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Conferences and Medical Updates

Medical updates from one note

Friday, November 2, 2018
1:12 PM

Pancreatic insufficiency
Tuesday, August 18, 2015

The gold standard is quantification of the coefficient of fat absorption (CFA); this requires patients to maintain a strict 5-day diet containing 100 g of fat/day and collection of all faeces produced over the last 3 days for faecal fat quantification.”
Despite most patients with CP and [EPI] having vitamin D deficiency, it is not a useful marker of [EPI] due to the high prevalence of this deficiency in the general population, at least in northern countries,” and “[p]lasma proteins may also be useful for the diagnosis of [EPI], with evidence suggesting that lower RBP is a marker for [EPI], at least in patients with CP.”. Retinol binding protein
[EPI] may have a deficiency in a particular parameter, any nutritional evaluation for [EPI] should comprise multiple nutritional markers, and include at least circulating levels of fat soluble vitamins (preferably vitamin E), prealbumin, RBP, zinc and magnesium.”

Friday, November 2, 2018
1:15 PM

Concussion test
Wednesday, February 14, 2018
3:44 PM

The Brain Trauma Indicator measures levels of two proteins — ubiquitin C-terminal hydrolase and glial fibrillary acidic protein — that are released from the brain into blood and measured within 12 hours of head injury.

Resistant asthma
Friday, January 26, 2018
4:45 PM

LFT hepatitis or cholestasis
Tuesday, February 6, 2018
9:21 PM

R ratio is ALT/ULN ALT divided by alk phos /ULN alk phos

More than 5 hepatitis, less than 2 cholestasis and 2-5 mixed

For example, examination of the local reference laboratory ranges for ALT used by the Nonalcoholic Steatohepatitis (NASH) Clinical Research Network demonstrated significant differences (range, 35-79 IU/L for men and 31-55 IU/L for women).[7] These wide ranges appeared to be due to the different reference populations used by each laboratory to establish the normal range; inclusion of data from these disparate local populations may not have taken such variables as body mass index into consideration.[2,7]
The authors of this guideline cite several studies that have proposed a standardized ULN for ALT based on prospectively acquired data using various methodologies.[2] They conclude that a normal ALT level in prospectively studied populations without identifiable risk factors for liver disease ranges from 29 to 33 IU/L for males and from 19 to 25 IU/L for females. They recommend that levels above this range should trigger an assessment. The authors emphasize that using a significantly lower ULN for ALT will have implications by defining many more patients as having abnormal ALT levels.[2]
Appropriate, age-specific ALT threshold values have also been established for the diagnosis of liver disease in children. Schwimmer and colleagues[8]reported sex-specific, biology-based, pediatric thresholds. The Screening ALT for Elevation in Today’s Youth (SAFETY) study collected observational data from acute care children’s hospitals, the NHANES (1999-2006), overweight children with and without nonalcoholic fatty liver disease (NAFLD), and children with chronic hepatitis. The 95th percentile ALT levels in pediatric NHANES participants who were of healthy weight, metabolically normal, and free of liver disease were 25.8 U/L for boys and 22.1 U/L for girls.

Asymptomatic IBD
Tuesday, February 6, 2018
9:37 PM

Most recently, a 2017 retrospective analysis of more than 31,000 screening colonoscopies performed in Spain after positive fecal immunochemical testing (FIT) during 2009-2014 reported new incidental IBD diagnoses in 0.35% of asymptomatic screened individuals.

Fructan food
Friday, January 26, 2018
4:43 PM


Types of Diabetes
Friday, March 2, 2018
8:37 AM

SAID – Severe autoimmune diabetes, usually GAD positive
SIDD – Severe insulin deficient diabetes, GAD neg
SIRD – Severe insulin resistant diabetes , benefit most by metform, elevated HOMA2-IR index
MORD- mild obesity related diabetes,
MARD- mild age related diabetes
Published in Lancet Diabetes and endocrinology

Liquid biopsy
Friday, March 2, 2018
8:40 AM

New blood test developed by Hopkins

CancerSEEK – it detects certain proteins and circulating tumor DNA ctDNA. Detects multiple types of cancers in the blood. Details being worked out. Keep an eye on it

Veno occlusive disease medication
Friday, January 26, 2018
4:43 PM

Thursday, June 22, 2017
10:17 PM


T2D 4 class of meds
Sunday, June 25, 2017
4:26 PM

Two types of incretin. GIP & GLP1
GLP 1 stimulates insulin release and inhibits glucagon
GLP1 agonist, first found in gila lizard monster saliva can be human / Synthetic. Byetta or victoza Liraglutide)
GLP 1 is destroyed by DPP 4 dipeptidyl peptidase. There are currently 4 DPP 4 antagonist. Linagliptin sitagliptin can be used in cardiac patients


SGTL drugs Dapagliflozin increases hb by acting on hepcidin


Starting dose of insulin – 0. 1 to 0.2 U /kg/day. If hba1c more than 8 0.2-0.3 u/Kg /day

Most events of hypoglycemia with NPH AND Morning BS variability

Most stable in that regard is insulin degludec and insulin glargine U300 ( more than 24 hour half life). Adjust dose every 4-5 days based on BS with 20 % increase

Intermediate stability insulin glargine U100, insulin detemir. Adjust ever 2-3 days with 20% dose change

Insulin is atherogenic but glargine shown NOT to increase cardiovascular mortality

NPH to other insulin conversion is 80% dose

Target Hba1c 6-8. Tighter control leads to higher risk of hypoglycemia which increases cathecholamines and higher chance of cardiovascular mortality

CHF nsaid mineralocorticoid receptor antagonist
Thursday, September 3, 2015

LONDON — The investigational non-steroidal mineralcorticoid receptor antagonist finerenone worked as well as eplerenone (Inspra) with a possible mortality advantage over the older drug in heart failure, the phase II ARTS-HF trial suggested.
Reductions in NT-proBNP of more than 30% from baseline to day 90, the study’s primary endpoint, occurred in 37.2% of eplerenone-treated patients compared with 30.9% to 38.8% of finerenone-treated patients across doses tested (P not significant), Gerasimos Filippatos, MD, of Athens University Hospital Attikon in Greece, and colleagues found.

Nausea medicine
Thursday, September 3, 2015

The U.S. Food and Drug Administration approved Tesaro Inc’s oral drug rolapitant (Varubi) for treatment for chemotherapy-induced nausea and vomiting in adults, the company said on Wednesday.

ORBIT bleeding risk
Friday, September 11, 2015

ESD Solutions
Saturday, September 12, 2015

Voluven hydroxyl ethyl starch
Glycerin solution – 10 % glycerol plus 5 % fructose mixed in normal saline – indigo carmine
Methyl cellulose – hydroxyl propyl methyl cellulose

You can take solid indigo carmine and make solution
Methylene blue is ok. 5 drops in 250 cc bag

Coaggraaper with soft coag.

Ovesco clip

Sergey : 6% hetastarch in 0.9% saline with 1-2 cc methylene blue

Saturday, September 12, 2015

HCV type 3
Monday, September 14, 2015

DM Type 1 prevention
Monday, September 14, 2015

Adrenal adenoma
Tuesday, September 15, 2015
4:54 PM

The recommended workup for an adrenal incidentaloma is

Hormonal evaluation . The evaluation in apparently asymptomatic patients has been debated. Even in asymptomatic patients, the European Network for the Study of Adrenal Tumors (ENSAT) recommends performing the following tests to determine the secretory activity of the tumor: fasting blood glucose, serum potassium, cortisol, corticotropin (ACTH), 24-hour urinary free cortisol, fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasone at bedtime, adrenal androgens (dehydroepiandrosterone-sulfate [DHEA-S], androstenedione, testosterone, 17-OH progesterone), and serum estradiol in men and postmenopausal women [76].

Adrenal carcinomas are typically inefficient steroid producers, but they secrete excessive amounts of adrenal steroid precursors due to decreased expression of several steroidogenic enzymes (which also results in diminished cortisol production). Even in patients with adrenal carcinomas who presumably did not produce excess steroids, more sensitive methods such as gas chromatography/mass spectrometry identify increased urinary metabolites of several steroids and precursors of androgens (pregnenediol, pregnenetriol, androsterone, etiocholanolone) or glucocorticoids (17-hydroxyproesterone, tetrahydro-11-deoxycortisol, cortisol, 6-hydroxy-cortisol, tetrahydrocortisol, and a-cortol); this is different from cortisol secreting adenomas which produce cortisol, but little androgens [77]. Low serum aldosterone concentrations, but normal or high serum or urinary concentrations of aldosterone precursors (ie, deoxycorticosterone, 18-hydroxydeoxycorticosterone, corticosterone, and 18-hydroxycorticosterone, tetrahydro-11-deoxycorticosterone (THDOC), and 5 alpha-THDOC) are found in most adrenal carcinomas, but not in adrenal adenomas [77,78].

The European Network for the Study of Adrenal Tumors (ENSAT) also recommends that plasma metanephrines or urinary metanephrines and catecholamines be obtained in all patients to exclude pheochromocytoma, and that plasma aldosterone and renin be obtained in patients with hypertension and/or hypokalemia (see “Establishing the cause of Cushing’s syndrome” and “Adrenal hyperandrogenism” and “Pathophysiology and clinical features of primary aldosteronism” and “The adrenal incidentaloma”). Hormonal evaluation may help in establishing the adrenal origin of the tumor and provide tumor markers that can be useful during follow-up to estimate the presence of residual tumor or tumor recurrence after surgery.

Friday, September 25, 2015

Naloxegol – 25 mg
GFR > 60, cyp34a, can cross bbb
Contraindicated with biaxin, ketoconazole

Lynch syndrome
Wednesday, September 30, 2015
12:05 PM

MLH1, MSH2, MSH6, PMS2 testing – 95% sensitive
If MLH1 def, BRAF and MLH1 promoter sequence hypermethylation studies. If either is positive no further studies needed
If PMS2, MSH2, MSH6 def pt or MLH1 def patients with neg BRAF and hypermethylation, germline genetic testing is done.

Ibd testing
Wednesday, September 30, 2015

Fecal calprotectin

Saturday, October 10, 2015

Make a Super Hidden Folder in Windows Without any Extra Software
Almost anyone knows how to make a “hidden” folder in Windows, but then again almost anyone knows how to make explorer show hidden folders. Let’s take a look at how to make a folder so hidden, only you will know its there. Anyone that has used Windows for a while knows that they can right-click on a file or folder and edit its properties, more so its attributes to make it a so called “hidden” file or folder. The problem is that just as many people know you can show files and folders that have the “hidden” attribute by simply changing a radio button under the folder view options. The easiest way to make a real hidden file or folder is to mark it as an important operating system file, that way Windows wont display it even if explorer is set to display hidden files and folders…

Sunday, October 11, 2015


Sunday, October 11, 2015


Sunday, October 11, 2015


Potassium sparing drug
Wednesday, October 21, 2015

The approval of patiromer for oral suspension (Veltassa, Relypsa) comes after the phase-2 AMETHYST-DN study showed that daily administration of the potassium-binding agent safely controlled hyperkalemia over 1 year in patients with type-2 diabetes and hypertension with or without heart failure (HF). They had entered with mild-to-moderate hyperkalemia secondary to treatment with renin-angiotensin-aldosterone system (RAAS)-inhibiting drugs.

• Veltassa treats “hyperkalemia”, which is a target population conservatively ten times the size of Renvela’s “hyperphosphatemia” population.
• ZS-9 has multiple characteristics which make drug interactions very likely, but even if proven otherwise Veltassa still appears best in class.

Meat and cancer
Monday, October 26, 2015

Wednesday, November 4, 2015

Sarcina ventriculi gastroparesis

Thursday, November 5, 2015


Dr Aihara. Boston

IT 2 – 3 or 9 to 6

Dual – 6 to 3

Two types of dual. Smaller one for colon. 1.5 mm

Gastric is 2.0

Thursday, November 5, 2015

Bleeding in rectum
Hemostatic sponge for rectum
Forced coag for bleeding
Marking soft coag
Coag- use ef 5 80w for gastric ESD
Ef 5 50w for colon
Hetastarch 500 ml 1 mg methylene blue and 5 of epinephrine 1:100,000
Gonak 45ml+ saline 50ml

Renal failure
Thursday, November 5, 2015

Make room, cholesterol. A new disease marker is entering the medical lexicon: suPAR, or soluble urokinase-type plasminogen activator receptor. A study in the New England Journal of Medicine shows that suPAR, a circulating protein measured by a simple blood test, can reliably predict a person’s chances of developing chronic kidney disease as much as five years before this common killer starts causing damage.

The New England Journal of Medicine article appears in Online First, November 5, 2015 to coincide with the American Society of Nephrology’s Kidney Week meeting. It will also appear in the printed issue of the journal on November 12.

Monday, November 9, 2015

Cardiac DAPT
Wednesday, November 11, 2015

The number needed to treat to prevent a heart attack for patients with a DAPT score of 2 or higher is 34 and the number needed to harm (to cause bleeding) is 272, Yeh said. When the score is less than 2, the number needed to treat to prevent ischemia is 153 and the number needed to harm is 64.
The DAPT Score ranges from -2 to 10 and is made up of the following factors:
• Age
• Diabetes status
• Smoking status
• PCI or MI history
• Presence of chronic heart failure or LVEF < 30%
• Index procedural characteristics: MI at presentation, vein-graft PCI, and stent diameter

Saturday, November 14, 2015
8:27 AM

For example, in patients who have a low pretest probability of PE, the so-called PERC (Pulmonary Embolism Rule-Out Criteria) algorithm should be applied. Those patients who meet all eight PERC items should not undergo either imaging or plasma D-dimer tests.
Instead, the ACP now recommends clinicians should take the following steps, depending on a patient’s pretest probability of PE:
• Obtain a high-sensitivity D-dimer measurement as the initial test only if the patient has an intermediate pretest probability of PE, or else a low pretest probability without meeting all of the PERC criteria. Avoid imaging as the initial test in patients with a low or intermediate probability of PE.
• Since normal D-dimer levels increase with age, use age-adjusted D-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 to determine whether imaging is appropriate.
• Do not order imaging studies in patients with a low age-adjusted D-dimer level.
• Do not order D-dimer testing for patients with a high pretest probability of PE; instead, order computed tomography pulmonary angiography (CTPA) while reserving ventilation-perfusion scans for situations in which CTPA is contraindicated or unavailable.

• Scoring System
• Revised Geneva Scoring System
• Simplified Revised Geneva Score
• Gestalt
• Show All
Modified Wells Scoring System
The AAFP/ACP guideline advocates use of the Modified Wells prediction rule for the above-specified estimation and interpretation requirements (see Table 1, below). However, the guideline notes that the Wells rule performs better in younger patients without comorbidities or a history of venous thromboembolism. Current evidence also suggests this tool is effective in pregnant patients.[8]
Moreover, the objective components of the Wells (Canadian Pulmonary Embolism Score) criteria have been shown to have little effect on the stratification power of the criteria; virtually all of the classification power is associated with a physician’s subjective prejudgment of the likelihood of pulmonary embolism.
Table 1. Modified Wells Prediction Rule for Diagnosing Pulmonary Embolism: Clinical Evaluation Table for Predicting Pretest Probability of Pulmonary Embolism* (Open Table in a new window)
Clinical Characteristic Score
Previous pulmonary embolism or deep vein thrombosis + 1.5
Heart rate >100 beats per minute + 1.5
Recent surgery or immobilization (within the last 30 d) + 1.5
Clinical signs of deep vein thrombosis + 3
Alternative diagnosis less likely than pulmonary embolism + 3
Hemoptysis + 1
Cancer (treated within the last 6 mo) + 1
Clinical Probability of Pulmonary Embolism Score
Low 0-1
Intermediate 2-6
High ≥6
*Reprinted from Am J Med, Vol. 113, Chagnon I, Bounameaux H, Aujesky D, et al, Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism, pp 269-75, Copyright 2002.
Next Section: Revised Geneva Scoring System

Sunday, November 15, 2015

SAN FRANCISCO — Eight weeks of therapy with grazoprevir and elbasvir may be effective in patients with low fibrosis scores, according to findings presented at The Liver Meeting 2015.

Saturday, November 21, 2015

Tedizolid phosphate is a second-generation oxazolidinone antibiotic that offers enhanced antimicrobial potency and low rates of bacterial resistance.[13-15] Available in both IV and oral forms, tedizolid exhibits bacteriostatic activity by binding the 50S subunit of the bacterial ribosome, resulting in inhibition of bacterial protein synthesis.[11,13-15] The recommended dosage is 200 mg once daily for 6 days,[6,7,14,16] which may offer increased convenience and compliance when compared to twice daily linezolid.

New Antibiotics in the Management of Acute Bacterial Skin and Skin Structure Infections

Dalbavancin is a long-acting IV semisynthetic lipoglycopeptide antibiotic with bactericidal activity against gram-positive cocci, including MRSA.[6-10] It is the first US FDA approved drug for adults with ABSSSIs that requires only 2 IV doses administered 1 week apart: the first dose is 1000 mg IV infused over 30 minutes, followed 1 week later by the second dose of 500 mg IV.[6-10]

Blood transfusion
Saturday, November 21, 2015


[ from “THE CLINICAL — USE OF BLOOD: HAND BOOK , World Health Organization & Blood Transfusion Safety , GENEVA ]

✔️Prefer a larger cannula: A doubling of the diameter of the cannula increases the flow rate of most fluids by a factor of 16.

✔️In case of Whole blood, red cells, plasma and cryoprecipitate

Use a new, sterile blood administration set containing an integral 170–200 micron filter

Change the set at least 12-hourly during blood component infusion
In a very warm climate, change the set more frequently and usually after every four units of blood, if given within a 12-hour period

✔In case of Platelet concentrates

Use a fresh blood administration set or platelet transfusion set, primed with saline.


