Biological therapy for ulcerative colitis

Ulcerative colitis (UC) is a major form of inflammatory bowel disease (IBD) worldwide. Better understanding of the pathogenesis of UC has led to the development of novel therapeutic agents that target specific mediators of the inflammatory cascade. A number of biological agents have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of UC and several more are currently in various phases of drug development. The commonly used agents include TNFα antagonists (e.g. infliximab, adalimumab, and golimumab) and anti-integrin agents (vedolizumab). These biological agents have profoundly influenced the management of UC patients, especially those with refractory disease. This paper reviews the currently available knowledge and evidence for the use of various biological agents in the treatment of UC.

Achalasia: current therapeutic options

Achalasia is a chronic incurable esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and loss of esophageal peristalsis. Although rare, it is currently the most common primary esophageal motility disorder, with an annual incidence of around 1.6 per 100,000 persons and prevalence of around 10.8/100,000 persons. Symptoms of achalasia include dysphagia to both solids and liquids, regurgitation, aspiration, chest pain and weight loss. As the underlying etiology of achalasia remains unclear, there is currently no curative treatment for achalasia. Management of achalasia mainly involves improving the esophageal outflow in order to provide symptomatic relief to patients. The most effective treatment options for achalasia include pneumatic dilation, Heller myotomy and peroral endoscopic myotomy (POEM), with the latter increasingly emerging as the treatment of choice for many patients. This review focusses on evidence for current and emerging treatment options for achalasia with a particular emphasis on POEM.

Clcn5 knockout mice exhibit novel immunomodulatory effects and are more susceptible to dextran sulfate sodium-induced colitis

Although the intracellular Cl(-)/H(+) exchanger Clc-5 is expressed in apical intestinal endocytic compartments, its pathophysiological role in the gastrointestinal tract is unknown. In light of recent findings that CLC-5 is downregulated in active ulcerative colitis (UC), we tested the hypothesis that loss of CLC-5 modulates the immune response, thereby inducing susceptibility to UC. Acute dextran sulfate sodium (DSS) colitis was induced in Clcn5 knockout (KO) and wild-type (WT) mice. Colitis, monitored by disease activity index, histological activity index, and myeloperoxidase activity were significantly elevated in DSS-induced Clcn5 KO mice compared with those in WT mice. Comprehensive serum multiplex cytokine profiling demonstrated a heightened Th1-Th17 profile (increased TNF-alpha, IL-6, and IL-17) in DSS-induced Clcn5 KO mice compared with that in WT DSS colitis mice. Interestingly, Clcn5 KO mice maintained on a high vitamin D diet attenuated DSS-induced colitis. Immunofluorescence and Western blot analyses of colonic mucosa validated the systemic cytokine patterns and further revealed enhanced activation of the NF-kappaB pathway in DSS-induced Clcn5 KO mice compared with those in WT mice. Intriguingly, high baseline levels of IL-6 and phospho-IkappaB were observed in Clcn5 KO mice, suggesting a novel immunopathogenic role for the functional defects that result from the loss of Clc-5. Our studies demonstrate that the loss of Clc-5 1) exhibits IL-6-mediated immunopathogenesis, 2) significantly exacerbated DSS-induced colitis, which is influenced by dietary factors, including vitamin D, and 3) portrays distinct NF-kappaB-modulated Th1-Th17 immune dysregulation, implying a role for CLC-5 in the immunopathogenesis of UC.

Role of wireless motility capsule in the assessment and management of gastrointestinal dysmotility in patients with diabetes mellitus

BACKGROUND

Gastrointestinal (GI) dysmotility is common in diabetic patients. Wireless Motility Capsule (WMC) provides the transit profile of the entire GI tract in a single study. Factors affecting GI dysmotility and utility of WMC study are not clearly established in diabetic patients. Our aims were to study the pattern of GI dysmotility using WMC and evaluate the effect of glycemic control and presence of diabetic microvascular complications on motility impairment in diabetic patients. We also assessed the impact of WMC findings on clinical management.

METHODS

Retrospective chart review of all diabetic patients who underwent WMC testing at our institution from 2010 to 2015 was performed. Demographics, hemoglobinA1c levels, microvascular complications, and WMC findings were obtained. Impact of WMC on clinical management was assessed.

KEY RESULTS

A total of 100 patients were included. Mean age was 45±19 years and 76% were female. Seventy-two percentage had abnormal WMC testing, of which 29 (40%) had multiregional dysmotility. There were no significant differences in demographics, diabetic microvascular complications or hemoglobinA1c levels among patients with normal and abnormal WMC testing or among patients with isolated vs multiregional dysmotility. Information about subsequent clinical management was available for 47 patients. WMC testing was abnormal in 33 (70%) patients and treatment changes based on WMC results were made in 24 patients (73%).

