A novel duodenal-release formulation of caraway oil and L-menthol is a safe, effective and well tolerated therapy for functional dyspepsia

BACKGROUND

A randomized, placebo-controlled clinical trial (FDREST) of a novel formulation of caraway oil and L-menthol (COLM-SST) demonstrated symptom relief in patients with functional dyspepsia (FD). Two follow-up studies were conducted to evaluate patient satisfaction, self-regulated dosing, and long-term safety data: FDACT, Functional Dyspepsia Adherence and Compliance Trial, and FDSU36, Functional Dyspepsia Safety Update at 36 months.

METHODS

A patient reported outcomes (PRO) questionnaire was designed and distributed online to assess real-world satisfaction and dosing frequency of open-label COLM-SST in patients with FD. A separate study analyzing voluntary safety surveillance data evaluated the frequency and severity of reported adverse events (AEs).

RESULTS

A total of 600 FD patients were enrolled in the PRO study. Ninety five percent of respondents reported a major or moderate improvement in their FD symptoms and 91.7% indicated a major or moderate improvement in quality of life (QOL) using COLM-SST. Between 1 and 4 capsules were consumed daily by 91.2% of respondents, with 56.2% taking them before meals. Symptom relief was rapid, with 86.4% of respondents indicating relief within 2 h of taking COLM-SST. Few adverse events (AEs) were reported (0.0187%) by patients using COLM-SST. No serious AEs were identified.

CONCLUSION

COLM-SST is safe, well tolerated, and provides rapid relief of FD symptoms. These findings, demonstrated in the FDREST trial, were further supported by a large prospective PRO study evaluating self-regulated dosing frequency, symptom improvement, and QOL. COLM-SST was well-tolerated based on review of AE data at 36 months.

Patient experience with NER1006 as a bowel preparation for colonoscopy: a prospective, multicenter US survey

BACKGROUND

NER1006 (Plenvu®, Salix Pharmaceuticals, Bridgewater, NJ) is a 1 L polyethylene glycol bowel preparation indicated for colonoscopy in adults. A US online survey assessed real-world ease of use and treatment satisfaction in individuals who received NER1006.

METHODS

Adults were recruited from 444 US community gastrointestinal practices and provided a kit number for enrollment into an online survey to be completed within 2 weeks. Survey questions evaluated colonoscopy history and prior bowel preparation(s) prescribed, patient experience during NER1006 administration, and patient satisfaction with the bowel preparation process. A 9-point predefined grading scale was used to evaluate ease of NER1006 preparation and consumption (range, 1 "very difficult" to 9 "very easy"); the perceived importance of volume requirement and clear liquid options (range, 1 "not important at all" to 9 "very important"); and patient satisfaction (range, 1 "not satisfied at all" to 9 "very satisfied").

RESULTS

1630 patients were enrolled, 1606 underwent colonoscopy, and 1598 completed the survey between September 15, 2018 and February 28, 2019. Among 1606 patients who had a colonoscopy, 62.5% were female, and the mean patient age was 54.4 years (range 18-89 years). Most patients (74.7%) did not report a family history of colon cancer, 62.6% had undergone prior colonoscopy, and 64.8% were undergoing colonoscopy for routine colorectal cancer screening. A majority (76.1%) of patients who completed the survey reported that NER1006 was very easy to prepare and take, and 89.9% were very or moderately satisfied with NER1006 overall. Most (97.6%) patients reported consuming all or most of the bowel preparation. Among 1005 patients with previous bowel preparation use, 84.7% indicated that their experience with NER1006 was much better or better (65.3%) or about the same (19.4%) compared with previously used bowel preparations, while only 15.3% rated NER1006 as worse or much worse.

CONCLUSIONS

In this first real-world, US multicenter survey, patient-reported experience with NER1006 as a bowel preparation for colonoscopy was favorable and adherence was high. The majority of patients were very or moderately satisfied with the overall experience and found it much better/better than previously used bowel preparations.

TRIAL REGISTRATION

Not applicable.