There is no evidence that warming blood is beneficial to the patient when infusion is slow.

At infusion rates greater than 100 ml/minute, cold blood may be a contributing factor in cardiac arrest. However, keeping the patient warm is probably more important than warming the infused blood.

Warmed blood is most commonly required in: [1]Large volume rapid transfusions:
-Adults: greater than 50 ml/kg/hour -Children: greater than 15 ml/kg/hour
[2]Exchange transfusion in infants [3]Patients with clinically significant cold agglutinins.

Blood SHOULD ONLY BE WARMED in a blood warmer. Blood warmers should have a visible thermometer and an audible warning alarm and should be properly maintained.

Blood should never be warmed in a bowl of hot water as this could lead to haemolysis of the red cells which could be life-threatening.

✔️Severe reactions most commonly present during the first 15 minutes of a transfusion. All patients and, in particular, unconscious patients should be monitored during this period and for the first 15 minutes of each subsequent unit.

✔️The transfusion of each unit of the blood or blood component should be completed within four hours of the pack being punctured. If a unit is not completed within four hours, discontinue its use and dispose of the remainder through the clinical waste system.

Saturday, November 21, 2015

Tenofovir Prevents HBV Transmission in Pregnancy

Saturday, November 21, 2015

LEAN trial: Victoza effective in resolving NASH

SPRINT trial
Sunday, November 22, 2015

hat said, he pointed out that in patients without chronic kidney disease (CKD) at baseline, there was a decline of at least 30% in estimated GFR in 1.21% of the intensive-therapy group per year vs 0.35% of the standard-therapy group (P<0.0001). “This could be due to the well-known renal hemodynamic reactions of more ARBs or more ACE inhibitors at higher doses. But still, that seems rather a large number.” Also, 4.1% vs 2.5% of each respective group had acute kidney injury (AKI). “We don’t know why and really look forward to seeing a more detailed analysis of the renal outcomes,” said Rosendorff. Complementary With ACCORD As reported by heartwire , the >9000-person SPRINT trial of hypertensive patients at increased CV risk showed that targeting systolic blood pressure of less than 120 mm Hg rather than the standard target of less than 140 mm Hg was associated with significantly lower risks of the primary composite end point (MI, ACS, stroke, acute decompensated HF, and CV death), as well as all-cause mortality and CV death.
However, there were also significantly higher rates of hypotension, syncope, and AKI in the intensive-therapy group, which received roughly three antihypertensive medications, vs the standard therapy group, which received an average of two antihypertensives.

Wednesday, November 25, 2015

The cancers that Dr Rehm refers to include those of the oral cavity, pharynx, larynx, esophagus, breast, colon, rectum, gallbladder, and liver.[4] It is also considered probable that alcohol increases the risk for pancreas cancer, although the evidence is inconclusive.[4]
Recent evidence suggests that melanoma, as well as cancers of the stomach, lung, and prostate, may be associated with alcohol consumption, although only with high levels of consumption and to a moderate excess risk.[3] There are also differences of opinion on whether liver cancer should be considered an alcohol-related cancer and whether the risk for colorectal cancer is increased in both sexes or only in men.[5]

Thursday, November 26, 2015
11:19 PM


Friday, November 27, 2015

esophagus patients. There are case reports of proton pump inhibitor induced gastric neuroendocrine tumours and adenocarcinomas as consequences of these effects. In pernicious anemia and chronic gastritis, clinicians should be aware of potential increased risk of gastric neuroendocrine tumour development with chronic proton pump inhibitor use in these patients. Eradication status of Helicobacter pylori prior to commencing long term proton pump inhibitor therapy should be established to reduce the risk of severe atrophic gastritis and development of gastric dysplasia.

  1. AIH review
    Friday, November 27, 2015


Wednesday, December 2, 2015

Sunscreens with DNA repair enzymes might lessen AK progression
At 6 months, improvements in field cancerization and levels of cyclobutane pyrimidine dimers were significantly greater for the sunscreen-plus-enzymes group compared with sunscreen-only patients. … »»

Quinolones cipro
Sunday, December 6, 2015

Fluoroquinolone labeling currently has warnings about the risks for tendonitis, tendon rupture, central nervous system effects, peripheral neuropathy, myasthenia gravis exacerbation, QT prolongation and Torsades de Pointes, phototoxicity, and hypersensitivity. But panel members called for stronger wording, with some suggesting the risks be called out with a black box warning.

Tuesday, December 8, 2015

Cardiac resync therapy with Defibrillator helps morbidity mortality in HF ( CRT-D)

Friday, December 11, 2015

The American Gastroenterological Association (AGA) has announced new guidelines for the management of acute diverticulitis, the first practice guidelines for the disease since 1999, and they appear in the December issue of Gastroenterology.
“The management of acute diverticulitis has undergone meaningful change over the past decade, including a more judicious use of antibiotics and surgery, as well as preliminary and ongoing investigations into medical therapies to decrease symptoms and reduce recurrences,” the AGA noted. “The majority of the evidence currently, however, is of poor quality, and most of our recommendations are therefore conditional.”

Courtesy Wikimedia Commons/Hellerhoff/Creative Commons
The guidelines strongly recommend that patients not use mesalamine after acute uncomplicated diverticulitis, citing “moderate” evidence to this effect and saying that currently available evidence regarding the anti-inflammatory agent often used for ulcerative colitis “does not suggest efficacy in reducing recurrence risk, pain resolution, or need for surgery in this specific population.” All other recommendations, however, are conditional and offer either “low-” or “very low-quality” evidence to support them.
These additional recommendations include the following:
• Antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis.
• Colonoscopy should be performed after resolution of acute uncomplicated diverticulitis in appropriate candidates to exclude the misdiagnosis of a colonic neoplasm, if a high-quality exam of the colon has not been recently performed.
• Patients with a history of diverticulitis should consume a fiber-rich diet or consider fiber supplementation.
• Patients with diverticular disease should consider vigorous physical activity.
The AGA recommendations also advise against certain practices, all with conditional application and either “low-” or “very low-quality” supportive evidence. These are as follows:
• Elective colonic resection should not be done in patients with an initial episode of acute, uncomplicated diverticulitis; the decision to perform elective prophylactic colonic resection in this setting should be individualized.
• Patients with a history of diverticulitis should not be advised to avoid consumption of seeds, nuts, and popcorn.
• Patients with a history of diverticulitis should not be advised to avoid the use of aspirin.
• Patients with a history of diverticulitis should not be advised to avoid the use of nonselective nonsteroidal anti-inflammatory drugs.
• Do not advise the use of mesalamine after acute uncomplicated diverticulitis.
• Do not advise the use of rifaximin after acute uncomplicated diverticulitis.
• Do not advise the use of probiotics after acute uncomplicated diverticulitis.
“Acute diverticulitis is the third most common inpatient gastrointestinal diagnosis in the United States, costing over $2 billion annually, and is a common outpatient and emergency department diagnosis as well,” stated the AGA recommendations, which were developed by the AGA’s Clinical Guidelines Committee and approved by the AGA Institute Governing Board.
The statement notes that the condition “occurs in approximately 4% of patients with diverticulosis, roughly 15% of whom will have complicated disease, defined as an abscess, perforation, fistula or colon obstruction, and 15%-30% will experience recurrence.”
The new guidelines do not address other forms of diverticular disease, including symptomatic uncomplicated diverticular disease, diverticular bleeding, and segmental colitis associated with diverticulosis. It does not address the prevention of incident diverticulitis or the management of complicated disease.
Areas of further research, advises the AGA, should be in identifying patients who will benefit the most from antibiotics, identifying those in whom antibiotics can be withheld safely, identifying risk factors for recurrent diverticulitis, examining the risks of colonoscopy following acute diverticulitis, and taking a closer looks at anti-inflammatory drugs, antibiotics, probiotics, and dietary interventions as viable therapies.

Friday, December 11, 2015

The trial, called UNITI-2, enrolled patients with moderate to severe Crohn’s disease who had failed traditional therapies but were naive to or at least had not failed a tumor necrosis factor (TNF) inhibitor, reported Dr. Brian Feagan, professor of medicine, University of Western Ontario, London. Results of a second and parallel phase III trial with ustekinumab, called UNITI-1, which enrolled TNF inhibitor failures, have not yet been reported.
In UNITI-2, 628 patients were randomized to placebo, 130 mg of ustekinumab in a fixed subcutaneous dose of 130 mg, or a weight-based dose of 6 mg/kg of subcutaneous ustekinumab. Major enrollment criteria, other than failure of a non-TNF inhibitor therapy, included a Crohn’s disease activity index (CDAI) score between 220 and 450. The primary endpoint was a CDAI reduction of at least 100 points at 6 weeks. Clinical remission at 8 weeks, defined as CDAI less than 150, was a secondary endpoint.
The primary endpoint was reached by 28.7% randomized to placebo, 51.7% of those randomized to the fixed dose of ustekinumab, and 55.5% of those randomized to weight-based dosing. The advantage for the active treatment arms was statistically significant (both P less than .001). For the secondary endpoint of clinical remission at 8 weeks, the rates were 19.6% for placebo, 30.6% (P = .009 vs. placebo) for fixed-dose ustekinumab, and 40.2% (P less than .001 vs. placebo) for the weight-based dose.

Relamorelin: Gastroparesis
Saturday, December 12, 2015
8:18 AM

Phase 2. Ghrelin agonist drug

Viberzi – IBS
Saturday, December 12, 2015
9:18 AM

VIberzi is contraindicated with SOD spasm, alcoholism or drink more than 3 drinks a day or pancreatitis or cirrhosis Child’s C or severe constipation or mechanical obstruction
It is the first and only mixed opioid receptor modulator. It binds to kappa, mu and delta. It stimulates kappa and mu and blocks delta which is antagonistic.
Overall, it then modifies GI motility and slows down contraction of smooth muscle.It also decreases the activity of afferent neuron of the gut.
This causes decreased visceral hypersensitivity.
It does not get absorbed and only binds to mucosal receptors in the gut. Give with food?
Bristol stool scale : Pain scale was 6.1 and stool consistency was 6.2 (max is 7 diarrhea)
The trial was 52 weeks and more than 1200 patients and the primary end point was improvement in pain, diarrhea at 12 weeks.
Composite responder ( improved pain and diarrhea )
Benefit was 30 and 33% in the 12 and 24 months compared to 16 and 20% in placebo
SOD occurs in patients with s/p chole. SOD occurs in 0.2% of s/p lap chole.
Pancreatitis occurred in 6 out of 3000 patients.
Side effect profile otherwise similar to placebo (except constipation 1-2% had to stop it). 1 % at 75 mg and 2% at 100 mg
It can cause euphoria (0.2%)and feeling drunk (0.1%). Since it can activate mu receptor it is labeled as Schedule IV.
75 mg dose for patients with child’s A or B cirrhosis, s/p chole patients, those unable to tolerate 100 mg bid dose or they are on gemfibrozil or cyclosporine. (Similar to lomotil)
OATP1B1 receptor ((drugs are Rifampicin, Rifamycin SV, Clarithromycin, erythromycin, roxithromycin, telithromycin indinavir, saquinavir, ritonavir, Cyclosporine, gemfibrozil) (organic anion transporting polypeptide)
It increases absorption of Viberzi.
40% increase in Crestor level
Developed by same scientist from J and J that developed loperamide.
10% delta (compared to placebo) of patients who did not respond to loperamide responded to Viberzi.
Agonist for mu, antagonist to delta and unknown to kappa. Passes BBB. Eat it with meal to decrease absorption
Avoid in lap chole : because they may have SOD.
Child’s A and B, use reduced dose and Child’s C contraindicated.
Most of the events of constipation occurred in first 2 weeks (50%)
P value for primary endpoint. Confidence interval for secondary endpoint.
SOD issues occurred in 0.2% at 75 mg dose and 0.8% in 100 mg dose. All resolved after stopping medication.
1 pt with SOD got abnormal LFT, one got pancreatitis. The other 5 pancreatitis had sludge or had alcohol.

Discontinuation rate of Viberzi is 8%

Saturday, December 12, 2015
9:56 AM

Combination of leucine, meteor in and sildenafil for NAFLD : accelerated trial. Measured with proton-density-fat fraction on MRI. NuSirt pharmaceutical

Saturday, December 12, 2015

Use bottled water or teaspoon of apple sauce
Open capsule. Drug is coating beads. So if beads remain it’s ok !

Monday, December 14, 2015

Rifaximin EIR 800 bid for moderately active crohns

Nodular regenerative hyperplasia
Monday, December 14, 2015

Tuesday, December 15, 2015

KALK German area

Viz scope
Tuesday, December 15, 2015

Markers at 25 and 15
Inflate balloon with water 5 cc, aspirated to get rid of air, empty air from syringe and then reinflate ballon to fit cap.
Use cap

Thursday, December 17, 2015

Among 10 patients who developed inflammation of the ileoanal anastomosis, or J-pouch, all reported clinical improvements in stool frequency, and symptomatic relief typically was observed within 2 to 3 weeks after treatment with serum-derived bovine immunoglobulin/protein isolate (SBI), according to Larry Good, MD, of South Nassau Communities Hospital in Oceanside, N.Y.

The product, also known as EnteraGam, is derived from bovine plasma that has been USDA approved and contains immunoglobulins (primarily IgG), albumin, and other proteins. Pouchitis is not currently included in the labeling for EnteraGam.

Pre clinical IBD
Thursday, December 17, 2015

The preclinical detection of markers such as IL-6 and high sensitivity C-reactive protein (CRP) suggests that there is a time lag between the initiation of mucosal immune dysfunction and disease manifestations, the researchers noted.
“Preclinical disease phases have been described for other immune-mediated inflammatory disorders such as rheumatoid arthritis, where inflammatory markers also appear to be elevated several years in advance of symptomatic disease,” they stated.
Multiple studies have demonstrated that patients with rheumatoid arthritis (RA) are positive for rheumatoid factor and/or antibodies to citrullinated protein antigens from 2 to 10 years before symptoms appear. Those preclinical findings are today being explored for potential in early disease detection and even prevention.

Breast cancer
Friday, December 18, 2015

Anastrozole/ tamoxifen for HR + which is better ?

Denosumab for post menopausal women breast cancer. Cancer prevention plus osteoporosis prevention

Friday, December 18, 2015

Subset of pbc pt do poorly
Correlated with bilirubin and Alk phos elevation
OCA start at 5 mg and titration at 3 or 6 months to 10 mg. Continue Urso ?
Fibrates help pruritis.
• Approximately half of patients will respond to cholestyramine
• Alternatives include rifampin (with a risk of hepatitis) and drugs with less evidence, such as naltrexone and sertraline
Sarna lotion for itching
Use zyrtec and zantac for itching
Check lipid panel in Ocaliva patients

fatalities, the agency determined that seven were in patients with moderate to severe liver impairment who were taking the drug at 5 mg daily; the drug’s label states that patients with this degree of impairment should not receive more than 10 mg twice weekly, the FDA said. For most of the other fatal cases, not enough information was provided to identify causes or contributing factors.

Complicated intra abdominal infection
Saturday, December 19, 2015

start treatment in a critically ill patient with piperacillin/tazobactam, meropenem, or imipenem
Dr Solomkin: Would you discuss the recent STOP IT trial, which is the first solid randomized trial of stopping antibiotic therapy early?
Dr Mazuski: In this National Institutes of Health – sponsored trial, patients were randomized either to limited antimicrobial therapy (4 days) after appropriate source control or longer antimicrobial therapy (8 days) based on resolution of signs and symptoms and resumption of gastrointestinal function, and they were continued on therapy for 2 days after that.
(Enlarge Slide)

The failure rate in both groups was the same, approximately 20%. This study provides good data showing that we do not need to give prolonged antimicrobial therapy for most patients with cIAIs, with the caveat that they have early and appropriate source contro
Dr Solomkin: Would you discuss the recent STOP IT trial, which is the first solid randomized trial of stopping antibiotic therapy early?
Dr Mazuski: In this National Institutes of Health – sponsored trial, patients were randomized either to limited antimicrobial therapy (4 days) after appropriate source control or longer antimicrobial therapy (8 days) based on resolution of signs and symptoms and resumption of gastrointestinal function, and they were continued on therapy for 2 days after that.
(Enlarge Slide)

The failure rate in both groups was the same, approximately 20%. This study provides good data showing that we do not need to give prolonged antimicrobial therapy for most patients with cIAIs, with the caveat that they have early and appropriate source control.
Dr Solomkin: Is it definitive? In other words, has it changed your practice?
Dr Mazuski: We were already practicing that way. Yes, I would say it is definitive. The study provides very good data showing that prolonged antimicrobial therapy provides no benefit in adult patients who have adequate source control.
(Enlarge Slide)

use: cefoxitin, ertapenem, moxifloxacin, or tigecycline. Ticarcillin and clavulanate are no longer available. We would typically use a first- or second-generation cephalosporin, or even ceftriaxone with metronidazole for a lot of the mild-to-moderate infections, such as a perforated appendicitis.
We recommended using carbapenem (piperacillin-tazobactam, and then combination regimens with ceftazidime or cefepime) for very ill patients with cIAI and high severity scores. Typically these are people who go to the ICU. In this group we recommend ceftazidime with metronidazole or clindamycin. Ceftazidime does not have good gram-positive activity and given the importance of streptococci, that is an issue. Cefepime is much better against gram-positive organisms. Ciprofloxacin and levofloxacin are crossed out, because in most hospitals in the United States, the susceptibility of these organisms, particularly E coli, is so low that it is not a concern.