CONCLUSIONS & INFERENCES

There was no association between hemoglobinA1c levels, microvascular complications and pattern of GI dysmotility in diabetic patients undergoing WMC. WMC testing lead to management changes in approximately 75% of diabetic patients with GI dysmotility.

Risk factors and clinical implication of superimposed Campylobacter jejuni infection in patients with underlying ulcerative colitis

Background and aims: Superimposed Campylobacter jejuni infection (CJI) has been described in patients with ulcerative colitis (UC). Its risk factors and impact on the disease course of UC are not known. Our aims were to evaluate the risk factors for CJI in UC patients and the impact of the bacterial infection on outcomes of UC.

Methods: Out of a total of 918 UC patients tested, 21 (2.3%) of patients were found to be positive for CJI (the study group). The control group comprised 84 age-matched UC patients who had tested negative for CJI. Risk factors for CJI and UC-related outcomes at 1 year after diagnosis of CJI were compared between the two groups.

Results: Ten patients (47.6%) with CJI required hospital admission at the time of diagnosis, including eight for the management of “UC flare”. Treatment with antibiotics resulted in improvement in symptoms in 13 patients (61.9%). On multivariate analysis, hospital admission in the preceding year was found to be an independent risk factor for CJI [odds ratio (OR): 3.9; 95% confidence interval (CI): 1.1–14.1] and there was a trend for chronic liver disease as a strong risk factor (OR: 5.0; 95% CI: 0.9–28.3). At 1-year follow up, there was a trend for higher rates of UC-related colectomy (28.8% vs. 14.3%; P = 0.11), and mortality (9.5% vs. 1.2%; P = 0.096) in the study group.

Conclusion: Recent hospitalization within 1 year was found to be associated with increased risk for CJI in UC patients. There was a trend for worse clinical outcomes of UC with in patients with superimposed CJI, which was frequently associated with UC flare requiring hospital admission.

Risk factors for Barrett's esophagus

Barrett's esophagus (BE) is a well-recognized precursor of esophageal adenocarcinoma (EAC) and is defined as ≥1 cm segment of salmon-colored mucosa extending above the gastroesophageal junction into the tubular esophagus with biopsy confirmation of metaplastic replacement of the normal squamous epithelium by intestinal-type columnar epithelium. The incidence of both BE and EAC has been increasing over the past few decades. As a result, preventing the development of BE by identifying and understanding its modifiable and non-modifiable risk factors may help reduce the incidence of EAC. Over the recent past, a tremendous amount of progress has been made towards improving our knowledge of risk factors and pathogenesis of BE. This article reviews the evidence for the various risk factors for developing BE.

Ohio solid organ transplantation consortium criteria for liver transplantation in patients with alcoholic liver disease

AIM

To evaluate risk of recidivism on a case-by-case basis.

METHODS

From our center’s liver transplant program, we selected patients with alcoholic liver disease who were listed for transplant based on Ohio Solid Organ Transplantation Consortium (OSOTC) exception criteria. They were considered to have either a low or medium risk of recidivism, and had at least one or three or more months of abstinence, respectively. They were matched based on gender, age, and Model for End-Stage Liver Disease (MELD) score to controls with alcohol-induced cirrhosis from Organ Procurement and Transplant Network data.

RESULTS

Thirty six patients with alcoholic liver disease were approved for listing based on OSOTC exception criteria and were matched to 72 controls. Nineteen patients (53%) with a median [Inter-quartile range (IQR)] MELD score of 24 (13) received transplant and were followed for a median of 3.4 years. They were matched to 38 controls with a median (IQR) MELD score of 25 (9). At one and five years, cumulative survival rates (± standard error) were 90% ± 7% and 92% ± 5% and 73% ± 12% and 77% ± 8% in patients and controls, respectively (Log-rank test, P = 0.837). Four (21%) patients resumed drinking by last follow-up visit.

CONCLUSION

Compared to traditional criteria for assessment of risk of recidivism, a careful selection process with more flexibility to evaluate eligibility on a case-by-case basis can lead to similar survival rates after transplantation.

Frequency, Timing, and Types of Medication Ordering Errors Made by Residents in the Electronic Medical Records Era

OBJECTIVES

To describe associations between resident level of training, timing of medication orders, and the types of inpatient medication ordering errors made by internal medicine residents.

METHODS

This study reviewed all inpatient medication orders placed by internal medicine residents at a tertiary care academic medical center from July 2011 to June 2015. Medication order errors were measured by pharmacists' reporting of an error via the electronic medical record during real-time surveillance of orders. Multivariable regression models were constructed to assess associations between resident training level (postgraduate year [PGY]), medication order timing (time of day and month of year), and rates of medication ordering errors.