High-quality colon cleansing and multiple neoplasia detection with 1L NER1006 versus mid-volume options: Post hoc analysis of phase 3 clinical trials

Background and study aims  Multiple neoplasia increase the risk of colorectal cancer. High-quality cleansing may improve adenoma detection. We assessed whether a new bowel preparation can improve colon cleansing and multiple lesion detection. Patients and methods  This post hoc analysis of two randomized clinical trials in Europe and the US assessed the per study and combined cleansing efficacy of overnight split dosing with (preparation + clear fluids) 1 + 1 L polyethylene glycol (PEG) NER1006 versus 2 + 1 L PEG + ascorbate (2LPEG) or 1 + 2 L oral sulfate solution (OSS) combined. Treatment-blinded central readers assessed cleansing quality using the Harefield Cleansing Scale (HCS). Patients with full segmental scoring were included. HCS segmental scores 0-4 (high-quality = HCS 3-4) were analyzed for NER1006 versus 2LPEG/OSS. Mean number of polyps or adenomas per patient (MPP/MAP) was calculated for treatments in patients with at least one polyp or adenoma. Results  In 1037 patients, NER1006 attained a greater rate of HCS 3 scores (29 % vs. 20 %; P  < 0.001) and HCS 4 scores (20 % vs. 17 %; P  = 0.007) versus 2LPEG/OSS. More polyps (678 versus 585) and adenomas (397 versus 331) were detected with NER1006 (N = 517) versus 2LPEG/OSS (N = 520). In all neoplasia-positive patients, with increasing minimal per-patient neoplasia multiplicity from 1 to 10, NER1006 numerically improved MPP (difference ± SE: 0.48 ± 0.24 to 3.89 ± 3.37) and MAP (0.47 ± 0.26 to 7.50 ± 9.00) versus 2LPEG/OSS. Conclusions  Low-volume NER1006 enhances high-quality cleansing versus medium-volume 2LPEG or OSS, individually and when combined. NER1006 may consequently facilitate the detection of multiple neoplasia in patients.

Nondestructive Determination of the Age of 20th-Century Oil-Binder Ink Prints Using Attenuated Total Reflection Fourier Transform Infrared Spectroscopy (ATR FT-IR): A Case Study with Postage Stamps from the Łódź Ghetto

The ability to determine the production date for a painting or print would be of great benefit in the forensic detection of fakes and forgeries as well as in art history and conservation. Changes in the pigments used at different times have been invaluable in detecting incongruities that suggest fraud, but relatively little work has been published that uses the chemical changes in oil binders as they dry to determine when an ink print or an oil painting was made. Using attenuated total reflectance-Fourier transform infrared (ATR FT-IR) spectroscopy and samples with known dates, we calibrate the drying of oil binders in inks and paints and cross-validate the paints with pyrolysis-gas chromatography-mass spectrometry (Py-GC-MS). We apply the ink calibration to a case study involving the age determination of possible philatelic counterfeits from a World War II Jewish Ghetto in Occupied Poland, obtaining a date of 1946 ± 6 (1 s, n = 9) for the genuine stamps, and 1963 ± 16 (1 s, n = 19) for the various reproductions.

Early clinical experience with networked system for promoting patient self-management

OBJECTIVE

To gain early experience with a networked system designed to assess a patient's adherence to oral medication and physiologic metrics in an ambulatory, at-home setting.

STUDY DESIGN

Prospective, observational studies.

MATERIALS AND METHODS

This networked system for patient self-management consists of ingestible markers and a wearable, personal monitor. When a marker is ingested, it communicates to a monitor that time-stamps the ingestion and identifies the marker as unique. The monitor also records heart rate and activity. Data from third-party monitoring equipment (eg, sphygmomanometer, weight scale) can be integrated into the system. Collected data are summarized for patient and physician review. Directly observed ingestion (DOI) of placebo tablet markers was used to assess the system's technical performance. Markers were also coencapsulated with drugs to capture at-home adherence. A performance criterion of <95% was set as the objective for system performance.