RECLAIM trial were recently presented at the 25th European Congress of the European Society of Clinical Microbiology and Infectious Diseases (ECCMID 2015), April 25-28, 2015, in Copenhagen, Denmark. In this trial, patients were randomized to receive ceftazidime/avibactam or meropenem for the treatment of cIAIs. Avibactam covers a large number of the ESBLs. It does not cover the metallo-beta-lactamases, but it does has activity against most of the carbapenemase-producing Klebsiella pneumoniae. The real role of this agent is probably going to be in therapy directed against carbapenemases. It has the potential for carbapenem-sparing therapy because it covers most of the ESBLs, but in the interest of antimicrobial conservation I would use it to target the carbapenemase producers (Carbapenem-resistant Enterobacteriaceae), even though there are not a lot of data about its efficacy in that group of patients.
(Enlarge Slide)

Chronic fatigue
Saturday, December 19, 2015

An isolated report from a single center suggested that a purple or crimson discoloration of both anterior tonsillar pillars (crimson crescents) in the absence of pharyngitis is might be a marker in patients with CFS. The cause of crimson crescents is unknown, but they are common in patients with CFS. However, crimson crescents are not specific for CFS,

CVS 2015
Tuesday, December 22, 2015

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News & Perspective Multispecialty
Mandrola’s Top 10 Cardiology Stories 2015
John Mandrola, MD
| DisclosuresDecember 17, 2015

  1. PCSK9 Inhibitors Released Into the Real World
    This year, the FDA approved the injectable monoclonal antibodies evolocumab[1] and alirocumab[2], which induce dramatic drops in LDL cholesterol. The problem is we do not know whether that translates to fewer heart attacks, strokes, or death. We also don’t know whether the drugs are safe over the long term. The longest follow-up in a clinical trial was less than 2 years; LDL-lowering is a lifelong proposal. I’m not saying the drugs are unsafe; I’m merely saying we don’t know.
    Without outcomes data, we can’t know anything about cost-effectiveness. We have made a big gamble. If the outcomes trial (FOURIER) due out in 2017 shows minimal to no benefit, we will have wasted a lot of money—and waste is something the US healthcare system needs less of. A caveat: patients with familial hypercholesterolemia who have high LDL-C levels uncontrolled with statin drugs might want to take a chance on these drugs.
  2. SPRINT Delivers, but Not Without Trade-offs
    Blood-pressure control is important, but we don’t know the ideal target. SPRINT[3] compared lowering blood pressure to 120 mm Hg against a more lenient goal of 140 mm Hg in high-risk older adults. The data safety monitoring board stopped the trial early because of an increased number of cardiac events in the lenient-BP arm. Efficacy of intense BP control came at a cost: more drugs were required, and more subjects in the intense-BP arm experienced syncope, acute kidney injury, and electrolyte abnormalities.
    SPRINT was a positive trial; the challenge will come in applying the results to real-world practice. Do not downplay the pill-burden issue. In a hypothetical study, many people would trade dying earlier[4] to avoid daily medications.
  3. Coffee and Fat Are Back
    Nothing is more basic to health than what we eat. This year, we relearned that not a single randomized controlled clinical trial backed the 1970s-era advice to cut fat consumption to less than 30% and saturated fat to less than 10%.[5] This revelation led an expert panel to release new recommendations to the US government.[6] In the 570-page report, many of the basics remained, such as eat more fruits, vegetables, whole grains, nuts, and fatty fish and fewer refined sugars and trans fats. Two major reversals included the allowance of moderate caffeine intake and removal of limits on dietary cholesterol. In 2015, a consensus grew that refined sugars promote illness—and momentum grew for using nudges, such as taxes, to reduce their consumption.
  4. The Basics Make a Comeback in AF Treatment
    There were three discoveries in atrial fibrillation (AF) this year. First, the STAR-AF 2 trial[7] surprised many because it found that additional ablation beyond pulmonary-vein isolation in patients with advanced forms of AF did not improve outcomes. Second, the LEGACY trial[8] and CARDIO-FIT trials[9] showed that weight loss and gains in fitness delivered potent antiarrhythmic effects. Finally, the ARREST-AF Substrate study,[10] which won a Young Investigators Award at the AHA meeting, showed that risk-factor modification worked by improving electrical and structural properties of human atria.
    The big difference in 2015 is that thought leaders now speak and write about risk-factor modification. They say, yes, it’s hard to achieve, but it is central to the care of patients with atrial fibrillation.
  5. SGLT-2 Inhibitors Impress, but Concerns Remain
    Medical meetings are conservative affairs. The fact that Dr Silvio Inzucchi (Yale University, New Haven, CT) received a round of applause during his presentation of the EMPA-REG Outcome trial[11] at a European diabetes meeting warrants mention. Patients with type 2 diabetes and established cardiovascular disease receiving empagliflozin (Jardiance, Boehringer Ingelheim/Lilly), a sodium glucose cotransporter-2 (SGLT-2) inhibitor, were less likely to die than those taking placebo. Experts called this a landmark trial because it’s the first time a drug for diabetes has lowered death rates.
    Two notes of caution: One is that no one understands how the drugs reduce mortality. Another is that the FDA issued warnings about ketoacidosis and bone fractures with these drugs.
  6. NOAC Reversal Agents Soothe Our Worrying Minds
    More than 70,000 patients were enrolled in the clinical trials comparing the new oral anticoagulant drugs against warfarin. All the trials reported fewer deaths in the NOAC groups. Yet, in the risk-averse human mind, the what-ifbleeding scenario weighs heavily.
    This year brought relief. The dabigatran reversal agent idarucizumab[12] (Praxbind, Boehringer Ingelheim) received FDA approval in October. And in a New England Journal of Medicine[13] paper released online in November, the factor Xa reversal agent andexanet alfa safely reversed the anticoagulant effect of apixaban and rivaroxaban in older volunteers. FDA approval for andexanet will likely come soon.
  7. Cutting the Cord in Pacing
    The Achilles’ heel of cardiac pacing devices is the lead. This year began the wireless revolution in cardiac pacing. Both the NanoStim LP[14] leadless pacemaker (St Jude Medical) and the Micra TPS15 performed well. Both devices have earned CE Mark in Europe, and FDA approval is likely.
    One way to look at these devices is that the impact will be small because single-chamber ventricular pacing accounts for a small proportion of devices. That’s true; but this is the first of many (wireless) disruptions to come in cardiac pacing.
    Two more thoughts: a leadless pacemaker is placed through a femoral sheath. That means any cardiologist can implant it. Look for a rise in the number of single-chamber device implants. Second, think forward 5 years. It’s likely that a leadless pacemaker will be combined with a subcutaneous ICD generator to make a leadless ICD.
  8. Interventional Breakthrough Not in the Heart but in the Brain
    Five clinical trials[16-20] demonstrated clear benefit for the use of endovascular treatments alone or as an add-on to tPA in patients who present with acute stroke. The numbers needed to prevent major long-term disability were consistently less than 10.
    Previous studies of endovascular therapy in patients with acute stroke had not shown benefit. The difference in the newer studies: faster interventions, newer-generation retrievable stents, and inclusion of patients with documented occlusion of a major vessel.
    There’s also a Watchman-like lesson embedded in this story. The first of these trials, MR CLEAN,[16] enrolled 500 patients from a small country of only 16.8 million people. In an editorial[21] in the New England Journal of Medicine, Dr Werner Hacke (University Hospital Heidelberg, Germany) gave the Dutch government credit for this feat. He said enrollment was that good because the device was only reimbursed when used in a clinical trial. He added this timely quote: “This policy may be difficult to implement in other healthcare systems, but imagine what progress the medical-device field would see if this strategy were the rule.”
  9. For Most Patients, Say No to Bridging
    The rationale for periprocedural bridging in patients taking anticoagulants is that exposing them to a higher risk of bleeding will be offset by fewer thrombotic events. That never made sense to me. Math dictates that the daily risk of coming off anticoagulants before and after an intervention is tiny. And many nonrandomized observational trials had failed to show a net benefit for bridging.
    This year, two studies, one observational[22] and one a large randomized clinical trial23, demonstrated that bridging resulted in higher bleeding rates and no lowering in thrombotic events. In the observational trial, bleeding was 17 times higher with bridging. A big caveat: investigators from the BRIDGE trial excluded high-risk patients with mechanical valves and previous stroke. So we don’t know the answer for these patients. For most, though, less is clearly more.
  10. MOC, Still in the ICU, but Off Pressors

Saturday, December 26, 2015
5:58 AM

Fibroblast growth factor 21 suppresses carbohydrate and alcohol craving. It is produced by the liver

Stroke app
Saturday, December 26, 2015

Hopkins bandits shark shutdown

Saturday, January 2, 2016

Taken together, our findings suggest it is possible that migraine is a neurologic disorder of ‘minor’ sphingolipid dysmetabolism,” they conclude. “Further research, validating the ceramide and sphingomyelin associations with migraine, as well as research examining mechanisms for these associations, may advance our understanding of migraine pathophysiology and open possibilities of the identification of novel migraine biomarkers and targeted drug therapies directed against sphingolipid pathways.”

Friday, January 8, 2016

CONCLUSIONS: In analysis of data from a phase 2 study of the effects of glycerol phenylbutyrate in patients with cirrhosis, we found that fasting levels of NH3 in blood can identify patients at risk for HE-related morbidity. Patients with HE might benefit from NH3-lowering therapy.

Hemorrhoid a
Friday, January 15, 2016

Recticare lidocaine
Either wipes or jelly

Tuesday, January 19, 2016


Colon cancer marker
Wednesday, January 20, 2016

CDX2. For stage 2. If absent aggressive cancer

Viral or bacterial
Friday, January 22, 2016

Gene marker in future
Right now pro calcitonin level

Colon cancer risk reduction
Saturday, January 23, 2016

including exercise, healthy diet, stopping smoking, or moderating alcohol intake if indicated. This little extra time is appreciated by the patients and goes beyond treating patients as if guidelines were a cookbook.

Wednesday, January 27, 2016

AIMS65 scoring system for survival. Older are rockall and Glasgow blatchford score

Age more than 65, bp less than 90, change in mental status, INR more than 1.5, albumin less than 3.
One point each.
0→0,3% || 1→1,2% || 2→5,3% || 3→10,3% || 4→16,5% || 5→24,5%


Friday, January 29, 2016

ESKAPE pathogens – Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species – named for their ability to resist the effects of antibiotics.

Mercy 2015
Friday, January 29, 2016
12:20 PM

Friday, September 18, 2015
Mercy conference 9/2016
I. FODMAP diet
By Lisa Pichney
I. Points

  1. Fructans causes problems – fructo oligosaccharides (FOS). Short chain carbs.
  2. Prebiotics – Oligosaccharides are needed to for colonic health. But bifidobacteria in the colon will cause gas and bloating! Catch 22 !
  3. Probiotics – helps with modulation of immune system, pain perception
  4. Synbiotics – prebiotics and probiotics together.
  5. MONASH univ – peter Gibson and Sheppard came out with FODMAP
  6. Luminal distension causes pain, bloating, abd. Distension, motility disorder.
  7. Short chain sugar molecule – less than 10 sugar molecules. They are broken down in distal sb and proximal sb and then digested by bacteria
  8. GLUT2 needs glucose to absorb fructose. So if you just take fructose without glucose then causes problems. If taken with glucose it can be absorbed
  9. Polyols : it causes diarrhea. These are sugar alcohols. This is present in artificial sugars, sorbitol etc.
  10. Bacterial fermentation leads to more hydrogen and problems this gas causes distension and a problem with patients with visceral hypersensitivity
  11. Hydrogen breath test for fructose. If positive stop fructose. But if negative then give fructose with glucose
  12. Patients may not have gluten sensitivity but have problems with Fructans
  13. FODMAP diet – it is additive with number of fodmap in diet.
    II. IBS-D
  14. BAD – bile acid diarrhea
  15. IBS is frequently post infectious
  16. BAD occurs from dihydroxy bile acids induces chloride and water secretion.
  17. Causes of BAD – 3 types
    a. Type 1 ileal resection or crohns disease,
    b. Type 2 primary with normal ileum and
    c. Type 3 post cholecystectomy, post vagotomy, celiac disease, bacterial overgrowth, pancreatic insufficiency
  18. How to diagnose BAD – therapeutic trial with colestipol, cholestyramine, colesevelam. This is non specific.
  19. SeHCAT retention less than 15% after 7 days indicates BAD. Available in UK/Europe
  20. Severe SeHCAT is less than 5% retention, moderate is 5-10 and mild is 11-15%
  21. BAD occurs due to defective feedback inhibition bile acid synthesis. Small intestinal cells produce FGF19 which inhibits liver bile acid production. This is defective in BAD patients.
  22. ASBT picks up bile acid in the TI. So either there is too much bile in TI that overwhelms ASBT or there is a defective ASBT
  23. Future – FGF 19 blood level or C4 (a product of bile acid metabolism). C4 has a 74% PPV and 98% NPV.
  24. MRI detection of fluorine labeled bile acids (done at Univ. Md)
  25. BAD is 30-50% of the IBS-D.
  26. NAFLD is in 3 stages
    a. NAFL – just fat with ballooning but no damage
    b. NASH is fat plus inflammation and scarring
    c. Cirrhosis
  27. US detects 50% NAFLD.
  28. It is adipocyte dysfunction :
  29. Secondary fat occurs in alcohol consumption, HCV type 3, lipodystrophy, starvation, TPN, abetalipoproteinemia, medications like amiodarone, methotrexate, tamoxifen, steroids. Microvascular steatosis occurs in Reyes syndrome etc
  30. Most patients with NASH die from high CV disease.
  31. Higher HCC in NASH and HCV and incidence increasing by 8% for HCV from 2004 to 2009 and 5% in NASH from same time frame
  32. Measure fibrosis with fibrosure, Fibrospect 2, ELF, hepascore. Non patented are APRI, or Fib-4
  33. Fibroscan, MRE,
  34. NASH – tier 1 or tier 2. Use liver biopsy for high score on tier 1, eg more than 9.6kPA (M probe) or 9.3 on XL probe
  35. NASH goal lose 5-10% of weight. Decrease carbohydrate and fructose. Caloric decrease by 25%. Use PUFA and not transfat. Fructose is high in soda, fast food, fruits, vegetables and dried fruits. Low fructose in strawberries, bananas, cantaloupe, pineapple, peaches, grapefruit, limes, avocados, tomatoes, apricots, mangos and plums
  36. High transfat in meants, cream cheese, butter, ice cream, shortening, stick margarine.
  37. High PUFA, nuts, seeds, avocados, olives,
  38. Treatment with pioglitazone ( actos 30 mg/day), vitamin E. Study was PIVENS. No change in fibrosis. Risk of pioglitazone – use in biopsy proven NASH. Vitamin E increases all cause mortality and prostate cancer. Not recommended to use vitamin E in diabetic pt, without liver biopsy, NASH cirrhosis or cryptogenic cirrhosis
  39. Future candidates are Victoza,
  40. FLINT trial obeticholic acid. It is semisynthetic bile acid analogue and activator of farnesoid x nuclear receptor. It improved histology by 45%. Side effect is itching. Also resolved fibrosis completely in 15% !!!
  41. LEAN study for victoza (liraglutide). Resolution of NASH in 39%.
  42. Remogliflozin : ?
  43. Target metabolic syndrome – DM , increased chol and TG. Metformin not effective, Statins are safe but no benefits.
  44. Alcohol in NASH – neutral. Acceptable alcohol is 21 drinks in men and 14 drinks in women per week. Heavy drinking is 4 drinks per day for men and 3 drinks /day in women. (per NIAAA – national institute of alcohol abuse and )
  45. 1 drink is 341 ml of 5% beer, etc
  46. Liver tonics or cleansers – hydroxycut, black cohosh, or herbalife are harmful.
    IV. Fibroscan and others
  47. Early cirrhosis from HBV can be reversed with viread
  48. F1 fibrosis, F2 with septa and F4 cirrhosis.
  49. — USE APRI – AST to platelets ratio.
  50. Sensitivity of Fibrosure is 60-75% and specific is 80-90%. Hepascore is the same (for F2). APRI is 77% sensitive and 72% specific. European liver fibrosis – F2 87% and specific is 40%. SHASTA for HIV. F 22 is 88% sensitive and specific 94%
  51. APRI score 1-1.5 78% specific and 2 or more is 87% specific. If 0.5 84% sensitive. Same is true for NASH and HCV patients if you use APRI
  52. Shear wave elastography ( transient or AFRI elastography) or strain elastography. Both are with US. Each one of them are 2 different types. One is semi quantitative and other is quantitative. Not a good test in heart failure, and affected by type of liver disease.
  53. Shear wave – reported as kPa. Transient F2, F4 (78 and 89%). AFRI F2 and F4 (74 and 87%) sensitivity. And specificity for each is 84 and 87% and 83 and 87%. Both are equivalent modalities
  54. The results are affected by inflammation and it increases the kPa. Like biomarkers are not reliable
  55. Strain elastography – limited experience
  56. MR elastography – better than US. F3 is 6.95 kPa
  57. Algorithm – if APRI is more than 2, fibrotest more than 0.7 and TE more than 14 has cirrhosis and no bx needed. (if all 3 present)
  58. If APRI less than 0.5, TE less than 7 kPa and fibrotest less than 0.2 – no biopsy…No cirrhosis. (if all 3 present).
  59. Do biopsy if uncertain scores for above
  60. The advantage is you can do TE every year on the same pt to measure progression
  61. APRI score :
    a. Divide the AST by 35.
    b. Divide that number by the PLATELET count (this should be in the range 0 to 500 or so – if there are extra zeros, delete these before computing).
    c. Multiply this number by 100.
    d. If this number is greater than 0.5, there is a good chance they have some liver damage. If greater than 1.5, the person very likely has cirrhosis. One can say APRI scores between 0.5 to 1.5 VERY LOOSELY correspond to Metavir Stages 1-3, and above 1.5 corresponds (again, very loosely) to Metavir Stage 4.