RESULTS

Of 1,772,462 medication orders placed by 335 residents, 68,545 (3.9%) triggered a pharmacist intervention in the electronic medical record. Overall and for each PGY level, renal dose monitoring/adjustment was the most common order error (40%). Ordering errors were less frequent during the night and transition periods versus daytime (adjusted odds ratio [aOR] 0.93, 95% confidence interval [CI] 0.91-0.96, and aOR 0.93, 95% CI 0.90-0.95, respectively). Errors were more common in July and August compared with other months (aOR 1.05, 95% CI 1.01-1.09). Compared with PGY2 residents, both PGY1 (aOR 1.06, 95% CI 1.03-1.10), and PGY3 residents (aOR 1.07, 95% CI, 1.03-1.10) were more likely to make medication ordering errors. Throughout the course of the academic year, the odds of a medication ordering error decreased by 16% (aOR 0.84, 95% CI 0.80-0.89).

CONCLUSIONS

Despite electronic medical records, medication ordering errors by trainees remain common. Additional supervision and resident education regarding medication orders may be necessary.

Non-surgical porto-mesenteric vein thrombosis is associated with worse long-term outcomes in inflammatory bowel diseases

Objective: Our aim was to assess the risk factors for non-surgery-related portal and mesenteric vein thrombosis (PMVT) and its impact on the outcomes of inflammatory bowel diseases (IBD).

Methods: All patients with a concurrent diagnosis of IBD and PMVT between January 2004 and October 2013 were identified from the electronic medical record (study group; n = 20). Patients were matched for age, sex, and IBD phenotype with control IBD patients who had no PMVT, with a ratio of 1:3 (control group; n = 60). Risk factors for PMVT and IBD-related outcomes at one year after diagnosis of PMVT were compared between the two groups.

Results: Of the 20 patients in the Study group, 6 (30%) had UC, 14 (70%) had CD and 11 (55%) were male. On multivariable analysis, inpatient status (odds ratio [OR] 6.88; 95% confidence interval [CI] 1.88–25.12) and baseline corticosteroid use (OR 4.39; 95% CI 1.27–15.19) were found to be independent risk factors for the development of PMVT. At one-year follow-up, PMVT patients were more likely to have an adverse outcome of IBD, including subsequent emergency room visit (26.3% vs. 1.7%; P = 0.003), hospitalization for medical management (60.0% vs. 20.0%; P = 0.001) or IBD-related surgery (65.0% vs. 26.7%; P = 0.003) than the non-PMVT controls. In multivariable analysis, PMVT (OR 5.19; 95% CI 1.07–25.28) and inpatient status (OR 8.92; 95% CI 1.33–59.84) were found to be independent risk factors for poor outcome, whereas baseline immunomodulator use (OR 0.07; 95% CI 0.01–0.51) was found to be a protective factor.

Conclusions: IBD patients who were inpatients or receiving corticosteroid therapy had an increased risk of the development of PMVT. The presence of PMVT was associated with poor clinical outcomes in IBD.

Influence of body mass index on the prevalence and progression of dysplasia in Barrett's esophagus: a retrospective analysis (.)

OBJECTIVE

High body mass index (BMI) is a risk factor for Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). Our aim was to determine if prevalence of dysplasia in BE varies by BMI and study the effect of BMI on progression to high-grade dysplasia (HGD) or EAC.

MATERIALS AND METHODS

This is a retrospective review of patients with endoscopic evidence of BE confirmed by presence of intestinal metaplasia on histology from January 2000 to December 2012 at Cleveland Clinic. Patient demographics, BMI and endoscopic findings such as length of BE, dysplasia in BE and size of hiatal hernia were reviewed. Dysplasia was classified as no dysplasia (NDBE), low-grade dysplasia (LGD), HGD and EAC.

RESULTS

In this cohort of 1239 patients, average BMI was 29.8 ± 6 kg/m(2). There were 228 (18.4%) in group with BMI <25, 236 (19%) in BMI group 25-27.4, 262 (21.1%) in BMI 27.5-29.9, 303 (24.5%) in BMI 30-34.9, 126 (10.2%) in BMI 35-39.9 and 86 (6.8%) in BMI ≥40. Lower BMI groups had lower prevalence of dysplasia while higher BMI groups had higher prevalence of dysplasia (p = 0.002). During mean follow up of 31.6 ± 26 months, there were 14 cases of HGD/EAC in NDBE group and 29 cases of HGD/EAC in LGD group. BMI or BMI change was not associated with progression to HGD/EAC in NDBE.

CONCLUSIONS

High BMI was associated with higher prevalence of dysplasia in BE. But once in a surveillance program, higher BMI is not associated with progression of dysplasia in NDBE.

Esophageal dysmotility and other preoperative factors associated with acid suppressive therapy after fundoplication

Background and aims: Acid suppressive therapy (AST) is frequently used after fundoplication. Prior studies show that most patients requiring AST after fundoplication have normal esophageal acid exposure and therefore do not need AST. Our aim was to determine the indications for AST use following fundoplication and the associated factors.Methods: Retrospective analysis of patients who underwent fundoplication at our institution between 2006 and 2013 with pre and postoperative esophageal physiologic studies was performed. Demographic data, symptoms, and findings on high resolution manometry, esophageal pH monitoring and upper endoscopy were collected.Results: Three hundred and thirty-nine patients were included with a median follow up time of 12.8[2.6, 47.7] months. Mean age was 59.6 ± 13.3 years and 71.4% were women. Of those, 39.5% went on AST following fundoplication with a median time to AST use of 15.7[2.8, 36.1] months. The most common reason for AST use was heartburn. Only 29% of patients had objective evidence of acid reflux. Preoperative factors associated with AST use following fundoplication were male gender (HR1.6, p = 0.019), esophageal dysmotility (HR1.7, p = 0.004), proton pump inhibitor use (HR2.3, p < 0.001) and prior history of fundoplication (HR1.8, p = 0.006). In those with paraesophageal hernia repair with Collis gastroplasty (N = 182), esophageal dysmotility (HR1.7, p = 0.047) and NSAID use (HR1.9, p = 0.023) were associated with AST use postoperatively.Discussion: AST use is common after fundoplication. Male gender, preoperative esophageal dysmotility, proton pump inhibitor use and redo fundoplication were associated with AST use following fundoplication. In those undergoing combined Collis gastroplasty, preoperative NSAID use and esophageal dysmotility predicted AST use.

Cannonball Metastatic Lesions in a Young Male: A Case Report

Testicular germ cell tumors are the most common malignancy among young men. These are highly chemo-sensitive tumors with high cure rates. More than 95% of patients with testicular cancer present with a painless testicular mass. Here we describe a rare initial presentation of testicular cancer in a previously asymptomatic 22-year-old male who presented with widespread metastatic cannonball lesions in his lungs.

The case of self-resolving type III achalasia after bilateral lung transplant

BACKGROUND

Post-surgical achalasia has been previously described in large case series but there are limited data on the natural progression of the disease process. In general, achalasia is considered an "incurable" disease as per published guidelines. We present here, the first report of a patient with post-surgical achalasia which resolved spontaneously.

METHODS

This is a retrospective chart review.

KEY RESULTS

A 60-year-old male presented for dysphagia 3 months status post-bilateral lung transplant and was diagnosed with achalasia following positive manometry. Absent any treatment, his repeat manometry showed complete, spontaneous resolution of the achalasia 2 years following lung transplant.

CONCLUSIONS & INFERENCES

To our knowledge, this is the first such case of spontaneously resolving achalasia following bilateral lung transplant. This case warrants further study in to the natural progression of post-surgical achalasia.

Low-carbon footprint diluents in solvent extraction for lithium-ion battery recycling

This study investigated the influence of the diluent on the extraction properties of three extractants towards cobalt(ii), nickel(ii), manganese(ii), copper(ii), and lithium(i), i.e. Cyanex® 272 (bis-(2,4,4-trimethylpentyl)phosphinic acid), DEHPA (bis-(2-ethyl hexyl)phosphoric acid), and Acorga® M5640 (alkylsalicylaldehyde oxime). The diluents used in the formulation of the extraction solvents are (i) low-odour aliphatic kerosene produced from the petroleum industry (ELIXORE 180, ELIXORE 230, ELIXORE 205 and ISANE IP 175) and (ii) bio-sourced aliphatic diluents (DEV 2138, DEV 2139, DEV 1763, DEV 2160, DEV 2161 and DEV 2063). No influence of the diluent and no co-extraction of lithium(i), nickel(ii), cobalt(ii), manganese(ii) and aluminum were observed during copper(ii) extraction by Acorga M5640. The nature of the diluent influenced more significantly the extraction properties of manganese(ii) by DEHPA as well as cobalt(ii) and nickel(ii) by Cyanex® 272. Life cycle assessment of the diluents shows that the carbon footprints of the investigated diluents followed the following order: (ELIXORE 180, ELIXORE 230, ELIXORE 205) from petroleum industry > kerosene from petroleum industry > diluent produced from tall oil (DEV 2063) > diluents produced from recycled plastic (DEV 2160, DEV 2161) > diluents produced from used cooking oil (DEV 2138, DEV 2139). By taking into account the physicochemical properties of these diluents (viscosity, flashpoint, aromatic content), the extraction properties of Acorga® M5640, DEHPA, Cyanex® 272 in these diluents and the CO2 footprint of the diluents, this study showed DEV2063 and DEV2139 were the best diluents. A low-carbon footprint solvent extraction flowsheet using these diluents was proposed to extract selectively cobalt, nickel, manganese, lithium and copper from NMC black mass of spent lithium-ion batteries.