RESULTS

A total of 111 subjects ingested 7144 ingestible markers; 3298 were DOIs. The system's positive detection accuracy and negative detection accuracy in detecting ingested markers were 97.1% and 97.7%, respectively. It differentiated 100% of multiple drugs and doses taken simultaneously by type and by dose. Medication adherence was >85%. The most common adverse effect was mild skin rash from the monitor's electrodes. No definitive marker-related adverse effects were reported.

CONCLUSION

The system appears to be safe and effective in capturing and integrating adherence and physiologic data. Efforts are under way to enhance system functionalities and refine user interfaces. By providing context-rich information, this system may enhance patient-provider collaboration.

Chemical attribution of corroded coins using X-ray fluorescence and lead isotope ratios: a case study from first century Judaea

Nondestructive analyses using a quadrupole inductively coupled plasma-mass spectrometer (ICP-QMS) and polarizing, multi-target, energy dispersive X-ray fluorescence (PEDXRF) with three-dimensional optics were conducted on Judean coins from the first century BCE and CE to determine the efficacy and limits of these methods for numismatic analyses of coins with a patina. Comparisons with destructive analyses and literature databases demonstrate their value even when corrosion is present. An outstanding question about the dating of Herod Agrippa I or II "canopy" coins that has significance to Biblical historians is used as a case study. Multiple lines of evidence attribute this coin to Agrippa I, with a date of 41 to 45 CE, produced using Faynan (Feinan), Jordan, and Cyprus ores.

Elemental composition of liver and kidney tissues of rough-toothed dolphins (Steno bredanensis)

On December 14, 1997, 62 rough-toothed dolphins (Steno bredanensis) stranded on Cape San Blas, on the Florida coast of the Gulf of Mexico. Approximately 30 animals died either on the beach or in rehabilitation facilities. Two were successfully rehabilitated and released. Liver, kidney, blubber, and muscle tissues were collected from 15 animals that died on the beach. Portions of the liver and kidney from each dolphin were analyzed using instrumental neutron activation analysis and inductively coupled plasma mass spectrometry to determine mass fractions of 37 elements. Levels of several electrolytes (Na, Cl, K, Br, Rb, I, Cs) and of the essential trace elements Fe, Cu, and Zn in both tissues were similar to those found in other Odontoceti. Mass fractions of Ca ranged from 60 mg/kg to 1,200 mg/kg (wet mass basis), indicating significant inhomogeneity in the kidney tissues of several animals. Necropsy reports noted that the kidneys of many of these animals contained fibrous nodules. The measured Ca inhomogeneity may be due to mineralization of the fibrous kidney tissue. Hepatic levels of Hg and Se were at the high end of the ranges generally found in livers of other Odontoceti and were slightly higher in animals with fibrous kidneys than in the others. Mass fractions of Se, Ag, and Hg in liver tissues increased with the size and age of the animals indicating accumulation of these elements in the liver with age. Results also indicate that Se and Hg accumulate in rough-toothed dolphin kidney. Accumulation of these elements with age has been reported commonly for marine mammals and other species.

Quality of life, taste, olfactory and oral function following high-dose chemotherapy and allogeneic hematopoietic cell transplantation

Multiple oral complaints develop following high-dose chemo/radiotherapy and hematopoietic cell transplantation (HCT) which can influence quality of life. The purpose of this investigation was to assess quality of life, oral function, taste and smell in a cohort of patients following HCT. A general quality of life survey (the European Organization for Research and Treatment of Cancer (EORTC)) Quality of Life (QOL) questionnaire (QLQ-C30), with an added oral symptom and function scale and assessment of taste and smell was administered to a consecutive series of patients at day 90-100 post HCT. General QOL was impacted by fatigue, affecting physical, social emotional and cognitive function. While oral function scales appeared to be little affected at day 90-100 post HCT, abnormalities of taste were reported. Reports of changes in taste and smell appeared to parallel each other and changes remained at the time of the survey post-HCT. Change in taste appeared to be closely associated with dry mouth. Patients appeared to have difficulty in differentiating sour and bitter, which had been more affected than salt and sweet taste. Females appeared to report greater changes in taste than males. Increased smell sensitivity and taste change resulted in changes in food preparation in some cases, as did reported increase in sensitivity to sour and bitter taste. Acute complications are well known to affect QOL during the early period following HCT, but little assessment of long-term changes in oral QOL and taste has been conducted following transplant. The EORTC QLQ C-30 questionnaire with the oral addendum provides a measure of the quality of life and oral function, and may provide useful outcome measures for assessment of oral care prevention and management in HCT patients.

Oral topical doxepin rinse: analgesic effect in patients with oral mucosal pain due to cancer or cancer therapy

Oral mucositis is a treatment limiting toxicity of cancer therapy. The purpose of this study was to assess the impact of doxepin oral rinse in the management of oral mucosal pain in cancer patients. Forty-one cancer patients with oral mucosal pain were provided a solution of doxepin (0.5%) for oral rinsing. Oral pain was assessed prior to rinsing, and following rinsing for 4 h using a visual analogue scale (VAS). Adverse effects were recorded. Doxepin rinse resulted in a reduction of pain intensity of more than 50%, with pain relief extending for more than 3 h with pain not returning to baseline 4 h after rinsing. The rinse was tolerated by patients with mucosal damage, and had acceptable taste, and infrequent mucosal stinging with use. Some patients reported sedation after use, likely due to systemic absorption. The results of this single dose trial suggest that topical doxepin rinse has significant ability to provide clinically significant pain relief in patients with mucosal damage with an extended duration of effect.

Topical azathioprine in the treatment of immune-mediated chronic oral inflammatory conditions: a series of cases

OBJECTIVES

After hematopoietic cell transplantation, a variety of complications can occur, including chronic graft-versus-host disease (GVHD), with 25% to 70% of these involving the oral cavity. Those lesions, as well as oral involvement of autoimmune mucocutaneous diseases, might present as painful, erythematous, and ulcerative oral lesions. Management includes topical and systemic immunosuppressive agents, including systemic azathioprine (AZA). The purpose of this study was to evaluate the efficacy of topical AZA in chronic oral GVHD and in oral autoimmune diseases in a series of patients.

METHODS

Four men and 2 women with GVHD and 2 men with autoimmune vesiculo-ulcerative oral lesions were treated with topical AZA. A rinse of 5 mL of 5 mg/mL AZA in methylcellulose were rinsed 3 to 4 times daily for over 1 minute and expectorated, or a gel in the same concentration in 3% methylcellulose was topically applied. The outcome was evaluated separately for total ulcer size, assessment of the erythema, and severity of pain by using a visual analogue scale. Global estimated improvements represented a proportional combined improvement of ulcers, erythema, and pain.

RESULTS AND CONCLUSIONS

The mean estimated global improvement for 6 patients with GVHD who used AZA rinse was 60% in a mean of 16.67 weeks. Ulcers improved by 58%, erythema by 55%, and pain was reduced by 63%. Two patients with oral lesions of vesiculo-ulcerative diseases (1 AZA rinse and 1 topical gel) improved by 95% and 96%, respectively, in 3 months. One patient with GVHD applied topical AZA gel in addition to mouthrinses, and a 29% estimated global improvement was achieved in addition to 50% of improvement achieved with AZA mouthrinses. The observed effect of topical AZA suggests that it can be used for management of oral immune-mediated inflammatory conditions, and for patients who are provided with systemic immunosuppressives it can allow control of oral findings with lower systemic dosing. The therapeutic potential of topical AZA as mouthrinse versus topical applications and the most effective concentration should be further investigated.

A prospective multicenter evaluation of new fecal occult blood tests in patients undergoing colonoscopy

OBJECTIVE

Guaiac-based fecal occult blood (FOB) tests, in particular, Hemoccult II (HO), are commonly used to detect colorectal neoplasia. Because the sensitivity and specificity of these tests are critical to cost-effective screening programs, we aimed to investigate the improved performance characteristics of new FOB tests for known colonic lesions.

METHODS

Nine centers worldwide performed FOB testing with guaiac-based tests (Hemoccult II [HO] and Hemoccult II SENSA [SENSA]) and immunochemical tests (HemeSelect [HS] and FlexSure OBT [FS]) on 554 patients referred for colonoscopy for predetermined indications. A combination testing strategy consisting of SENSA followed by HS or FS (which was considered positive only when both tests were positive) was also evaluated. Results of FOB tests were compared to findings on colonoscopy.

RESULTS

Cancers were identified in 2.9% of subjects, whereas adenomas > or =10 mm were found in 39 patients. Small adenomas, colitis, and other lesions were identified in 141 patients. The positivity rate of HO for adenomas > or =10 mm was less than for SENSA (20.5% vs 35.9%, p < 0.05), whereas the positivity rate of HO, SENSA, FS, HS, or the combination tests for cancers was not statistically different. The overall positivity rates were significantly greater for FS (15.9%, p = 0.0002) and significantly lower using the combination tests (SENSA/FS 6.0%, p = 0.01; SENSA/HS 6.2%, p = 0.02) compared to HO (9.4%). In this study population, the relative specificity (i.e., true-negative tests/true-negatives + false-positives in patients without adenomas > or =10 mm or cancers) of HO (93.9%; 95% CI, 91.7-96.1) was similar to that of SENSA (92.8%; 95% CI, 90.4-95.2) and HS (90.1%; 95% CI, 87.4-92.8), and greater than FS (88.0%; 95% CI, 85.1-90.9, p < 0.001). When considering adenomas > or =10 mm, cancers alone or cancers and adenomas combined, the combination test using SENSA/FS was associated with significantly fewer false-positive tests than any of the individual tests.

CONCLUSIONS

Compared to single tests, the combination test with the highly sensitive SENSA and an immunochemical test had slightly reduced sensitivity but significantly fewer false-positive tests than any single test. These data raise the possibility that a combination test (i.e., highly sensitive guaiac plus immunochemical) could reduce the costs of screening for colon cancer, and suggest that further study of combination test strategies is warranted.

Munchausen syndrome: case reports and literature overview

Munchausen syndrome is a subset of factitious disorders with a number of distinguishing characteristics. This article presents three case reports and brief discussions to facilitate recognition. Management techniques are also presented.

Hepatic sarcoidosis. Clinicopathologic features in 100 patients

The patterns of hepatic injury were studied in 100 patients with a diagnosis of sarcoidosis and clinical evidence of liver disease that led to diagnostic liver biopsy. Granulomas were present in all patients; they occupied from < 1% to > 90% of the total volume of tissue examined and were most often located in the portal/periportal region. In none of the 100 cases were infectious organisms identified by special stains, culture, or serology. In 99% of cases, these granulomas were noncaseating; in one of the 100 cases central caseation was noted. In addition to the granulomas present in all biopsies, three broad categories of histologic change were found: cholestatic (58%), necroinflammatory (41%), and vascular (20%). Among those with cholestasis, 19 patients had bile duct lesions similar to primary biliary cirrhosis, whereas another 13 had a pattern of periductal fibrosis reminiscent of primary sclerosing cholangitis. In 37 patients with chronic cholestasis, a decrease in the number of bile ducts (ductopenia) was noted. Twelve patients had an acute cholangitis suggestive of mechanical obstruction--although no clinical evidence of ductal obstruction was found. Necroinflammatory changes included spotty necrosis suggesting hepatitis of diverse etiologies (including viral infection and drug reaction) and chronic portal inflammation suggestive of chronic active hepatitis. Vascular changes consisted of sinusoidal dilatation (14 cases) and nodular regenerative hyperplasia (9 cases). In 6% of the patients, the only changes in the biopsy were those of granulomatous inflammation; each of these patients had a dominant mass ("sarcoidoma"), which had been biopsied to rule out tumor. Fibrosis was seen in 21% of the biopsies--periportal (13%), bridging (2%), or cirrhosis (6%). It is clear that sarcoidosis can cause progressive liver disease with a wide array of histologic features that can mimic those of other primary liver diseases.