V. Acute on chronic liver disease

  1. ACLF : Acute decompensation of cirrhosis resulting in liver failure (jaundice or elevated INR and associated with extra hepatic organ failure with high short term 4 weeks and 3 month mortality. It is in 3 grades
  2. Ppt factors are alcohol, HDV, HBV reactivation, dili, GI bleed, infection, ischemia, and portal vein thrombosis precipitates it.
  3. Def – when 2 extra hepatic organ failure ( shock, grade 3 HE or dialysis or ventilation).
  4. European def is
    a. Grade 1 AKI requiring HD or single organ damange 22% mortality
    b. 2 organ damage is grade 2 32% mortality
    c. 3 organ damange is grade 3 78% mortality
  5. Liver failure if bilirubin is 5 mg and INRO more than 1.5 by Asian def.
  6. EASL def by CANONIC study – Cr more than 2, bili more than 12, INR more than2.5, plt less than 20 or 3-4 for stage HE, need for pressures or Pa02/Fio2 ratio less than 200.
  7. ACLF stage 2 or 3 withdraw care candidates. Best time to prognostic between days 3-7.
  8. CLIF consortium organ failure score
  9. CLIF-sofa score for alcoholic cirrhosis pt.
  10. Immune dysfunction in ACLF leads to sepsis. Bacterial translocation, endotoxemia and then reduced immune response and reduced albumin function.
  11. Management is identification of SBP, treat in ICU, plasma expansion with albumin, airway protection and transfer to transplant center.
  12. Liver support devices : plasma exchange dialysis, or albumin dialsys. Benefit was only in pt more than 30 MELD.
  13. Neupogen or erythropoietin may help in some patients. Simultaneous liver-kidney transplant is a thought.
    VI. Anticoagulation use in endoscopy
  14. High risk for thromboembolic event
    a. A fib with prosthetic valve, valvular heart disease, LVEF less than 35 %, DM, age more than 75, are at high risk of thromboembolic phenomenon
    b. Mech. Valve in mitral area or any mech valve with history of embolic phenomenon
    c. Recent stent
    d. ACS
    e. Non stented CAD
  15. Low risk procedure is risk of bleeding less than 1.5%, eg ERCP without sphincterotomy, stent deployment, diagnostic endoscopy, EUS etc
  16. NEJM for bridging therapy. Eg. NOT needed for AVR and no prior event However, GFR less than 30 require bridging use heparin and not LMWH. (ASGE guidelines 2009). Start warfarin after 24 hours. If large polyp taken out – wait 48 hours and if ERCP with sphincterotomy wait 72 hours !!
  17. If mechanical valve present – restart Coumadin same day.
  18. Ok to do procedure when INR is less than 1.5
  19. Warfarin effect is reversed in 93% of cases after stopping 5 days
  20. SQ heparin 24 hours hold and IV heparin 6 hours
  21. Pradaxa (dabigatran), direct thrombin inhibitor, with normal Cr hold for 1-2 days and if Cr clearance is less than 50, then 3-5 days.
  22. Xaralto (rivaroxoban) 1 day for normal Cr, 2 days for GFR between 60-90 GFR3 days for 30 to 60 GFR and less than 15 to 30 4 days hold.
  23. Eloquis hold for 1, 3 and 5 days for normal GFR, above 50 and 30-50 GFR
  24. Aspirin 7-10 days.
  25. Plavix is 5 days, Ticlopidine is 7-10 days
  26. New NOAC have half life of 9-17 hours
  27. All NOAC are renaly excreted.
  28. Reverse NOAC – Novoseven (factor 7) or PCC (K centra)
  29. Pradaxa can be dialysed.
  30. Give oral charcoal if patient got NOAC within 2 hours. Also give oral prep to flush out NOAC.
  31. Dabigatran can cause GERD and bloating.
    VII. Travelers diarrhea
  32. Canada has a vaccine for TD
  33. TD is in Asia, Africa, mexico, Caribbean. Less than 5% in Europe USA
  34. Drink carbonated drinks
  35. NO ice cubes
  36. Higher altitude – boil water longer
  37. EAEC and ETEC are 50-70% of bacteria
  38. South east asia incidence is usually campylobacter.
  39. Treatment is hydration, antimotility drug.
  40. Cipro 500 mg bid for 1-3 days, Levofloxacin 500 mg once a day, same duration. Do not use in young children and pregnant women
  41. Azithromycin 500 mg once a day for 1-3 days. Ok to use in pregnancy. Drug of choice in South east Asia. Rest of the world Cipro. Causes arrhythmia (azithromycin)
  42. Xifaxan can be used for TD. More beneficial for ETEC. Campy is resistant to it. 200 mg tid for 3 days.
  43. Is it ok to use immodium with antibiotic? Yes, it should be used. Do not use lomotil.
  44. Lomotil causes urinary retention due to anti cholinergic effect.
  45. Use prophylaxis if you are using PPI or H2 blockers, IBD,AIDS, DM, hypertension, important business meeting.
  46. Non antibiotic prophylaxis, 2 tab qid peptobismol
  47. Probiotics are effective. Worth trying.
  48. Prophylaxis is 500 mg of Cipro or levaquin or azithromycin 250 mg. All once a day.
  49. Doxycycline for malaria, lepto and TD prophylaxis for all 100 mg a day
  50. Xifaxan 200 mg bid is effective for TD prophylaxis but not FDA approved
    VIII. Microbiome
  51. 100 trillian microorganisms in human gut.
  52. Firmicutes and bacteroidetes are more than 90% of it.
  53. Most of them are in colon
  54. 90% have never been cultured.
  55. In 2006 we found 100 of bacteria in stomach!
  56. If immunosuppressed or HIV have fermicutes in stomach
  57. 20,000 deaths per year from CDAD
  58. RCDI (recurrent c diff infection). Success FMT
  59. In crohns disease, reduced Firmicutes, esp faecalibacterium prausnitzi.
  60. Diagram from cell host microbe by Peterson et al, 2008
  61. Liver disease and microbiome : liver is exposed to endotoxins, petidoglycans.
  62. Proteobacteria produce ethanol. Ethanol is detectable in adolescents all coming from gut microbiome !
    IX. Endoscope cleaning!
  63. ESBL (extended spectrum beta lactamases)
  64. MDRO (multidrug resistant organisms)
  65. 1988 to 1992 – 12 cases of transmission per year from scope
  66. Most dangerous medical equipment in hospital transmitting infection
  67. So far 98 outbreaks have occurred in USA.
  68. Breach in protocol
  69. ERCP scopes – Pseudomonas, E coli, K pneumonia, and E coli. Comes from elevator, biopsy forceps etc
  70. Grove in elevator is difficult to clean.
  71. Culture and quarantine practice. Culture is not 100% sensitive !!
  72. Surgical equipment has 10 to 2 power bacteria. Scopes have 10 to the power 5 on the outside and 10 to the power 10 on the inside of scope.
  73. Endoscopes need high level disinfection. It does not kill spores
  74. 8 steps to cleaning.
  75. Cleaning machine has long tubes, angles and blind lumens. Low temperature also
  76. Office based flex sig. Everyone failed cleaning protocols !
  77. Options are
    a. Ethylene oxide sterilization and culture
    b. Double high level disinfection with culture
    c. Use ETO (after standard disinfection)
  78. Do not replace or modify manufacturers reprocessing suggestion
  79. Rapicide PA peracetic acid high level disinfectant effectively kills CRE. Use Bar code on the machine.
  80. Scope cleaning – in and out doors.
    X. Management and evaluation of pancreatic cyst
  81. Dr Brugge, Harvard
    a. 4 types
    a. Serous, mucinous, pseudocyst and IPMN (main and side branch)
    b. Pancreatic cancer – 90% PanIN – 1 ,2 and 3 pathway and are less than 5 mm in size. Cannot be detected by current EUS etc.
    c. Pathway is kRAS mutation, then PanIN1 then PanIN2 and then PanIN3 and finally cancer.
    d. IPMN – 2 types. Growth more than 2 mm/year and less than 2 mm/year growth. 2 % malignancy in 5 years if less than 2 mm growth
    e. Risk of cancer is 0.4% year with IPMN
    f. 4 types of IPMN
    a. Side branch
    b. Diffuse main branch
    c. Focal main duct
    d. Mixed duct
    g. Consider IPMN with dilated PD. IPMN is a villous adenoma
    h. Types of IPMN based on bx
    a. Gastric (best survival)
    b. Intestinal
    c. Pancreatic – biliary (worst survival)
    d. Oncocytic
    i. Branched chain IPMN are usually gastric mucosa
    j. Detection in IPMN use CEA, KRAS, cytology
    k. Look at size, growth rate, wall thickness, mural nodule and adjacent mass.
    l. FNA of cyst – evacuate cyst and send for 0.3 cc for KRAS, 0.3 for CEA and 0.5 for cytology. Also cytology of nodule and cytology of mass
    m. Using KRAS and CEA increases sensitivity and specificity to 85%
    n. Molecular analysis : KRAS, GNAS, TP53
    o. Cyst ablation : inject palitaxol after lavage of cyst. Do this for 2-4 cm cyst in Branched duct IPMN if moderate surgical risk. If in tail do it only for high risk surgical patient.
    p. EUS guidelines are
    a. If 2-3 cm EUS, cyst fluid analysis to be done every 6 months
    b. If cyst more than 3 cm,recommend surgery and follow up every 3-6 months
    XI. Sphincterotomy of pancreas
  82. Pancreas divisum does not cause pancreatitis. Probably from genetic mutation
  83. Idiopathic pancreatitis is from genetic mutation
  84. Pancreatic SOD are more likely to get recurrent pancreatitis ???
  85. SOD pt should not get ERCP or ES. Does not help. Most of the patients have psychological issues
  86. ASGE guidelines probably faulty for SOD
  87. Post ERCP pancreatitis (PEP)
    a. Women less than 60, women, suspected SOD, normal Bilirubin, non dilated ducts are all high risk ERCP
    b. Under opacify duct and drain PD
    c. Hydration : give them 2 liters of fluid after ERCP.
    d. Chemoprophylaxis : indomethacin – rectal.
    e. Use 100 mg indomethacin rectally
    XII. Celiac Neurolysis
  88. Chronic pancreatic pain : This occurs due to increased nerves in pancreatic cancer. The nerves produce growth factors that increases the number of nerves and a vicious cycle occurs. This is also true in pancreatic cancer.
  89. Laproscopic celiac plexus block or EUS guided block. Do not use x ray block
  90. Primary failure if no response with anti TNF in 4 weeks
  91. Entyvio takes 10 weeks
  92. Asian may take 3-4 months
  93. Secondary failure is relapse
  94. Check biomarkers fecal lactoferrin, CRP
  95. Failure can be lactose intolerance, CMV< C diff, celiac sprue, microscopic colitis
  96. Immunogenicity is cause of secondary failure
  97. Pseudo-failure from inadequate drug levels or because of rapid clearance of drug. Eg. Low albumin then will fail infliximab. (Alb less than 2.2). That is because of rapid clearance. In those pt, dose escalate quickly.
  98. Treatment for primary failure – vedolizumab – NEJM august 2013. TNF naïve 53%response and TNF failure 39 % clinical response. Remission was in 23% and 10% for naïve and failure
  99. GEMINI data
  100. Natalizumab ENACT 1 trial. 27% of the patients were treatment failure. It is not used because of PML. JC antibody must be checked. NOT — USED
  101. Secondary failure – use a single extra dose. It increases drug level and there is 39% chance of response.
  102. Adalimumab – use weekly dose and gain regain remission in 57% patients
  103. Change different TNF : 21% benefit in patients who failed infliximab – when changed to humira.
  104. WELCOME trial – cimzia used in failed remicaide. Benefit was 30% patients responded
  105. Therapeutic drug monitoring – Proactive and reactive monitoring. How to avoid antibodies –use immunosuppresants
  106. Low albumin 80% non responder
  107. Baseline CRP – more likely to fail treatment.
  108. Males are more likely to fail.
  109. Subtherapeutic levels –dose escalation 86% or change anti tnf response is 33%. If anti TNF antibody – switch 92% response, increase dose 17% response Antibody level if low – dose escalation works but if high level of antibody change to anti TNF
  110. Infliximab increase by 2.5 mg/kg if undetectable level. If detectable but low (less than 5)increase by 50 -100 mg. Ifx level 5-10 no change and if level more than 10 decrease. Study from beth Israel shows benefit of measuring in all patients
  111. Using Imuran decreases ATI level (antibody to infliximab) From Israel
  112. Use drug monitoring in treatment non responders
  113. Check calprotectin
  114. Consider golimumab ?
  115. Stop smoking improves reticulin endothelin activity
  116. If drug level is low, then antibody develops
  117. Methotrexate 12.5 mg ?
  118. Azathioprine under age 30 7 times risk of lymphoma. Risk of lymphoma in 30-50 years risk is 3 x risk of lymphoma.
  119. Non melanoma skin cancer is high in all patients
  120. A level of 125 of 6 TG prevents immunogenicity !!
  121. If antibody falls, drug level goes up.

XIV. Perianal crohns disease

  1. 21% of patients have perianal crohns
  2. 5% patients have isolated perianal crohns
  3. Low fistula – below dentate line, high fistula – above dentate line
  4. Types superficial, intersphincteric, trans sphincteris, supra sphinctering and extra sphincteric fistulas
  5. 2 types Simple fistula and complex. Simple is superficial, intersphincteris or low transphincteric fistula with single opening and no adjacent structures or abscess. Complex is above anal sphincter, multiple opening, horse shoes, absess, connects to adjacent structure
  6. Features are rectal pain, drainage, recurrent UTI, fecal incontinence and do not heal without treatment.
  7. Evaluation is MRI, anorectal US, exam under anesthesia,
  8. EUS has 82% detection rate for fistula.
  9. Simple fistula – non cutting seton with medications
  10. Medications include antibiotics, Imuran, anti TNF and surgery.
  11. Cipro and flagyl. Use in combination
  12. Cimzia does not work for fistula
  13. ? stem cell therapy from adult adipose tissue may work. Works well with fibrin glue
  14. Italy does cone resection of fistulas
  15. Vidaluzimab week 14 28% fistula closure
    XV. Extraintestial disease management of IBD
  16. Presentism : being present but not effective or productive.
  17. Use zoster and pneumovax irrespective of age.
  18. Cannot use live vaccines.
  19. Zoster vaccine – zoster virus is present in saliva upto 28 days
  20. Live vaccines are : yellow fever virus, MMR, oral typhoid, oral polio, intranasal influenza and TB
  21. Rabies, injectable typhoid, injectable polio, injectable flu, hepatitis B, A, HPV, meningococcal, Td, Tdap, Japanese encephalitis virus
  22. No live viruses with Imuran, methotrexate, anti TNF, low protein status and prednisone more than 20 mg
  23. Pathogens that cause death in IBD : pneumocystis, histoplasmosis, herpes, candidiasis, listeriosis,
  24. Abstract – 50% of GI rooms were positive for C diff even after wipe down./disinfectant
    XVI. Novel therapies for IBD
  25. Anti selective adhesion molecule
  26. Anti linterleukin therapy
  27. Antagonist to janus kinase
  28. Anti sense SMAD7 inhibition
  29. Regulation of T and B cell trafikking
  30. Anti integrin therapy – vedolizumab and natalizumab Alpha4beta7 (Madcam-1 receptor) integrin. Additionally natalizumab is alpha4beta1 (VCAM-1 receptor in brain). Beta1 goes to cns. New ones to come out etrolizumab, then others are anti madcam-1, anti alpha 4.
  31. Antagonists of chemokines (mediate integrin activation)
  32. Etrolizumab – for severe and mod. UC. Very promising
  33. Anti-IL12/23. Ustikinumab at 1, 3 and 6 mg/kg with response rate of 69% and 41 percent response and remission !! (for Crohns)
  34. JAK stat ihibitors is used in cancer. (Janus kinase inhibitor). It affects IL-2,4,7,9,15 and 21. Tofacitinib. 10 mg dose. 15 mg twice daily response was 70%
  35. Novel immune modulators : Angrographis paniculata : it is an herb.
  36. DIMS0150 is a TLR-9 agonist. For moderately severe UC. Steroid refractory UC patients
  37. Regulation of T and B cell trafficking. : Sphingosine 1-phosphate receptor 1 modulation. FIngolimod – oral medication. No serious infection, etc. No malignancy. Causes LFT elevation, causes bradycardia and macular edema. Ozanimod for moderate to severe UC is under TOUCHSTONE trial. Dose 1 mg per day.
  38. FMT for UC.
  39. Mongersen in CD : oral agent. Dose 40 or 160 mg. NEJM in 2015 Italian study. 65% response rate at 160 mg.
  40. Anti cytokines :MEDI0270.
    XVII. Full thickness endoscopic resection
  41. Subepthelial tumors are 1% of GI tumors. 70% in stomach and found in 0.36% of EGD. They are mostly GIST.
  42. If more than 2 cm – resection.
  43. If less than 2 cm, EUS surveillance.
  44. EFTR has advantages over ESD. It involves resecting muscularis mucosa layer
  45. Combined laproscopic endoscopic techniques
  46. Device assisted EFTR. OTSC over the scope ovesco clip
  47. Ovesco clips 11 mm. 21 mm ovesco is only for colon
  48. ALL small bowel and colon GIST must get EUS for it.
    XVIII. Flat colonic polyps
  49. If LN present, then must send for surgery. Must be well differentiated tumor before considering ESD.
  50. Do not remove ulcerated lesion. Non lifting polyp, do not remove endoscopically
  51. EMR for large polyps, – you must go consecutive piece meal resection
    XIX. Colon screening
  52. FIT is better than FOBT. It uses antibodies to human globin in the stool. It does not detect UGI bleed. No dietary modification is needed. (Fecal immunochemical test)
  53. 79% sensitive and 95% specific test – FIT
  54. Cologard – check every 3 years. It is good for cancer but not for polyps. It checks 11 DNA markers. 42% for advanced polyps. But for cancer sensitivity is 92%. Negative predictive for cancer is 99.4%
  55. Adenoma detection is 17 % with cologard, cost is 600$.
  56. Serum markers for colon cancer are NOT prime time. Only 70% sensitive. It looks for septin 9hypermethylation in DNA. (Colovantage by quest). Early CRC 50% detection rate. Adenoma detection is 14%
  57. Colosentry 7 gene panel blood test. Just like colovantage. Not good

  58. XX. Non cardiac CP
  59. Definition: recurrent chest pain that is indistinguishable from cardiac pain after a reasonable workup.
  60. GI disorder for chest pain is commonest cause, then cardiac and then chest wall.
  61. NCCP is most common functional GI disorder. Incidence is same all over the world – around 25%
  62. The incidence decreases as people get older and M=F. Except between 50-59, F>>M due to menopause?
  63. Panic disorder is the commonest cause to drive patients to the ER for chest pain
  64. Commonest cause of nCCP is reflux. Half of them will have abnormal pH studies but range of erosive esophagitis is 10-70%. But most patients will NOT have erosions in esophagus
  65. Second most common cause after reflux is esophageal dysmotility 15-18%. But 70% of them will have normal motility
  66. Nutcracker esophagus – high amplitude contraction with more than 180 mm pressure. It is most common motor disorder in NCCP pt. Nutcracker is caused by reflux, possibly.
  67. Hypercontractile esophagus / jackhammer esophagus when index is more than 8000.
  68. Chest pain of presumed esophageal origin / functional chest pain. Not burning, no reflux and no motility disorder. Symptoms present for 3 months.
  69. Esophageal hypersensitivity is when non painful stimuli appears as painful stimuli
  70. Lower esophagus is constantly exposed to reflux, then patients develop primary hyperalgesia. The proximal esophagus also develops hyperalgesia and is called secondary hyperalgesia. Eventually they develop chest wall hypersensitivity also from somatic nerves
  71. How do you evaluate ? – Start with cardiac evaluation
  72. Second step is PPI trial. Omeprazole 40 mg in AM and 20 mg in PM for 7 days to 14 days.
  73. 24 hour pH off treatment with impedence measurement. If on treatment then use bravo
  74. Role of EGD for NCCP:
  75. Always compare psychological issues in all patients. Eg panic disorder, depression and anxiety
  76. Treat motility with nitrates, ca channel blocker, sildenafil, botox injection, Surgery or POEM for NCCP.
  77. Procardia 10-30 mg tid takes 3 weks to respond and response is not enduring.
  78. Botox for NCCP works.
  79. TCA, trazodone, selective serotonin antagonists, adenosine, pain modulators work for NCCP.
  80. TCA work on NE, 5 HT, H1 receptors. Use low dose TCA.
  81. TCA – start with 10 mg a day at bedtime. Good sleep is analgesic ! Weekly increase by 10 mg and target is 10-50 mg a day. May combine with SSRI. TCA – they do not cause mood altering at this dose
  82. Venlafaxine 75 mg at bedtime. Citalopram 20 mg once a day is effective. Venlafaxine pt have problems falling asleep.
  83. Zofran is a pain modulator; gabapentin also is a pain modulator.
  84. Hypnotherapy gives a good response.
  85. Johrei treatment – Similar to Reiki. It works too.
    XXI. Refractory GERD
  86. Bariatric surgery causes secondary achalasia !
  87. Sigmoid esophagus if more than 8 cm esophagus diameter
  88. Refractory reflux : Symptoms that don’t respond to bid PPI for 12 weeks.
  89. More common in females, and is in 32% -45% of patients
  90. Non responders is around 3% and partial responders are 20%?
  91. Most common breakthrough is at nighttime. More than 60% of them
  92. Nighttime reflux drives barretts and esophageal adenoca
  93. NERD: more acid, more likely they will respond
  94. Erosive esophagitis: more acid, less likely they will respond
  95. Mechanisms for refractory reflux: EoE, compliance, improper dosing time, psychological issues, bile reflux, IBS, gastroparesis, acid pocket. The most common cause is FUNCTIONAL REFLUX
  96. Functional reflux: heartburn without acid reflux.
  97. Usually esophageal hypersensitivity.
  98. Acid pocket: an unbuffered acid pocket in the stomach. Partial responders have more proximal reflux events and increased sensitivity to balloon distension.
  99. Proximal reflux: have liquid and gas and usually refractory
  100. Dilated intercellular space in NERD with resistant to PPI is abnormal
  101. Value of upper endoscopy: indicated if PPI bid fails after 4-8 weeks.
  102. Role of pH in failed PPI bid patients: only 7% will have abnormal results
  103. Mucosal impedance is done through scope: This uses dilated interstitial space. If dilated space, then reflux.
  104. pH plus impedance: On treatment. Is best. High probability for gerd, do it on treatment. If low probability of gerd then do Bravo off treatment.
  105. First step in management of refractory is: compliance. Most patients take it only on demand 70%. Moreover, PPI is taken incorrectly. Take it 30 min before meals.
  106. Dose splitting of PPI is more effective or switch to another PPI. Dexilant once a day works in 88% of patients on bid PPI
  107. Baclofen reduces TLESR. 10 mg q hs and can increase to 20 tid. Has neurological side effects
  108. Stretta: is effective in 20% cases
  109. Esophyx TIF: good success.
  110. Antireflux surgery in refractory reflux. Useful in large HH, severe erosive esophagitis and regurgitation
  111. LINX reflux management: Effective in partial responders. Study from NEJM.
  112. Functional reflux: follow the tegaserod, TCA, SSRI, etc
  113. Melatonin in functional reflux is effective also.
  114. Hypnotherapy helps in functional reflux.
  115. Acupuncture plus PPI bid helps.


Friday, January 29, 2016
8:58 PM

Unit is Sv which is seivert 1 Sv is 100 rem.
CT of abd and pelvis is 10-20mSv (this is like 3-7 years of radiation exposure from natural environment)

Saturday, January 30, 2016

Approved for 1, 4

Saturday, January 30, 2016

Soft coag. 80 watts effect 5. For marking

Forced coag. 50 watts. Effect 2. ( 3-1-1)

Endocut 3-1-1 50 watts effect 3. Or 3-2-1 or 3-3-1

Increase cutting duration for larger duration

Let cautery do the cutting

Dry cut : 50 watts effect 2

Submucosal dissection. : endocut or drycut. Less used is swift coag

Forced coag. 25 watts effect 2. For pedunculated polyp

EMR. Endocut. Q. 3effect duration 1 and 3 interval
Upside down. Take lower part first. Must close in 1 cm. And check mobility Only polyp should move and not wall

Submucosal dissection : Stomach Dual knife Forced coag Effect 2 Watts 40. For esophagus and colon Effect 1 watts 40

Effect is voltage. Higher the number the higher the voltage
IT 2 knife in stomach : Effect 2, watts 50-6 0

Fold convergence, mucosal bleb are sign of fibrosis under polyp. Also when snare is around polyp you should be able to lift it otherwise fibrosis

Endocut effect is the blend. Goes from 1-4. Higher the number more coag. For EMR use effect 2 less coag. You decrease the thermal injury by squeezing tightly before cautery
Forced coag – deep injury. So prefer soft coag.
Soft coag by Doug Rex – effect 5, watts 80 blue pedal
Hot forceps avulsion technique – use endocut i( letter ) effect 3 cut duration 1 interval 3. Advantage over q lowers voltage setting 313
Underwater technique – use pure autocut effect 5 max watt 80
APC for flat lesion – power 30 flow 0.8 to 1 liter flow

Zika virus
Thursday, February 4, 2016

Can cause :intracranial calcifications, ventriculomegaly, and neuronal migration disorders (lissencephaly and pachygyria). Other anomalies included congenital contractures and clubfoot, microcephaly
Babies check eyes and hearing 6 months
Testing 3 tests PCR, IgM, PRNT
reverse transcriptase-polymerase chain reaction (RT-PCR) on infant serum. Serology assays can also be used to detect Zika virus-specific IgM and neutralizing antibodies. Plaque-reduction neutralization testing (PRNT) can also be performed to measure virus-specific neutralizing antibodies and differentiate from other flaviviruses.

Monday, February 8, 2016

Like the more well-known Borrelia burgdorferi, Borrelia mayonii causes symptoms like fever, rash, headache, and neck pain, and as the disease progresses it can cause arthritis. Unlike the original strain, though, Borrelia mayonii can also cause vomiting and nausea. The initial bacteria was also characterized by a rash that looked like a bull’s eye, but an infection with Borrelia mayonii can cause a more widespread rash on the body.

Wheat allergy
Wednesday, February 10, 2016

The Making of a Dietary Phenomenon
The question of whether to adopt a gluten-free diet is especially timely, given its impressive increase in popularity over the past decade. In fact, gluten avoidance has become the most popular dietary trend in the United States, with approximately 100 million Americans consuming gluten-free products last year.
Presently, there are at least three proposed clinical syndromes related to gluten ingestion: celiac disease, an autoimmune-mediated disorder; wheat allergy, an immunoglobulin E (IgE)-mediated entity; and gluten sensitivity, in which celiac disease and wheat allergy have been ruled out. Therefore, the decision to “go gluten-free” is either mandatory or elective; a gluten-free diet is mandatory for those individuals with appropriately diagnosed celiac disease and possibly wheat allergy. However, many individuals elect to follow a gluten-free diet because of a presumed sensitivity. While approximately 1% of the population are believed to have celiac disease, it is estimated that as many as 60% of Americans believe that a gluten-free diet will improve their physical and/or mental health.[1-4] It is their choice to follow a gluten-free diet in the hopes of improving digestion and bolstering their immune system, while also enabling enhanced performance and weight loss.
This belief has been fostered by the testimony of celebrities and athletes who attribute their success and well-being to adherence to a gluten-free diet. A survey done by Lis and colleagues[5] of 910 world-class athletes and Olympic medalists found that 41% followed a gluten-free diet, the majority because of a self-diagnosis of “sensitivity to gluten” and perceived ergogenic or health benefits. The same authors investigated the effects of a gluten-free diet on exercise performance, gastrointestinal symptoms, perceived well-being, intestinal injury, and inflammatory responses in nonceliac endurance athletes.[6]The short-term gluten restriction had no overall beneficial effect on any of these outcomes. In addition, numerous books and websites cater to this gluten-free phenomenon. Claims have even been made that gluten can be harmful to all of us.
The appeal of a gluten-free diet has become big business, leading to greater gluten-free product availability and a wider variety of dietary options. The market for gluten-free foods continues to expand and is estimated to have reached over $4 billion in retail sales in the past year. However, there are barriers to going gluten-free, including the cost and long-term safety of gluten-free foods and the potential for gluten cross-contamination of products. In addition, a gluten-free diet could present social restrictions, possibly leading to nonadherence.[7-9]
Nonceliac Gluten Sensitivity
Nonceliac gluten sensitivity (NCGS) is the newly minted term used to describe a clinical disorder related to ingestion of gluten or gluten-containing cereals.[8-13] Lebwohl and colleagues[14] suggest that a more accurate term for this condition is simply “people who avoid gluten.”
Clinical Spectrum
NCGS has largely been characterized by a series of self-reported gastrointestinal symptoms such as abdominal pain, gastroesophageal reflux, gas/bloating, nausea, diarrhea, and/or constipation.[15] However, a wide variety of nongastrointestinal symptoms has also been reported, including headache, fatigue, “foggy mind,” anxiety, depression, muscle aches, and skin rashes. A similar spectrum of symptoms has been reported in children.[16,17] Aziz and Hadjivassiliou[9]demonstrated that in patients with NCGS, gluten is independently associated with depression, which might share pathophysiologic mechanisms with other neurologic manifestations observed in gluten-related disorders, such as ataxia and encephalopathy.
Working Definition
A recent report by Fasano and colleagues[8] reviewed the current understanding of NCGS and outlined steps to dissipate some of the confusion related to this disorder. They propose a working definition as follows: “a clinical entity induced by ingestion of gluten leading to intestinal and/or extraintestinal symptoms that resolve once gluten is eliminated.” This definition requires that celiac disease and wheat allergy have been ruled out. They further propose that NCGS is associated with prevalent gluten-induced activation of innate—rather than adaptive—immune responses in the absence of detectable changes and mucosal barrier function. Gluten sensitivity was similarly defined by an international panel as the occurrence of intestinal and extraintestinal symptoms related to the ingestion of gluten-containing food in subjects without celiac disease or wheat allergy.[18-21]
Aziz and colleagues conducted a survey in order to estimate the prevalence of self-reported NCGS in the general population and the frequency of adherence to a gluten-free diet outside of celiac disease.[1,22] They determined that 13% of the population (79% female; mean age, 39.5 years) self-reported gluten sensitivity, only 0.8% of whom had a valid diagnosis of celiac disease. During investigation of another cohort of 200 patients with presumed gluten sensitivity (84% female; mean age, 39.6 years), 7% were found to have celiac disease and 93% to have NCGS.[1,22] All patients with celiac disease were HLA (human leucocyte antigen) DQ2 or DQ8 positive compared with 53% of the subjects with NCGS. Nutritional deficiencies, autoimmune disorders (23% vs 10%), and a lower mean body mass index were significantly associated with celiac disease compared with NCGS.
In a survey of more than 1000 Australians, 7% reported adverse effects when ingesting wheat products, although the majority had not undergone formal assessment for celiac disease or wheat allergy.[23]
Biesiekierski and colleagues[15] also surveyed a series of adults who believed that they had NCGS. They learned that a gluten-free diet was most commonly self-initiated among respondents (44%) and was less often prescribed by alternative health professionals (21%), dietitians (19%), or general practitioners (16%). Initiation of a gluten-free diet without adequate exclusion of celiac disease was common; no investigations to rule out celiac disease had been performed in 15% of respondents. In 25%, symptoms are poorly controlled despite gluten avoidance
Fad or Fact?
The postulated entity of NCGS has raised considerable interest and debate in both the medical and nonmedical literature.[24-28]
A report by Fasano and colleagues[8] emphasized that although there is clearly a “fad component” to NCGS, there is increasing evidence for its existence as a true clinical entity. However, much of the published information on NCGS was obtained from patients self-reported to be gluten-sensitive, calling into question data regarding the high prevalence,[18]activation of the innate immunity as the presumed pathogenic mechanism,[29,30] specific mucosal cytokine profile,[30,31] and the clinical spectrum.[22,32]
Fasano and colleagues[8] emphasized a need for better understanding of the role of gluten and wheat in irritable bowel syndrome (IBS), chronic fatigue syndrome, and autoimmunity, with precise nomenclature and definitions. In the absence of intestinal injury, specific antibodies, or any other biomarker, there is a clear need for an optimal diagnostic algorithm and consensus-based diagnostic criteria.[20]
Relationship to Irritable Bowel Syndrome
Individuals with gluten sensitivity have an increased prevalence of fulfilling the Rome III criteria for IBS.[1,22] It is not uncommon for patients with IBS to report improvement in clinical symptoms when gluten intake is restricted.
A series of studies have investigated the response to gluten in patients with IBS in whom celiac disease has been excluded. Wahnschaffe and colleagues[33] noted an improvement in patient-reported outcomes following institution of a gluten-free diet, including a decrease in the frequency of bowel movements, in patients with diarrhea-predominant IBS in whom celiac disease had been excluded.
Biesiekierski and colleagues[34] also studied patients with IBS who were proven not to have celiac disease and whose symptoms were under control on a gluten-free diet. Participants in this randomized trial were asked to eat a muffin containing gluten or a placebo of identical taste and texture. They found that symptoms were present in 68% of those ingesting gluten compared with 40% of those receiving a gluten-free product.
Vazquez-Roque and colleagues[35] studied 45 patients with diarrhea-predominant IBS who had no history of gluten avoidance. They were randomly assigned to receive either a gluten-free or a regular diet. Those on the gluten-containing diet had more frequent bowel movements.
Di Sabatino and colleagues[36] administered small amounts of purified gluten (4.4 g per day, equivalent to the amount present in two slices of bread) to 61 adults without celiac disease or wheat allergy who believed that ingestion of gluten-containing food was the cause of their intestinal and extraintestinal symptoms. In this crossover trial, the severity of overall intestinal—as well as extraintestinal—symptoms increased significantly during 1 week of intake of small amounts of gluten, compared with placebo. However, most patients showed no significant difference and the positive result was driven by a large effect of gluten in three patients.[14]
Gluten: Guilty as Charged?
While these studies seem to convincingly support gluten’s role in causing a wide variety of ailments, recent studies have suggested that there is more to the story, casting doubt on whether NCGS is a distinct clinical entity.
Zanini and colleagues[37] studied 35 subjects (31 females) who did not have celiac disease but were adhering to a gluten-free diet. Participants were randomly assigned to receive either gluten-containing flour or gluten-free flour for 10 days. This double-blind gluten challenge induced symptom recurrence in just one third of patients, fulfilling the clinical diagnostic criteria for NCGS.
Several authors have suggested that the improvement in symptomatology may be due to a placebo effect or to the fact that other nongluten components of wheat, such as fiber and wheat itself, are removed from the diet during adherence to a gluten-free diet.[38]
Several investigators have proposed a role for poorly absorbed carbohydrates in the genesis of the clinical symptoms. Intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) can trigger gastrointestinal distress.[39,40] These carbohydrates are poorly absorbed from the small intestine and thus enter the colon, where they osmotically increase luminal water, produce short-chain fatty acids, and induce gas production through fermentation by colonic bacteria. This leads to luminal distension, gas, and bloating. FODMAPs may also affect the microbiota, immune function, and the barrier of the gut, which might also generate gastrointestinal symptoms.[40] A diet with reduced FODMAPs has been reported to be effective in the treatment of patients with IBS.[41,42]
Biesiekierski and colleagues[43] reported results from a double-blind crossover study in patients with self-reported NCGS where those who were feeling well on a gluten-free diet improved further on a diet in which FODMAPs were eliminated. Participants were randomly assigned to a 2-week diet of reduced FODMAP intake and were then placed on a high-gluten (16 g gluten/d), low-gluten (2 g gluten/d and 14 g whey protein/d), or control (16 g whey protein/d) diet for 1 week. In all participants, gastrointestinal symptoms consistently and significantly improved during the phase of reduced FODMAP intake. Reintroduction of gluten in the otherwise low-FODMAP diet did not lead to a specific or dose-dependent relapse. Gluten-specific effects were observed in only 8% of participants. This placebo-controlled, crossover re-challenge study found no evidence of specific or dose-dependent effects of gluten in patients with NCGS ingesting a diet low in FODMAP components.
Nonceliac Wheat Sensitivity
To date, it is not known what component of wheat actually causes the symptoms.[44-46] Studies have specifically implicated wheat sensitivity (non-IgE-mediated wheat allergy) as a cause of symptoms in subjects with self-reported gluten sensitivity.
Nonceliac wheat sensitivity (NCWS) is the term applied to a clinical entity that has many similarities to celiac disease and NCGS, in that clinical manifestations can involve the gastrointestinal tract, the nervous system, the skin, and other organs.[47] Other shared features include the observation that the symptoms of NCWS disappear on exclusion of wheat from the diet and reappear on wheat consumption. Wheat contains both gluten and poorly absorbed carbohydrates, which can also undergo fermentation (as will other FODMAP components) and alter the microbiome, ruling out an immunologic involvement in NCWS.
Carroccio and colleagues[47] reviewed data on 276 patients diagnosed to have NCWS by means of double-blind, placebo-controlled wheat challenge. NCWS was characterized by a personal childhood history of food allergy, coexistent atopic diseases, positive serum anti-gliadin and anti-beta lactoglobulin antibodies, positive cytofluorimetric assay revealing in vitro basophil activation by food antigens, and a presence of eosinophils in the intestinal mucosa biopsies. Patients with NCWS and multiple food sensitivities showed several clinical, laboratory, and histologic characteristics that suggest they might be suffering from a non-IgE-mediated food allergy.
Guandalini and colleagues[48] also support a broader view, stating that there is no proof that gluten is causing NCGS. They reiterate that the majority of patients considered to have NCGS have not eliminated celiac disease as the cause of their symptoms before instituting a gluten-free diet. They cite studies that demonstrate a strong role for a placebo/nocebo effect of dietary elimination of gluten. Genetic testing for HLA-DQ2 and/or HLA-DQ8 genotypes (which are detected in nearly 100% of people with celiac disease) are present in about 40% of those with NCGS, which does not differ from the general population.
They suggest use of the term “wheat intolerance syndrome,” as this reflects the objective elements: the causative role is wheat and not gluten; the symptoms are best described as intolerance, a term which does not imply a specific mechanism as “sensitivity” does; and the series of reported symptoms may be due to various causes. Therefore, they argue, this is a syndrome.
A Suggested Approach
Differentiating between celiac disease, NCGS, and other wheat-related disorders can be challenging, but it is important for appropriate management.[8,49] As stated in a recent editorial, it is counterproductive to debate whether NCGS is “real”; the patients are real and are seeking care.[50]
The current clinical approach involves ruling out celiac disease and wheat allergy, testing for additional food intolerances or gastrointestinal conditions, and providing the latest data on the benefit/unintended consequences of gluten avoidance and these evolving entities.[50] It is also important to inform patients and their families about what is not known. It may also be effective to individualize the recommended dietary strategy by eliminating certain components of the FODMAP class, wheat products, and/or gluten sequentially.
Because there is no specific biomarker for NCGS, the diagnosis is “confirmed” by dietary elimination, followed by double-blind, placebo-controlled gluten-based re-challenges. This is a cumbersome, time-consuming, and difficult-to-access clinical approach. Even with this information at hand, the diagnosis of NCGS may remain unclear, raising the question of whether the salutary effects of gluten withdrawal are specifically attributed to the gluten-protein per se or to nongluten components such as fermentable carbohydrates and amylase-trypsin inhibitors.[49]
Khabbani and colleagues[51] reviewed records from 238 patients who presented for the evaluation of symptoms responsive to gluten restriction without prior exclusion of celiac disease. Of these study subjects, 42% had celiac disease and 52% had NCGS; the remainder had an indeterminate diagnosis. The majority (67%) of subjects with celiac disease presented with symptoms of malabsorption, compared with 25% of the NCGS subjects. In addition, those with celiac disease were significantly more likely to have a family history of celiac disease, personal history of autoimmune diseases, or nutrient deficiencies.
On the basis of these findings, the authors proposed a diagnostic algorithm to differentiate celiac disease from NCGS.[51] They state that subjects with negative celiac serologies (IgA tTG or IgA/IgG DGP) ingesting a gluten-containing diet are unlikely to have celiac disease. Those with negative serology who also lack clinical evidence of malabsorption and risk factors for celiac disease are highly likely to have NCGS and may not require further testing. Those with equivocal serology should undergo HLA typing to determine the need for biopsy.
Guandalini and colleagues[48] proposed assessment of the levels of gamma delta T-cell receptors in intraepithelial lymphocytes (which are specific for celiac disease) or detection of IgA anti-tissue transglutaminase antibody deposits in intestinal mucosa in order to more clearly exclude celiac disease in problematic cases.
Remaining Questions
As stated by Fasano and colleagues,[8] a better understanding of the clinical presentation of NCGS is needed, as well as its pathogenesis, epidemiology, management, and role in conditions such as IBS, chronic fatigue, and autoimmunity. There also must be agreement on the nomenclature and definition of gluten/wheat-related disorders based on proper peer-reviewed scientific information.
It is hoped that in the future, the terms NCGS, NCWS, andwheat intolerance syndrome will be replaced by well-defined nosology, that the phenotypes and mechanisms of syndromes responsive to gluten withdrawal will be better defined, and that there will be biomarkers and definitive therapy for distinct entities.

Medications — Several medications can delay gastric emptying. These include [2]:
Narcotics (affecting mu opiate receptors alone or combined with inhibition of norepinephrine reuptake [eg, oxycodone and tapentadol, respectively]) [28]
●Alpha-2-adrenergic agonists (eg,
●Tricyclic antidepressants [
●Calcium channel blockers
●Dopamine agonists
●Muscarinic cholinergic receptor antagonists

Octreotide [
●Glucagon-like peptide (GLP)-1 agonists and amylin analogues [
●Phenothiazines [

Cyclosporine (but not
tacrolimus, which is derived from macrolide molecule like
erythromycin, and does not inhibit gastric emptying)


Gastroparesis that occurs from medicines
Wednesday, February 10, 2016
3:18 PM

Thursday, February 25, 2016

Cirrhosis ALF
Monday, February 29, 2016

In patients with acute liver failure (ALF), decreasing platelet counts after hospital admission signaled systemic inflammation and a greater likelihood of systemic complications, such as high-grade hepatic encephalopathy, cardiovascular collapse, the need for liver transplant, and death, according to researchers.
Patients with systemic inflammatory response syndrome (SIRS) had significantly lower platelet counts at admission, compared with those without SIRS, and their platelet counts decreased dramatically (from 182 plus or minus 27 times 109/L on admission to 103 plus or minus 3.20 times 109/L on day 6) compared with stable platelet counts in patients without SIRS. For days 2-7 postadmission, lower platelet counts were associated with high-grade hepatic encephalopathy, as well as the need for vasopressor support and renal replacement therapy (Pless than or equal to .001 for all).

Tuesday, March 1, 2016

Larger virus. Like a prokaryote
Get infected by virophage ( eg zamilon phage virus)
Have CRISPR immunity that destroys the phage virus. ( areas of DNA that mimic phage DNA and destroy it )

Oxford GI cases
Tuesday, March 1, 2016

Tuesday, March 1, 2016

Telmisartan is an angiotensin receptor blocker that could be used as a weapon against NAFLD by increasing insulin sensitivity (and decreasing hepatic fat accumulation), and suppressing hepatic fibrogenesis. It is also reported to be effective in mild to moderate hypertension, and improves insulin sensitivity to type 2 diabetes mellitus, as well as cholesterol and triglyceride levels.

Cancer immunotherapy
Saturday, March 5, 2016

Keytruda and Opdivo

Glycemic index and glycemic load for 100+ foods – Harvard Health
Saturday, March 5, 2016

Tuesday, March 8, 2016

acoustic radiation force impulse was more accurate for detecting hepatitis C virus infection positivity in liver transplant recipients vs. Fibrotest, according to published findings.

Alzheimer’s prevention diet
Tuesday, March 15, 2016

This is the Medscape Neurology Minute. I’m Dr Alan Jacobs.
The MIND diet, created by researchers at Rush University Medical Center, has repeatedly ranked as the easiest to follow and second best diet overall in terms of reducing the risk for hypertension, heart disease, and stroke. It has now been found to protect against dementia. The name MIND stands for Mediterranean-DASH Intervention for Neurodegenerative Delay, where DASH stands for Dietary Approaches to Stop Hypertension.
In a recent study, the MIND diet lowered the risk for Alzheimer’s disease by 53% in participants who rigorously adhered to it and by nearly 35% in those who followed it moderately well.[1] Adhering to the MIND diet has also been found to slow cognitive decline among aging adults independent of any Alzheimer’s disease risk.[2]
The MIND diet has 15 dietary components: 10 brain-healthy food groups and 5 unhealthy groups, which consist of red meat, butter and margarine, cheese, pastries and sweets, and fried or fast food. To adhere to and benefit from the MIND diet, one would need to eat at least 3 daily servings of whole grains, a green leafy vegetable and one other vegetable every day, drink a glass of wine daily, snack mostly on nuts, have beans every other day or so, eat poultry and berries at least twice per week, and eat fish at least once per week. Limiting intake of the unhealthy foods is imperative to realizing the full benefits of the diet. Confirmation of these results in different populations and through randomized trials is needed.

Short bowel syndrome
Wednesday, March 16, 2016


Sleep disturbance, atoms complicatioattex – 0.5 mg /kg
Usual pt is TPN Or frequent dehydration from diarrhea
Polyps or colon cancer or other cancers
Reduce doses of opiates
Increased absorption of fluid so can cause CHF
It is GLP 2 agonist with single ALA with Gly
Monitor LFT
Colonoscopy 6 months before starting
SQ injection
Respiratory infection, nausea, bloating, hypersensitivity , abd pain


Doug Rex
Wednesday, March 16, 2016

Hydroxy ethyl starch plus methylene blue injection
Right squeeze first
Use Endo cut

Margins use tip of snare with soft coag

SPS use serrated polyposis syndrome
Do annual colonoscopy
If more than 5 lesions or more than 2 cm every 3-6 cm

Use serrated squeeze
Serrated polyp have more fat Some people squeeze, open a little and then squeeze again. This lets muscularis pop up

Aspirin colon ca
Wednesday, March 16, 2016

A modest but significantly reduced risk for overall cancer, especially gastrointestinal tract tumors, was observed with long-term aspirin use among 88,084 women and 47,881 men who underwent follow-up in 2 large US prospective cohort studies and reported on aspirin use biennially. Researchers found:
• Compared with nonregular use, regular aspirin use was associated with a lower risk for overall cancer (RR=0.97), which was primarily owing to a lower incidence of gastrointestinal tract cancers (RR=0.85), especially colorectal cancers (RR=0.81).
• Regular aspirin use may prevent a substantial proportion of colorectal cancers and complement the benefits of screening.
• The benefit of aspirin on gastrointestinal tracts cancers appeared evident with the use of at least 0.5 to 1.5 standard aspirin tablets per week with the minimum duration of regular use associated with a lower risk being 6 years.
• Among individuals aged ≥50 years, regular aspirin use could prevent 33 colorectal cancers per 100,000 person-years.

Broccoli and NASH
Sunday, March 27, 2016
“We found that the Westernized diet did increase fatty liver, but we saw that the broccoli protected against it,” she said. “Broccoli stopped too much uptake of fat into the liver by decreasing the uptake and increasing the output of lipid from the liver.”

Previous research conducted by Dr Jeffery found that chopping or steaming broccoli was the best way to enhance the availability of sulforaphane, broccoli’s anticancer compound.

Sunday, March 27, 2016
The four steps of the BBTI involve the following:
• Reduce time in bed. This doesn’t mean decreasing the amount of sleep per se, but rather the amount of wakefulness that can occur during a night. “By reducing time in bed we’re trying to increase the homeostatic drive to sleep,” said Dr. Reynolds, also director of the University of Pittsburgh Medical Center Aging Institute. “Being awake longer leads to quicker, deeper, more solid sleep.”
• Get up at the same time every day of the week.This practice “provides a kind of circadian anchor to the brain’s sleep wave rhythms, and reinforces those rhythms, and hence the efficiency of sleep,” he explained. “Even if you’ve slept poorly, getting up at the same time helps you to sleep better the next night.”
• Don’t go to bed unless sleepy. This strategy helps to increase sleep drive by keeping you awake longer. “Going to bed when you’re not sleepy can lead to frustration and gives your brain the wrong message,” he said. “The principles of stimulus control and temporal control are at the behavioral root of BBTI prescriptions.”
• Don’t stay in bed unless asleep. “We are teaching patients how to associate lying in bed with sleeping, and not with worrying or other activities that may lead to frustration or hyperarousal,” he said.
Studies have demonstrated that BBTI produces improvement in 70%-80% of patients. “It is a briefer, less complicated approach than traditional cognitive-behavioral therapy for insomnia,” Dr. Reynolds said. “BBTI also provides a wonderful behavioral foundation for intelligent evidence-based pharmacotherapy for common sleep disorders.”

Monday, March 28, 2016

The tests measured two proteins nicknamed GFAP and UCH-L1, which are present in brain cells. In a head injury, the proteins can leak into the bloodstream, Papa said.

Do blood test for upto 1 week after concussion

Tuesday, March 29, 2016

CURB65. Confusion, uremia, respiration, blood pressure and age. Score to admit

Artificial Sweeteners: A Wolf in Sheep’s Clothing?
Tuesday, March 29, 2016

Thursday, March 31, 2016

“Now the microbiome is another element in this equation—it’s not just diabetes, high blood pressure and obesity,” Iadecola notes. “There are also other factors which we need to know in order to tailor treatment.” The study suggests that such treatment may involve antibiotics, probiotics, dietary changes or other interventions that would change the gut’s microbiota to be supportive of regulatory T cells and reduce delta gamma T cells. For example, patients undergoing heart surgery, many of whom end up suffering a stroke, might go on a special preemptive diet, he says.

Sunday, April 3, 2016

In the study of nearly 3,000 patients, researchers from the Intermountain Medical Center Heart Institute in Salt Lake City discovered that the presence of high levels of the biomarker glycoprotein acetylation, or GlycA, was associated with an increased risk of heart attack or stroke.

Colon cancer
Sunday, April 3, 2016
LOS ANGELES (CBS News) – Drinking coffee may cut your risk of colon cancer by as much as 50 percent, a new study suggests.

The more you drink, the more you may reduce your risk – and it makes no difference whether the coffee is regular or decaf, researchers said.

“The protective effect is not caffeine, per se, but probably a lot of other antioxidant ingredients in the coffee that are released in the roasting process,” said senior researcher Dr. Gad Rennert. He is director of the Clalit National Israeli Cancer Control Center in Haifa, Israel.

Background: Coffee contains several bioactive compounds relevant to colon physiology. Although coffee intake is a proposed protective factor for colorectal cancer, current evidence remains inconclusive.
Methods: We investigated the association between coffee consumption and risk of colorectal cancer in 5,145 cases and 4,097 controls from the Molecular Epidemiology of Colorectal Cancer (MECC) study, a population-based case–control study in northern Israel. We also examined this association by type of coffee, by cancer site (colon and rectum), and by ethnic subgroup (Ashkenazi Jews, Sephardi Jews, and Arabs). Coffee data were collected by interview using a validated, semi-quantitative food frequency questionnaire.
Results: Coffee consumption was associated with 26% lower odds of developing colorectal cancer [OR (drinkers vs. non-drinkers), 0.74; 95% confidence interval (CI), 0.64–0.86; P < 0.001]. The inverse association was also observed for decaffeinated coffee consumption alone (OR, 0.82; 95% CI, 0.68–0.99; P = 0.04) and for boiled coffee (OR, 0.82; 95% CI, 0.71–0.94; P = 0.004). Increasing consumption of coffee was associated with lower odds of developing colorectal cancer. Compared with <1 serving/day, intake of 1 to <2 servings/day (OR, 0.78; 95% CI, 0.68–0.90; P < 0.001), 2 to 2.5 servings/day (OR, 0.59; 95% CI, 0.51–0.68; P < 0.001), and >2.5 servings/day (OR, 0.46; 95% CI, 0.39–0.54; P < 0.001) were associated with significantly lower odds of colorectal cancer (Ptrend < 0.001), and the dose–response trend was statistically significant for both colon and rectal cancers.
Conclusions: Coffee consumption may be inversely associated with risk of colorectal cancer in a dose–response manner.


Coffee and colon cancer
Monday, April 4, 2016
3:19 PM

Bariatric arterial embolization safe, effective in sustaining weight loss in severely obese people
Tuesday, April 5, 2016

NAFLD Blood test
Saturday, April 9, 2016
n this first stage of research the team developed the blood analysis in 26 patients with NAFLD. The test detects chemical changes on tiny amounts of “cell-free” DNA that are released into the blood when liver cells are injured. Changes in DNA methylation at genes like PPARγ that controls scar formation are then used to stratify patients by fibrosis severity.
Senior author Dr Jelena Mann of Newcastle University’s Institute for Cellular Medicine added: “This is the first time that a DNA methylation ‘signature’ from the blood has been shown to match the severity of a liver disease.

Colon cancer
Saturday, April 16, 2016

researchers at the Dana-Farber Cancer Institute and the Broad Institute of MIT and Harvard report on their findings from a new study, which found that colorectal cancers festooned with tumor-related proteins called neoantigens were likely to be saturated with disease-fighting white blood cells, mainly lymphocytes.

. Patients whose tumors had high numbers of neoantigens also survived longer than those with lower neoantigen loads.”

Hepatitis b
Saturday, April 16, 2016
In general, for HBeAg-positive patients with evidence of chronic HBV disease, treatment is advised when the HBV DNA level is at or above 20,000 IU/mL (105copies/mL) (or, per the EASL, >2,000 IU/mL[53] ) and when serum alanine aminotransferase (ALT) is elevated for 3-6 months.[5]
For HBeAg-negative patients with chronic hepatitis B disease, treatment can be administered when the HBV DNA is at or above 2000 IU/mL (104 copies/mL) and the serum ALT is elevated (ALT levels >20 U/L for females; 30 U/L for males) for 3-6 months.
NIH also indicates that immediate therapy is not routinely indicated for patients who have the following[5] :
• Chronic hepatitis B with high levels of serum HBV DNA but normal serum ALT levels or little activity on liver biopsy (immune-tolerant phase)
• Low levels of or no detectable serum HBV DNA and normal serum ALT levels (inactive chronically infected/low replicative phase)
• Positive serum HBV DNA but not HBsAg (latent HBV infection), unless the patient is undergoing immunosuppression
Caution must also be used with long-term and high-dose administration of adefovir or tenofovir therapy in patients with chronic HBV disease. In a National Institutes of Health (NIH) study, 15% of patients on adefovir or tenofovir for 2-9 years developed proximal renal tubular dysfunction, defined as de novo incidence of 3 of the following 5 features[61] :
• Hypophosphatemia
• Hypouricemia
• Elevated serum creatinine level
• Proteinuria
• Glycosuria
Switching to other antiviral agents in the study allowed for partial reversal of the renal tubular dysfunction.[
Low vaccination response rates have been associated with obesity, smoking, immunosuppression, and advanced age. Approximately 25-50% of persons who initially do not have a vaccine response will show a response to 1 additional vaccine dose, and 50-75% of individuals will have a response to a second 3-dose series.
It is recommended that testing for anti-HBs be obtained 4-12 weeks following vaccination.[43, 58] Revaccinate nonresponders, (HBsAb levels < 10 IU/L) with another series of 3-dose hepatitis B vaccine. Consider delaying revaccination for several months after initiation of antiretroviral therapy in patients with CD4 counts below 200 cells/mm3 or those with symptomatic HIV disease. The delay in these individuals is an attempt to maximize the antibody response to the vaccine.[43, 58]
Do not defer vaccination in pregnant patients or patients who are unlikely to achieve an increased CD4 count.[43, 58] Individuals at increased risk of severe complications due to HBV infection include those unlikely to achieve CD4 counts of 200 cells/mm3 or above after antiretroviral therapy (eg, HBV/hepatitis C virus [HCV] coinfection) and HIV-infected pregnant women.[43]

Medications that may increase the risk for hepatitis B reactivation include:
• Anti-CD20 antibodies: Ofatumumab (Arzerra), rituximab (Rituxan)
• Antineoplastic agents (including methotrexate) [98, 99]
• Glucocorticoids, especially with abrupt discontinuation [100, 101]
• Interleukin receptor antagonists: Ustekinumab (Stelara), [102] anakinra (Kineret), tocilizumab (Actemra)
• Nucleoside and nucleotide therapy, due to immune reconstitution syndrome or discontinuation of antiviral therapy with anti-HBV properties
• T-cell regulator: Abatacept (Orencia) [103]
• Tumor necrosis factor (TNF) inhibitors: Infliximab (Remicade), [102] etanercept (Enbrel), [102] adalimumab (Humira), [102] certolizumab pegol (Cimzia), golimumab (Simponi, Simponi Aria

Methods. A total of 48 nonresponders and 20 subjects naive to the HBV vaccine received a double dose of combined hepatitis A and B vaccine (Twinrix) at 0, 1, and 6 months. The levels of anti-HBs and antibodies to hepatitis A virus (anti-HAV) were determined before vaccination and 1 month after each dose.
Results. Among 44 nonresponders, protective anti-HBs levels were found in 26 (59%) after the first dose and in 42 (95%) after the third dose. Among the control subjects, the corresponding figures were 10% and 100%, respectively. All subjects seroconverted to anti-HAV. The titers of both anti-HBs and anti-HAV were lower in the previously nonresponsive subjects (P<.01).
Conclusion. Revaccination of nonresponders to the standard hepatitis B vaccine regimen with a double dose of the combined hepatitis A and B vaccine was highly effective. This is most likely explained by the increased dose, a positive bystander effect conferred by the hepatitis A vaccine, or both.

Gut bacteria
Saturday, April 16, 2016

This article has pictures that explains it succinctly

Basically, there are CB ( cannabinoid receptors ) in the brain and gut. Two types. They are very lipophilic. Certain gut bacteria up regulate it and some down regulate it.
When certain gut bacteria bind to it, it decreases mucos production , increase intestinal cell permeability and that leads to translocation of pro inflammatory systemic conditions. Moreover , other things that happen are GLP receptors get stimulated and this affects the glucose metabolism locally and then systematic to lead to T2D. This is at gut level, pancreas, liver and skeletal muscle
At central level, it increases sense of odor and craving of food

There are on the other hand certain gut bacteria that do the exact opposite! This there is a balance that is needed. When people get gastric bypass even the gut microbiota changes

Hope that is not over simplified but it is a primer 101

Bhavin Dave

Colon cancer
Saturday, April 16, 2016

ECR is performed in the setting of clinically obvious associated high-risk features (polyposis, IBD, synchronous/metachronous cancers) but not in isolated/sporadic CRC. However, attention must be paid to patients with seemingly lower risk characteristics (isolated CRC, no polyposis), as LS can still be present. In addition, the presumed sporadic group requires further study as metachronous CRC risk in early-onset sporadic CRC has not been well-defined, and some may harbor undefined/undiagnosed hereditary conditions. Abnormal MSI (LS risk) is not associated with ECR; abnormal MSI results often return postoperatively after segmental resection has already occurred, which is a contributing factor.
Extended colon resection versus local resection

Coffee benefits
Saturday, April 16, 2016

Heart disease, cancer, liver disease and obesity / metabolic syndrome

Sunday, April 17, 2016

When patients with lean-NAFLD and overweight patients were divided according to waist circumference, lean-NAFLD with higher waist circumference had greater prevalence of metabolic syndrome, carotid plaques and significant fibrosis compared with patients who were overweight or had obesity.

Sunday, April 17, 2016
Soy is of two types. Fermented and non fermented. Non fermented has phytic acid and lecithin which some people is chelating and toxic. Fermented soy has iso flavin which is beneficial.
So not straightforward.

Tuesday, April 19, 2016

Reduced total cortical volume and temporal lobe cortical thickness and greater lateral ventricle and inferior lateral ventricle volumes were seen in the AC+ participants relative to the AC− participants.

Weschler Memory Scale–Revised Logical Memory Immediate Recall

For elderly patients above 70

This was part of Alzheimer’s Disease Neuroimaging Initiative (ADNI) and the Indiana Memory and Aging Study (IMAS). Published in JAMA neurology

Wednesday, April 20, 2016
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Forget the energy bar, scientists say CHOCOLATE could give the ultimate boost to athletes
By Fiona Macrae for the Daily Mail20:40 19 Apr 2016, updated 20:49 19 Apr 2016

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• 19comments
• Cyclists who snacked on the sweet treat were able to go faster and further
• Thought epicatechin gives the body a boost by widening the blood vessels
• Plant chemical is particularly abundant in dark chocolate
Scientists may have found the ultimate sports enhancing drug – dark chocolate.
Cyclists who snacked on the sweet treat were able to go faster and further.
It that thought that epicatechin, a plant chemical particularly abundant in dark chocolate, gives the body a boost by widening the blood vessels.

Is that thought that epicatechin, a plant chemical particularly abundant in dark chocolate, gives the body a boost by widening the blood vessels.
Same with beet root but milder

Pancreatic cancer
Thursday, April 21, 2016

Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans.” Individuals “who carried Porphyromonas gingivalis had an overall 59 percent greater risk of developing pancreatic cancer, and those who carried Aggregatibacter actinomycetemcomitans were at least 50 percent more likely overall to develop the disease.”

Gastric cancer
Friday, April 22, 2016
Three or more alcoholic drinks per day every day increases risk of stomach cancer. A standard drink is 12 ounces of beer, 5 ounces of wine or 1.5 ounces of distilled spirits, according to the U.S. National Institutes of Health.

• For every 1.8 ounces of processed meat eaten every day – the equivalent of one hot dog or two slices of bologna – the risk of cancer in the lower stomach rises by 18 percent.

• Every five-unit increase in body mass index – BMI, a ratio of weight to height – causes a 23 percent increased risk of cancer in the upper stomach.

Saturday, April 23, 2016

Burning Mouth Syndrome: Background, Anatomy and Physiology, Pathophysiology
Sunday, April 24, 2016

Monday, April 25, 2016
BARCELONA – Although a new histological scoring system was able to predict mortality from nonalcoholic fatty liver disease (NAFLD), fibrosis remains the key predictor of whether an individual is likely to die decades later.
Patients with severe NAFLD, as determined by having a high steatosis, activity, and fibrosis (SAF) score, were more than twice as likely to die than those with mild-to-moderate disease up to 41 years later.
However, when a sensitivity analysis was performed to adjust for fibrosis stage or exclude patients with stage 3-4 fibrosis, the hazard ratio for mortality was no longer significant.

Sara Freeman/Frontline Medical News
Dr. Hannes Hagström
“Severe SAF score was associated with increased mortality, but this largely depended on fibrosis stage,” Dr. Hannes Hagström of the Karolinska Institutet in Stockholm reported at the International Liver Congress.
Although it is known that the more severe the disease the more likely the risk for death, assessing the severity of NAFLD can be challenging for clinicians because it is a continuum of disease, he explained. “NAFLD is the most prevalent liver disease globally with a prevalence of around 25%; it is very heterogeneous and makes prognostication difficult.” This has implications for including people in trials and for determining what the clinical endpoints should be, as well as making it difficult to determine the outlook for individual patients.
There are several histological scoring systems developed over the years trying to help with this issue, including the Brunt score, the NAFLD activity score (NAS), and fibrosis stage.
While the latter has previously been shown to be a robust marker for mortality, the NAS has been criticized, Dr. Hagström noted. This is because the effect of steatosis may be overestimated and because NAS does not measure fibrosis. Thus, there is a need for new means to risk-stratify patients and one relatively new method is the SAF score.
The SAF score was developed to evaluate the severity of fatty liver lesions, originally in morbidly obese individuals (Hepatology. 2012 Oct;56:1751-9). Using this score, the extent of fatty accumulation in the liver can be assessed, with a score of 0 signifying that steatosis is present in less than 5% of the liver and a score of 3 signifying that more than two-thirds of the liver is affected. NAFLD activity is determined on a scale of 0 to 4 by assessing the degree of ballooning and lobular inflammation. Finally, the score looks at the extent of fibrosis, rating it from 0 (not present) to 4 (cirrhosis).
The aim of the study was to examine the impact of this score on overall mortality in a previously published (Hepatology. 2015 Mar;61:1547-54) cohort of patients with long follow-up, Dr. Hagström explained at the meeting sponsored by the European Association for the Study of the Liver (EASL). Data on 139 patients with biopsy-proven NAFLD were obtained from a historical cohort of patients who had undergone liver biopsy between 1974 and 1994. Their biopsies were reclassified using the SAF score and the presence of nonalcoholic steatohepatitis was also determined using the FLIP algorithm and the NAS score. Data on causes of death were taken from a national Swedish population register. At baseline, 35 patients had mild, 35 had moderate, and 69 had severe NAFLD.
After a median follow-up of 25 years, ranging from 2 to 41 years, 74 patients died. Of these deaths, 45 occurred in patients with severe NAFLD, representing 65% of the severe NAFLD group. Half (n = 18; 51%) of the patients with moderate NAFLD and just under one-third (n = 11; 31%) of those with mild NAFLD had also died. The median time to death was 18 years after liver biopsy.
Dr. Hagström reported that cardiovascular causes were the main cause of mortality, in 21% of patients; extrahepatic malignancy caused 12% of deaths, 7% of deaths were liver related, and 13% were due to other reasons. Patients with severe NAFLD identified by a high SAF score were more than two and a half times more likely to die than those with mild NAFLD, with a hazard ratio of 2.65 (P = .02). Patients with moderate NAFLD were no more likely than those with mild liver disease to die (HR = 1.23; P = .84). Data had been adjusted for gender, body mass index, and for the presence of type 2 diabetes.
HRs for mortality comparing high with low SAF scores after adjusting for fibrosis stage and excluding patients with fibrosis stages 3-4 were a respective 1.85 (P = .18) and 1.94 (P = .15). In a press statement issued by EASL, Dr. Laurent Castera of Hôpital Beaujon in Paris noted that these data were an important step forward for the medical community in being able to identify the patients who are most at risk of death from NAFLD. Dr. Castera, who is the secretary general of EASL, noted that these long-term study data also demonstrated the importance of having sufficient follow-up periods for patients with NAFLD.
In an interview after his presentation Dr. Hagström also emphasized the importance of long-term follow-up of patients.
“The clinical importance of this is that it is most important for clinicians to look at fibrosis stage, and I think to have to follow these patients a little bit more,” he said. “You can’t just do a liver biopsy, say ‘you just have steatosis, you don’t have NASH [nonalcoholic steatohepatitis], [so] you are fine’,” he added. Equally, it is not possible to say that because NASH is not present that patients won’t advance in the future. Patients need to be followed up for a long period of time.
“Fibrosis is the most important thing, both for clinicians and for patients,” Dr. Hagström said.Dr. Hagström has been a consultant to Novo Nordisk. Dr. Castera had no relevant financial disclosures.
Key clinical point: The steatosis, activity, and fibrosis (SAF) score predicted NAFLD mortality but fibrosis remains the most important factor.
Major finding: The adjusted hazard ratio (HR) for mortality with a high SAF score (severe NAFLD) versus low SAF score (mild NAFLD) was 2.65 (P = .02). HRs for mortality comparing high with low SAF scores after adjusting for fibrosis stage and excluding patients with fibrosis stage 3-4 were a respective 1.85 (P = .18) and 1.94 (P = .15).
Data source: 139 patients with biopsy-proven NAFLD from a historical cohort (1974-2015).
Disclosures: Dr. Hagström has been a consultant to Novo Nordisk.

Histopathological algorithm and scoring system for evaluation of liver lesions in morbidly obese patients – Bedossa – 2012 – Hepatology – Wiley Online Library
Monday, April 25, 2016

NAFLD and CV risk
Friday, April 29, 2016
7:09 AM

Steatosis predicted C-IMT better than diabetes or dyslipidemia, and steatosis independently predicted C-IMT (P=0.002) and FRS (P <0.001) after adjustment for the metabolic syndrome and cardiovascular risk factors, Pais and colleagues reported.

In the 1,872 patients with a follow-up ultrasound, C-IMT increased in patients with steatosis, from 0.60 ± 0.13 mm to 0.66 ± 0.14 mm (P=0.001), but C-IMT did not change in patients who remained free of steatosis.

(Carotid intima media thickness). Did not do biopsies though. Cannot differentiate between NASH and NAFLD. From France, Journal of Hepatology

Gut Microbiome
Friday, April 29, 2016
10:55 AM

After analyzing the samples and comparing them with other data collected in the Lifelines-DEEP study, the scientists found that consuming fruits, vegetables and yogurt positively influenced microbial diversity in the gut.
In addition, drinking tea, wine, coffee and buttermilk was also correlated with more diversity.
On the flip side, sugary sodas and savory snacks were associated with lower levels of diversity. So was having irritable bowel syndrome and smoking during pregnancy.


C diff zinplava
Sunday, May 1, 2016

“Results of these studies showed that a single, one-time infusion of the antitoxin bezlotoxumab given with standard of care C. difficile antibiotic treatment significantly reduced the recurrence of C. difficile infection compared to standard of care alone, and demonstrated this benefit over a 12-week period,” said Dr. Mark Wilcox, Leeds Teaching Hospitals and University of Leeds, U.K., and a lead investigator for the studies. “These results were also demonstrated in patient subgroups known to be at high risk for C. difficile recurrence.”

Monday, May 2, 2016

Relamorelin (RM-131, Motus) is a ghrelin agonist being developed for treating patients with diabetic gastroparesis or GI functional disorders, which works by stimulating GI motility in these patients, according to a press release. The FDA has granted fast track review status to relamorelin for the indication of diabetic gastroparesis, and phase 2a clinical trials in diabetic gastroparesis and chronic constipation have already been completed.

Hep Ichart
Wednesday, May 4, 2016

Hcv drug interactions

Wednesday, May 4, 2016

Thursday, May 5, 2016

When perimenopausal AMH “goes below 250 pg/mL, you are beginning to lose bone, and, when it goes below 200 pg/mL, you are losing bone fast, so that’s when you might want to intervene.” The finding “opens up the possibility of identifying women who are going to lose the most bone mass during the transition and targeting them before they have lost a substantial amount,” said lead investigator Dr. Arun Karlamangla of the department of geriatrics at the University of California, Los Angeles.

Anti mullerian hormone

Ulcerative colitis
Thursday, May 5, 2016

Ozanimod is a modulator of the sphingosine-1-phosphate subtype 1 (S1P1) and S1P5 receptors. Agonists of S1P1 interfere with the migration of B and T lymphocytes from secondary lymphoid tissues, so the lymphocytes are unable to track to the sites of inflammation. Its mechanism is thus similar to that of the multiple sclerosis dr

In addition, clinical responses at that time point were seen in 57% of the 1-mg group and in 54% of the 0.5-mg group, compared with 37% of the placebo group (P=0.02 and P=0.06, respectively), the investigators reported in the May 5 New England Journal of Medicine.

Thursday, May 5, 2016
Sea hero quest. How good are you at it?
Have your patients play it! Poor scores?
dementia is a possibility

Cancer antibody
Thursday, May 5, 2016

The antibody, researchers believe, only recognizes the structurally different part of CFH protein that they believe is only found in tumor cells. It then impacts tumor growth by disabling the protective CPH layer and destroying cancer cells. They don’t necessarily want the antibody to kill all the tumor cells, though, Patz noted.

Audio recording started: 17:55 Thursday, May 5, 2016

C diff
Friday, May 6, 2016

Clostridium difficile infections, according to a case-control study presented at the European Society of Clinical Microbiology and Infectious Diseases annual congress. Tigecycline effected a 76% clinical cure rate, compared with 53% for the combination regimen of intravenous metronidazole and oral vancomycin, Dr. Baltin Gergely Szabo reported.

Entyvio vidalizumab
Friday, May 6, 2016

44% chance of infection after abd or perianal infection

Saturday, May 7, 2016

NAFLD and fibrosis will be dosed with either 400 mg of aramchol (Galmed) — a conjugate of cholic acid and arachidic acid — vitamin D, 400 mg of aramchol plus vitamin D or placebo for 24 weeks, followed by a 4-week follow-up period.

Sunday, May 8, 2016
Impella was approved for pVAD Tandem is another one. Both are used for CHF
Mirca is a leadless pacing device. A good option for pediatrics
MRI safe pacemakers about to be released
TAVRcuriously causes renal flow by high urine flow nephritis small study

Ppl damage mechanism
Tuesday, May 10, 2016

Researchers found that while the H2 blockers had no effect on vascular aging, chronic use of the PPIs indeed impaired the lysosomes, preventing them from generating acid.

“We also saw the telomeres shortening – they’re on the tips of chromosomes and like our biological clock,” Cooke added. “Those vascular cells couldn’t proliferate or divide as well, and that’s necessary for repairing a wound in the vessel.”

Wednesday, May 11, 2016

Friday, May 13, 2016

resveratrol, which occurs naturally in blueberries, raspberries, mulberries, grape skins and consequently in red wine.
Counters effect of high fat and sugar

Anti TNF
Tuesday, May 17, 2016

The researchers determined that 19% of the infections were serious, while 27% were considered uncomplicated and 7% were recurrent. About 10% of the 42 patients who had been treated with the anti-TNF drugs had been diagnosed with rheumatologic diseases; about 25% of the patients identified with IBD experienced infections. Recurrent infections were observed in 2% of the rheumatologic patients and in 11% of IBD patients.

Cirrhosis. Nash
Tuesday, May 17, 2016

cenicriviroc showed favorable pharmacokinetics in patients with mild-to-moderate liver cirrhosis.
Fast track for NASH

Exercise and cancer
Tuesday, May 17, 2016
These exercisers were 42% less likely than those who got little to no exercise to develop esophageal adenocarcinoma. They were 27% less likely to develop liver cancer, 26% less likely to develop lung cancer and 23% less likely to develop kidney cancer. Their rates of gastric cardia and endometrial cancers were 22% and 21% lower, respectively, than were those of non-exercisers. And the most frequent exercisers drove their rates of myeloid leukemia down by 20%.
Those who worked out most saw their rates of six types of cancer drop by 10% to 20% compared with those who reported the least exercise. Their rates of myeloma, colon and head and neck cancers were 17%, 16% and 15% lower, respectively. They were 13% less likely to develop cancers of the rectum or bladder and 10% less likely to develop breast cancer.

Tuesday, May 17, 2016

GERD is actually an inflammatory response prompted by the secretion of proteins called cytokines.

JAMA. 12 patients

Hepatitis B and statin
Thursday, May 19, 2016

“This large population-based study in a hepatitis B virus endemic country suggested that statins independently protect [chronic hepatitis B] patients from the development of cirrhosis, its complications and its decompensation according to a dose–response relationship,” Yi-Wen Huang, MD, PhD, of the Liver Center, Cathay General Hospital Medical Center, Taiwan, and colleagues wrote.

Cancer prevention
Monday, May 23, 2016

nearly half of cancer deaths in the United States could be prevented if Americans decided to quit smoking, reduce their drinking, maintain a healthy weight, and include at least 150 minutes of exercise into their schedule each week.

Contrast Enhanced US for liver
Monday, May 23, 2016

also helpful for kidneys and crohns

Low residue colonoscopy diet
Tuesday, May 24, 2016

contrast, the low-residue group were allowed to eat three meals that included small portions of foods such as eggs, yogurt, bread, rice, chicken breast, and ice cream.

Tuesday, May 24, 2016
traditional 4-quadrant forceps biopsy found seven of these lesions, the addition of wide area transepithelial sampling (WATS) detected 23 of these lesions, reported Prashanth Vennalaganti, MD, of the University of Kansas Medical Center in Kansas City, and colleagues at the annual Digestive Disease Week.
“I would expect the use of WATS to become the standard of care for patients at risk of esophageal cancer,” Vennalaganti told MedPage Today. “Fortunately we have a pre-malignant condition, Barrett’s esophagus, for which we have evidence that it progresses cancer. Unfortunately, we have few good techniques that can identify the stages that it can progress through.”
He said use of established biopsy protocols to detect high-grade dysplasia or early-stage cancer can be inefficient, and sometimes doctors fail to adhere to the standard protocol that, in the case of a 10-cm Barrett’s lesion, could involve taking 20 to 40 samples. As a result, a vast majority of Barrett’s lesions are not sampled, he added.
By supplementing the standard biopsy protocol with WATS, which utilizes a brush that scrapes up tissue that is then processed by a computer, more suspicious lesions can be identified, he said.
But he cautioned that WATS is intended to supplement, not replace, standard biopsy protocols.
“We lumped high grade dysplasia and early-stage esophageal cancer together because we treat both conditions the same way, with endoscopic ablative procedures,” he said.
In the study, 160 patients from 16 U.S. institutions were enrolled. All had a diagnosis of Barrett’s esophagus and underwent the standard biopsy and WATS. The mean patient age was 63.4, and 76% were male while 95% were Caucasian. The mean Barrett’s esophagus circumferential extent was 4.7 cm and the mean maximal extent was 7.1 cm.
The WATS protocol consisted of one kit (two brushes) for each 5 cm of Barrett’s esophagus length.
The diagnostic yield for forceps biopsy was high-grade dysplasia/cancer (4.4%), low-grade dysplasia/indefinite for dysplasia (17.5%), non-dysplastic Barrett’s esophagus (66.25%), and no Barrett’s esophagus (11.9%).
Using WATS in addition to forceps biopsy, an additional 23 cases high-grade dysplasia/cancer were identified for an absolute increase of 14.4% (95% CI 7.5-21.2% and a relative increase of 428%.
One high-grade dysplasia/cancer patient diagnosed by forceps biopsy was misclassifed by WATS as low-grade disease.
The authors concluded that “the use of WATS can improve surveillance programs in patients with Barrett’s esophagus.”
The ability to detect dysplasia in Barrett’s esophagus needs to be optimized, pointed out Philip Katz, MD, of the Albert Einstein Medical Center in Philadelphia, who was not involved in the study.
“Our biopsies have met the test of time and are the standard to which we compare everything to,” he said. “What [WATS] seems to do is to allow us to add to our ability to detect [dysplasia in Barrett’s esophagus]. The way it has been designed, and the computerized analysis seems, based on the data, to offer an ability to enhance detection.”
While WATS did add procedure time, it would be time “well spent,” if the data hold up over the long-term, he stated.
“Like everything we do, we will learn more about it, as we use it more and it will find its appropriate place “Right now, I’m using it as an adjunct to my traditional endoscopic intervention for detection of dysplasia in patients with Barrett’s.”
The study was supported by CDx Diagnostics.
Vennalaganti disclosed no other relevant relationships with industry.
Katz disclosed no relevant relationships with industry.
• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine
• Primary Source
Digestive Disease Week
Source Reference: Vennalaganti P, et al “Increased detection of barrett’s esophagus-associated neoplasia using wide area transepithelial sampling in conjunction with 4-quadrant forceps biopsies: final results from a multi-center, prospective, randomized trial” DDW 2016; Abstract 60.

Wednesday, May 25, 2016

At week 12, clinical remission was reached by 24.4% of patients given 200 mg of the monoclonal antibody risankizumab (BI 655066) at weeks 0, 4, and 8 and by 36.6% of those given 600 mg at those time points compared with 15.4% of those receiving placebo (P=0.308 and P=0.025), according to Brian G. Feagan, MD, of Robarts Clinical Trials in London, Ontario, and colleagues.

Thursday, May 26, 2016
The cure for type 2 diabetes may be all in your head, a new study in rats and mice suggests.
With a single shot to the brain, researchers can rid rodents of all symptoms of the disease for months. The injection, a relatively low dose of a tissue growth factor protein called fibroblast growth factor 1 (FGF1), appears to reset powerful neural networks that can control the amount of sugar in the blood.

Crohns fistula
Thursday, May 26, 2016

A bioprosthesis plug soaked in autologous mesenchymal stem cells appeared to heal refractory perianal fistulas that commonly occur in Crohn’s disease, researchers reported here.

SAN DIEGO — Intensive treatment with fecal microbiota transplantation (FMT) showed efficacy for ulcerative colitis in patients who were resistant to or intolerant of conventional therapy, a randomized trial found.

Thursday, May 26, 2016

Action Points
A total of 27% of patients given the active treatment met the study’s primary outcome of clinical remission plus endoscopic response or remission after 8 weeks compared with 8% of those who received placebo (P=0.02), reported Sudarshan Paramsothy, MD, of the University of New South Wales in Australia.
In addition, at week 8, steroid-free clinical remission and clinical response rates compared with placebo were 44% versus 20% (P=0.02) and 54% versus 23% (P<0.01), he said at the annual Digestive Disease Week.
“In recent years, researchers have gained a better understanding of the gut microbiota and the critical role it plays in health and disease, including conditions like ulcerative colitis,” Paramsothy said during a press briefing. The estimated prevalence of ulcerative colitis is 200/100,000 adults, according to the CDC.
“The FDA has approved FMT for recurrent Clostridium difficile infection, but questions remain as to whether FMTs could be useful for other types of digestive disorders,” said Beth McCormick, PhD, of the University of Massachusetts Center for Microbiome Research in Worcester, who was not involved in the study. “This randomized, placebo-controlled trial demonstrated promising results for ulcerative colitis, a treatment that hasn’t received FDA approval specifically for this indication, but there’s potential for future progress here,” she said in a press briefing.
“FMT has a lot of promise in ulcerative colitis,” Paramsothy told MedPage Today.
And while the gut microbiota is the antigenic driver in ulcerative colitis, the efficacy of microbial manipulation has not been established, although preliminary low-dose studies suggested potential benefit.
To test FMT in a population of treatment-resistant patients, the authors enrolled 81 patients with active disease, in that Mayo scores were 4 to 10. They were given FMT via a colonoscopic infusion on day 1 and then self-administered FMT enemas 5 days per week for 8 weeks.
“This population is accustomed to using enemas as part of their treatment, so our approach would not be unusual to them,” he said.
The enemas consisted of stool from at least three different donors, to avoid potential “donor effect,” in which the microbial characteristics of a single patients could be unduly influential. Donors are screened to ensure safety of the stool.
Patients were allowed to continue taking immunomodulators such as 5-aminosalicylate and and steroids in doses no higher than 20 mg/day, but had to have stopped previous biologics at least 12 weeks earlier. They also had to stop using any other enema treatments.
The primary endpoint required a Mayo score of 2 or less with subscores of 1 or less for rectal bleeding, stool frequency, and endoscopic appearance, as well as a 1-point or more reduction from baseline on the endoscopy subscore. Clinical remission required a combined total score of 1 or less for the rectal bleeding and stool frequency subscores.
Steroid-free endoscopic remission scores for the FMT and placebo groups were 17% versus 8% at week 8 (P=0.19), while endoscopic response rates were 37% versus 10% (P<0.01).
After the initial 8-week phase, 37 of 40 patients who had been randomized to placebo and went on to receive the active FMT for an additional 8 weeks. Of these, 27% met the primary endpoint, 46% were in clinical remission, and 24% had endoscopic remission.
There were three serious adverse events of worsening of colitis. Two of these were in the active treatment group, with one requiring colectomy, and one in the placebo group.
“We were able to show definitively that fecal microbiota transplantation is an effective treatment for ulcerative colitis. This is important because there are millions of people worldwide seeking alternative treatments for this condition,” Paramsothy said.
The long-term effects of the treatment have yet to be established, he cautioned.

Thursday, May 26, 2016

In healthy cells Bak sits in an inert state but when a cell receives a signal to die, Bak transforms into a killer protein that destroys the cell.

Web page final 2016
Monday, May 30, 2016


Wednesday, June 1, 2016

Sleep apnea. One third of patients with insomnia have obstructive sleep apnea (OSA),[8] which is caused by upper-airway collapse during sleep that leads to repeated breathing stoppages throughout the night. If a patient has OSA, their insomnia may be refractory to both nonmedication and medication treatment options. Once OSA is formally diagnosed with polysomnography and treated, the associated insomnia symptoms often completely resolve.
In addition to insomnia, there are also long-term risks associated with untreated OSA. These include an association with long-term cardiovascular and cerebrovascular disease.[5]
The STOP BANG Inventory[9] can help you quickly establish whether your patient is at high risk for OSA and would benefit from polysomnography. If they have five or more of the following factors, they are considered at high risk:
• Snoring
• Tiredness
• Observed that you stop breathing
• History of high blood pressure
o Body mass index > 35 kg/m2
o Age older than 50 years
o Neck circumference > 40 cm (15.75 in)
o Gender: male
Although polysomnography is not part of the standard workup of insomnia, it is warranted in specific cases, such as when sleep apnea or another sleep disorder is suspected or if the insomnia remains refractory to treatment.[2]

Medicines that cause insomnia
Wednesday, June 1, 2016

Common medications than can cause insomnia include anticonvulsants, beta-blockers, antipsychotics, antidepressants, and nonsteroidal anti-inflammatory drugs.[12] A timeline may be useful to determine whether the initiation of a new medication, or a change in dose, correlates with worsening of insomnia.

Wednesday, June 1, 2016

Eogenius for tissue diagnosis

High sensitivity troponin and rapid serial testing
Thursday, June 2, 2016
Myocardial infarction

The second study released alongside in JAMA Cardiology affirmed that serial use of the high-sensitivity test at presentation and at 1 hour was “comparable” in performance to a 3-hour protocol, as had been initially reported at the European Society of Cardiology meeting.

“With application of a low troponin I cutoff value of 6 ng/L, the rule-out algorithm showed a high negative predictive value of 99.8% (95% CI, 98.6%-100.0%) after 1 hour for non-ST-segment elevation MI type 1,” Dirk Westermann, MD, PhD, of the University Heart Center Hamburg, Germany, and colleagues reported. “Similarly, a rule-in algorithm based on troponin I levels provided a high positive predictive value with 82.8% (95% CI 73.2%-90.0%).”

Again, a lower cutoff appeared better, the researchers wrote, as “application of the cutoff of 6 ng/L resulted in lower follow-up mortality (1.0%) compared with the routinely used 99th percentile (3.7%) for this assay.”

Their prospective Biomarkers in Acute Cardiac Care (BACC) study included 1,040 patients presenting to the emergency department with acute chest pain from July 19, 2013, to Dec. 31, 2014, along with two independent cohorts totalling 4,009 patients.

High-sensitivity troponin tests are used routinely in many regions of the world but haven’t yet become available in the U.S., David A. Morrow, MD, MPH, of Brigham and Women’s Hospital in Boston, noted in an accompanying editorial.

Tuesday, June 7, 2016
Professor Chris Chang, from the University of California, Berkeley, who led the study, said: ‘We find that copper is essential for breaking down fat cells so that they can be used for energy.
‘It acts as a regulator. The more copper there is, the more the fat is broken down.
‘We think it would be worthwhile to study whether a deficiency in this nutrient could be linked to obesity and obesity-related diseases.’
He said copper could potentially play a role in restoring a natural way to burn fat.

Monday, June 13, 2016

Tacrolimus worsens IBD when gives post OLT for PSC

Friday, June 17, 2016

A first-in-human study suggests that a novel technique holds promise for the treatment of diabetes, reducing the complications, associated morbidity, and economic burden of this disease. Duodenal mucosal resurfacing (DMR) achieved a significant reduction in hemoglobin A1c (HbA1c) levels as well as a robust reduction in the liver enzymes aspartate aminotransferase and alanine aminotransferase in patients with poorly controlled type 2 diabetes.

Monday, June 27, 2016
11:01 PM

Prostate cancer
Monday, June 27, 2016
11:01 PM

The test, called Oncotype DX, which looks at the expression of 17 genes in a tumor, cost about $4,000 and was not covered by Mr. Woska’s insurance. But through a patient assistance program, the company that created it, