldwide and manifest as a parenchymatic and/or biliary injury due to several causes as well as focal liver lesions, ranging from benign to malignant ones. The diagnosis of liver diseases is based mainly on biochemical and advanced imaging studies and, when required, on liver biopsy. Endoscopic ultrasound (EUS), which combines endoscopy and ultrasonography, is one of the main examination techniques used in gastroenterology as it is applied to evaluate abnormalities in the lumen of the upper and lower gastrointestinal tract and to define pancreatic and hepato-biliary features, often in chronic patients. Given its high spatial resolution and its proximity to the liver, EUS is gaining popularity in the diagnostic work up of liver diseases. This is a comprehensive overview of the current literature on the diagnostic indications for EUS use in patients with liver diseases. We performed a MEDLINE\PubMed and Embase search, and all articles that were relevant, after reviewing abstracts, were assessed and the full text was analyzed to extract data regarding technical success, diagnostic yield, bioptic characteristics, and complications rate. EUS-guided imaging and biopsy techniques in liver diseases have shown consistent favorable promising results among the reports through the literature, with an excellent diagnostic yield and safety profile, especially in the context of focal lesions and portal hypertension. The application of EUS in the diagnosis of liver diseases is a promising technique and should be considered as a first-line therapeutic option in selected cases.

Eosinophilic esophagitis: pitfalls and controversies in diagnosis and management

Formerly considered a rare disorder, eosinophilic esophagitis (EoE) has emerged as a leading cause of feeding problems in children and an increasingly recognized cause of dysphagia and food impaction in adults. Our understanding of EoE and its complex interplay with gastro-esophageal reflux disease (GERD) has evolved over the past decade and culminated in the introduction of proton pump inhibitor (PPI) responsive EoE as a distinct entity which has added to this complexity. It is now clear that this entity is on the same spectrum as the original EoE, and that PPIs should be considered as part of treatment protocol and should not be recommended as a diagnostic tool. As such, removing the PPI trial from the diagnostic algorithm has been encouraged recently. Recent guidelines and reviews thoroughly address various aspects in EoE pathogenesis and diagnostic workup as well as management endpoints, treatment options and novel therapies. However, despite the recent extensive study and the advances in our knowledge of this disease, unmet needs and pitfalls in diagnostic workup and management of these patients are still to be clarified and will be under focus in this review.

Achalasia: Insights into Diagnostic and Therapeutic Advances for an Ancient Disease

Achalasia is a chronic idiopathic disease characterized by the absence of esophageal body peristalsis and by defective lower esophageal sphincter (LES) relaxation. The incidence rate ranges from 1.07 to up to 2.8 new cases per year per 100,000 population. Presenting symptoms include dysphagia, regurgitation, vomiting, and weight loss. The diagnosis of achalasia has undergone a revolution in the last decade due to the advent of high-resolution manometry (HRM) and the consequent development of the Chicago Classification. Recent progress has allowed achalasia to be more precisely diagnosed and to be categorized into three subtypes, based on the prevalent manometric features of the esophageal peristalsis. Treatment options are pharmacotherapy, endoscopic management (Botox injection or pneumatic dilation), and surgery, e.g. laparoscopic Heller myotomy (LHM). More recently, a new endoscopic technique, per oral endoscopic myotomy (POEM), has developed as a less invasive approach alternative to the traditional LHM. Since the first POEM procedure was performed in 2008, increasing evidence is accumulating regarding its efficacy and safety profiles. Currently, POEM is being introduced as a reasonable therapeutic option, though randomized controlled trails are still lacking. The current review sheds light onto the diagnosis and management of achalasia, with special focus on the recent advances of HRM and POEM.

Non-alcoholic fatty liver disease: a survey of involvement of primary care physicians

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are neglected in most patients' electrical medical report by their family physicians (FP). We have assessed whether family physicians have the proper knowledge of NAFLD and accurate training to diagnose and treat NAFLD/NASH in overweight and obese patients.

METHODS

We conducted an anonymous survey questionnaire. Family Physicians who participated completed 4 years of residency and have passed the final examination. Our survey contained questions to measure the physician's attitudes, source of knowledge and recommendation regarding NAFLD/NASH treatment and attitudes toward patients with NAFLD/NASH. Categorical variables were extracted and analyzed using SPSS.

RESULTS

A total of 310 of 422 FPs were included in the study with a compliance rate of 73%. Our data suggests that 167 of the 310 FPs (55%) refer their patients to a specialist for consultations if they exhibited fatty liver disease. Yet, 284 of 310 send their patients to consolations if exhibiting elevated liver enzyme. Our data significantly suggests that 241 of 310 (78%) reported that they have limited efficacy in treating NAFLD/NASH and consider themselves not properly prepared, by medical schools, to treat NASH/NAFLD patients; as well as patients with obesity and metabolic syndrome without fatty liver.

CONCLUSIONS

FPs are more likely to neglect proper treatment for NAFLD/NASH due to lack of proper knowledge and are more likely neglect referring patients to specialist. Patients with significant obesity and obesity related conditions are more likely to have proactive treatment plans by their FPs.

Demographics and Clinical and Endoscopic Characteristics of Patients with Helicobacter pylori Infection and Gastroesophageal Reflux Disease: A Case-Control Study

Background

The correlation between Helicobacter pylori (H. pylori) and gastroesophageal reflux disease (GERD) is complex. Some studies showed a protective role of H. pylori infection against GERD. This study was aimed at assessing the role of H. pylori infection in GERD utilizing a large cohort of patients diagnosed with GERD.

Methods and Materials

All patients who underwent gastroscopy for an indication of GERD during the study period between 2015 and 2017 at the EMMS Nazareth Hospital were considered eligible for the study and therefore were included. H. pylori infection was determined by the rapid urease test or histology. Severity of esophagitis was assessed using the Los Angeles classification. Univariate analysis was performed to figure out differences between patients according to H. pylori infection status. Multivariate regression analysis was conducted to illustrate the predictors of positivity for H. pylori infection.

Results

2,508 GERD patients were included with a median age of 49.42 ± 17.96 years. H. pylori infection was detected in 299 (11.9%) patients. GERD patients with H. pylori infection were found to be younger (48.83 ± 17.42 years versus 44.57 ± 17.69 years, p < 0.001), have the tendency to smoke more (1406 (63.6%) versus 266 (89.0%), p < 0.001), and use more proton pump inhibitors or PPIs (1314 (59.5%) versus 242 (80.9%), p < 0.001). In multivariate regression analysis, age (OR 0.987, p < 0.001), smoking status (OR 0.190, p < 0.001), use of ASA/NSAIDs (OR 1.652, p = 0.004), and use of statins (OR 0.499 (95%CI 0.295-0.846), p = 0.010) were found significant among H. pylori-positive individuals. H. pylori-positive subjects have less severe esophagitis and more hiatus hernia.

Conclusion

Patients with GERD and H. pylori infection were significantly younger, tended to smoke more, and used more PPIs and had significantly lower grades of esophagitis compared to noninfected ones.

Proton Pump Inhibitor Use May Increase the Risk of Diverticulitis but Not It's Severity among Patients with Colonic Diverticulosis: A Multicenter Study

Colonic diverticular disease, especially diverticulitis constitutes a major cause of hospitalization and an economic burden in developed countries. Proton pump inhibitors (PPIs) are among the commonest drugs used to treat several diseases affecting the upper gastrointestinal tract. A few studies have reported that the use of Proton Pump Inhibitors PPIs caused dysbiosis. In this study, we searched for a relationship between PPI use and the onset and severity of diverticulitis in patients with colonic diverticulosis. In a retrospective study, patients who were hospitalized for documented diverticulitis were enrolled as cases and compared with a control group of patients with uncomplicated diverticulosis. Overall, 613 patients who had a diagnosis of diverticulosis were included in the study, 217 of whom had diverticulitis. After multivariate analysis, the non-modifiable risk factors associated with diverticulitis included: age (p < 0.0001), hypertension (p < 0.0001), chronic renal failure (p = 0.007), diabetes mellitus (p < 0.0001), and left colon location (p = 0.02). However, among the modifiable factors, only PPI use (p < 0.0001) showed a significant association. Advanced disease severity (according to Hinchey classification of diverticulitis stages II–IV) was associated with aspirin use (p = 0.0004) and pan-colonic location (p = 0.02). PPI use was the only modifiable factor significantly associated with diverticulitis, but not with its severity, among patients with diverticulosis. This observation should be confirmed in future multicenter prospective studies.

Livovsky D, Nubani A, Mari A, Goldin E, Mahamid M. Long-Term Safety of Endoscopic Biliary Stents for Cholangitis Complicating Choledocholithiasis: A Multi-Center Study

BACKGROUND

Treatment of cholangitis complicating choledocholithiasis includes biliary sphincterotomy and stone extraction. In certain cases of elderly comorbid patients with high risk for definitive endoscopic treatment, biliary stenting is the only measure for relieving biliary obstruction.

AIM

We aimed to report the safety of retained biliary stone.

METHODS

a multi-center, retrospective case-control study conducted at two Israeli medical centers from January 2013 to December 2018 including all patients 18 years of age or older who underwent ERCP and biliary stent insertion for the treatment of acute cholangitis due to choledocholithiasis.

RESULTS

Three-hundred and eight patients were identified. Eighty-three patients had retained long-term biliary stents of more than 6 months (group A) from insertion compared to 225 patients whose biliary stents were removed within a 6-month period (group B). The mean follow-up in group A was 66.1± 16.3 vs. 11.1 ± 2.7 weeks in group B. Overall complications during the follow-up were similar between groups A and B (6% vs. 4.9%, OR 1.24, Chi square 0.69). Similarly, the rate of each complication alone was not different when comparing group A to group B (3.6%, 1.2% and 1.2% vs. 2.7%, 0.44% and 1.8%) for cholangitis, stent related pancreatitis and biliary colic, respectively (Chi square 0.85). Even after 12 months, the rates of overall complications and each complication alone were not higher compared to less than 12 months (Chi square 0.72 and 0.8, respectively).

CONCLUSION

endoscopic biliary stenting for cholangitis complicating choledocholithiasis is safe for the long-term period without increase in stent related complications.

The association between non-alcoholic fatty liver disease and valvular heart disease

BACKGROUND

Non-alcoholic fatty liver (NAFLD) disease has become the commonest cause of end-stage liver disease. Patients with NAFLD have an increased risk of associated extrahepatic conditions, including structural and functional cardiovascular disease. Still, it is unknown if there is an association between NAFLD and valvular heart disease (VHD). The aim of this paper was to determine the association between NAFLD and VHD.

METHODS

We performed a single center retrospective study in EMMS Nazareth Hospital from April 2010 to April 2018. All patients who were diagnosed with NAFLD and who had an echocardiography performed within one year were included. Subjects age and sex-matched, who had echocardiography performed in the same period were included in the control group.

RESULTS

The mean age of the NAFLD group was 41.5±11.7 vs. 42.8±10.8 years of the control group (P=0.2). The prevalence of aortic stenosis, aortic insufficiency, mitral stenosis and mitral insufficiency were significantly higher in NAFLD patients compared to the control group (1.2% vs. 0.22%, 1.32% vs. 0.32%, 0.66% vs. 0.27%, and 1.87% vs. 0.41%, respectively; P<0.001). In the multivariate logistic regression analysis, NAFLD was found to be independent risk factor for VHD (OR 2.39, 95% CI 2.17-2.78, P<0.001).

CONCLUSIONS

VHD was significantly seen more frequently in NAFLD patients compared to controls. Prospective studies are needed to validate our findings and to elucidate the pathogenesis of VHD in patients with NAFLD.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Are Correlated with Complicated Diverticulitis and Hinchey Classification: A Simple Tool to Assess Disease Severity in the Emergency Department

Background and Aim

Rapid identification of patients with complications related to acute diverticulitis who require urgent intervention in the emergency department (ED) is essential. The aim of our study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting severity of diverticulitis as assessed by Hinchey classification.

Patients and Methods

We performed a single retrospective study in EMMS Nazareth Hospital from 4/2014 to 4/2018. Patients were categorized into two groups: group A with mild to moderate complicated diverticulitis (Hinchey 1-2) and group B with severe complicated diverticulitis (Hinchey 3-4).

Results

Two hundred twenty-five patients were included. Two hundred seven patients were in group A, and 18 patients were in group B. On univariate analysis, age, NLR, and PLR correlated with advanced Hinchey classification and disease severity (stages 3-4) (OR 1.038, 95% CI 1.001–1.076, P=0.0416; OR 1.192, 95% CI 1.093–1.300, P < 0.0001; and OR 1.011, 95% CI 1.005–1.017, P=0.0005, respectively). On multivariate logistic regression analysis, the NLR and PLR remain significantly correlated with Hinchey 3-4 (OR 1.174, 95% CI 1.071–1.286, P=0.0006, and OR 1.008, 95% CI 1.001–1.015, P=0.0209, respectively). The area under the curve (AUC) for the NLR and PLR on univariate analysis was 0.7526 and 0.6748, respectively, and 0.7760 and 0.7391 on multivariate logistic regression analysis, respectively, and receiver-operating characteristic (ROC) curves were drawn.

Conclusion

The NLR and PLR independently associated with diverticulitis severity and positively correlated with advanced Hinchey classification. This simple available laboratory tool can be implemented into clinical practice to optimize patient management.

Estimation of Gastric Volume Before Anesthesia in Term-Pregnant Women Undergoing Elective Cesarean Section, Compared With Non-pregnant or First-Trimester Women Undergoing Minor Gynecological Surgical Procedures

BACKGROUND

Traditionally, intubation of pregnant women has been performed using a rapid sequence induction. This is due to the classical concept that women with more than 18 weeks of pregnancy (mid-second trimester) are always considered to have an increased risk of aspiration due to a number of factors, regardless of the fasting duration. Rapid sequence induction is associated with a higher rate of adverse events.

AIMS

Our study aimed to illuminate the hypothesis that there is no difference in gastric volume between term-pregnant women and non-pregnant or first-trimester pregnant women who were undergoing minor gynecological surgical procedures. Accordingly, we measured gastric volume and content before anesthesia in term-pregnant women undergoing elective cesarean section, and to compare it with non-pregnant or first-trimester pregnant women who were undergoing minor gynecological surgical procedures.

METHODS

In this single-center prospective study, the gastric volume and content were assessed by abdominal ultrasound (AUS) just prior to the scheduled procedure. AUS was performed in the sagittal or para-sagittal plain in the upright position and the stomach content was estimated according to the antral circumferential area. Group 1 consisted of 50 term-pregnant women scheduled for cesarean section. Group 2 consisted of 45 non-pregnant or first-trimester pregnant women who were scheduled for minor gynecologic procedure.

RESULTS

Despite significant longer fasting time prior to the interventional procedure in the non-pregnant or first-trimester women group, there was no significant difference in gastric volume between term-pregnant and first-trimester pregnant women (3.2 ± 0.97 cm2 vs 3.2 ± 0.79 cm2; P = .97). Gastric volume was small in the two groups.

CONCLUSION

Fasting gastric volume before cesarean section in term-pregnant women is small and is not different than in non-pregnant or first-trimester women undergoing minor gynecologic procedures. Ultrasound estimation of gastric volume is a reliable and easy-to-perform technique which might help in decision-making regarding the airway management prior to induction of anesthesia in pregnant women.

Impact of Chronic Statins Use on the Development of Esophagitis in Patients with Gastroesophageal Reflux Disease

BACKGROUND AND AIMS

We aimed to assess whether chronic statins used (> 6 months) were protective of the development of esophagitis in patients with gastroesophageal reflux disease. In the presence of esophagitis, complications such as strictures, Barrett's esophagus, and adenocarcinoma were the most common. Statins, lipid lowering drugs with a pleiotropic effect, are recently implicated in various pathologies. Nevertheless, the possible impact of statins in esophagitis development has never been assessed.

METHODS

We performed a retrospective, cross-sectional, single center study that included 4148 gastroesophageal reflux disease patients from 2014 and 2018 at EMMS Nazareth Hospital. We divided the patients into 5 groups. The groups were split into positive control group, which was the nonesophagitis group, and the other 4 groups were A-D (as per Los Angeles classification).

RESULTS

Overall, out of the 4148 patients included, 48% were males and 2840 patients were in the control group. In groups A, B, C, and D there were 818, 402, 72, and 16 patients, respectively. Logistic regression analysis revealed that chronic statins usage is protective by preventing development esophagitis (OR 0.463 [95%CI 0.370-0.579], p < 0.0001). NSAIDS use, Hiatus hernia, and H. pylori were promoting factors (OR, 1.362, 1.779, and 1.811; 95% CI, 1.183-1.569, 1.551-2.040, and 1.428-2.298; P<0.0001, P<0.0001, and P<0.0001, respectively).

CONCLUSION

Using chronic statins was protective to the development of esophagitis among GERD patients. Our findings of potential clinical application mandate further randomized controlled trials to better assess the impact of statins on esophagitis.

Pulmonary embolism risk in hospitalized patients with nonalcoholic fatty liver disease: A case-control study

Abundant research has associated nonalcoholic fatty liver disease (NAFLD) with atherosclerosis, but very few reports have evaluated the association between NAFLD and venous thromboembolism. We aimed to investigate the association between NAFLD and pulmonary embolism (PE) in hospitalized patients. In this retrospective case-control study, we included consecutive patients from 2 university-affiliated hospitals who were referred for CT pulmonary angiograms for a suspected PE. Patients with a history of excessive alcohol consumption, chronic liver diseases or cirrhosis were excluded. The imaging studies of the entire cohort were reviewed by 2 expert radiologists who confirmed the diagnosis of PE and examined the liver to detect and grade hepatic steatosis. Accordingly, patients were categorized into NAFLD patients and non-NAFLD controls. Patient demographics, medical history, hospitalization details as well as patients' outcomes were documented. Multivariate analysis was performed to identify predictors for developing PE and hazard ratios with corresponding 95% confidence intervals were estimated. A total of 377 patients (101 with NAFLD and 276 controls) were included. NAFLD patients had significantly higher BMI values (33.16 ± 6.78 vs 26.81 ± 5.6; P < .001) and prevalence of diabetes (41 (40%) vs 85 (30.8%); P = .03). The prevalence of PE was significantly higher in the NAFLD group (80 (79.2%) vs 147 (53.3%), P < .001). In a multivariate analysis, older age, recent surgery or trauma, active malignancy, smoking, and NAFLD (HR ratio = 4.339, P < .0001 and 95% CI = 2.196-8.572) were independently associated with PE development. Patients with NAFLD were associated with an increased risk of developing PE independent of other classical risk factors for PE.

Predictors of in-hospital mortality among patients with clostridium difficile infection: a multicenter study

BACKGROUND

Clostridium difficile infection (CDI)-associated mortality is a major global health concern. Several clinical and laboratory parameters have been linked to poor prognosis in patients with CDI. In the current study, we aimed to assess the rate of in-hospital mortality among Israeli CDI patients and to look for clinical and laboratory parameters associated to death.

METHODS

We performed a multicenter retrospective study enrolling all patients above 18-years old who were hospitalized for CDI or with diagnosis made during hospitalization in two regional, teaching hospitals in the north of Israel (Galilee Medical Center, Nahariya and the Nazareth Hospital, Nazareth, Israel), from January 1, 2015 until January 1, 2020. All files of eligible patients were reviewed for demographic (age, gender), medical history and laboratory tests.

RESULTS

Overall, we included in the study 180 patients, among them 56 died in hospital due to CDI (group A) while 124 survived (group B). The average age in groups A and B was 77.02±13 vs. 71.5±19.1, respectively. On univariate analysis, several clinical and laboratory parameters were associated with in-hospital mortality, including: advanced age, renal failure, antibiotics treatment while on treatment for CDI, need for mechanical ventilation, level of hemoglobin, white blood cells (WBC) and neutrophils count, neutrophil/lymphocyte ratio, serum level of albumin, creatinine and C reactive protein. On multivariate logistic regression analysis, only 4 parameters showed statistically significant association with in-hospital mortality, including age (odds ratio [OR]: 6.97, 95%confidence interval [CI]: 4.94-8.72, P=0.003), renal failure (OR: 3.72, 95% CI: 1.22-11.24, P=0.02), WBC count (OR: 1.09, 95% CI: 1.02-1.16, P=0.008), and lower albumin level (OR: 47.62, 95% CI: 10.31-200, P<0.0001).

CONCLUSIONS

In this retrospective, multicenter study, age, serum albumin level, leucocytes count, and renal failure were the main predictors of in-hospital mortality in patients with CDI. Thus, antibiotic use should be weighed carefully in elderly comorbid patients, at increased risk of mortality from CDI .Prospective multicenter randomized studies investigating the effect of albumin infusion on in-hospital death of CDI patients are needed, thus enabling us to direct monitoring and treatment accordingly.

Comparison in Adherence to Treatment between Patients with Mild-Moderate and Severe Reflux Esophagitis: A Prospective Study

Purpose: Gastro-esophageal reflux disease (GERD) is prevalent and causes erosive esophagitis (EE) with varying degrees of severity (A to D according to the Los Angeles Classification). Adherence to medical therapy is crucial for treatment success. We compared adherence to treatment recommendations between patients with EE grades C/D and A/B. Methods: A follow-up study was conducted during 2019−2020 among GERD patients who underwent a diagnostic gastroscopy 1−4 years earlier. Telephone interviews were conducted with patients diagnosed with severe EE grades C/D (n = 99) and randomly selected patients with mild−moderate EE grades A/B (n = 50). Patients with grades A/B were classified as adherent if they took proton pump inhibitors (PPIs) for 2−3 months as recommended. Patients with grades C/D were classified as adherent if they took medications for a prolonged period (>6 months) and performed a follow-up endoscopy as recommended. Results: The mean age of the participants was 44.6 years (SD = 15.1). The mean duration of PPIs therapy in patients with EE grades A/B was 9.4 months (SD = 8.7). Fourteen (14.2%) patients with EE grades A/B were non-adherent to treatment, compared to 21 (40.8%) patients with EE grades of C/D: adjusted OR = 0.06; CI 95% 0.02−0.18, p < 0.001. Follow-up endoscopy was performed by 44% of EE−C/D patients. Unmarried patients compared to married ones were less adherent (adjusted OR = 0.23; 95% CI 0.08−0.69, p < 0.001). Conclusions: Patients with esophagitis (EE−A/B) were more adherent to medical therapy when compared to patients with more severe esophagitis (EE−C/D).

Pre-endoscopic tachycardia predicts increased sedation dose and lower adenoma detection rate in patients undergoing endoscopic procedures: a case control study

BACKGROUND

Tachycardia prior to endoscopic procedures is commonly encountered which reflect patient anxiety status. Despite this frequent occurrence, it is unclear if in a patient with tachycardia sedation dose should be modified. The aim of our study was to assess the effect of pre-endoscopic tachycardia on sedation dose.

METHODS

A retrospective analysis of all patients who underwent upper endoscopy and colonoscopy at EMMS Nazareth hospital were performed. We excluded patients with diseases and medications affecting the heart rate.

RESULTS

A total of 2855 patients were included in the study. Two-hundred and thirty-seven patients had tachycardia before endoscopy (8.3%, group A) as compared to 2618 (group B) patients who had heart rate ≤100 beats per minute. The mean dosage of propofol in group A was significantly higher (62.6±33.2 mg vs. 57.4±29.9 mg) than in group B (P=0.01). There was no difference in the cecal intubation rate among the two groups (P=0.9). Notably, the adenoma detection rate was significantly lower among group A patients as compared to group B (13.6% vs. 22.8%, P=0.02) patients. There were no sedation related complications.

CONCLUSIONS

Tachycardia prior to endoscopic procedures was associated with higher sedative dosage and lower adenoma detection rate, however no major complications were recorded. These data should be taken into consideration to optimize procedure quality.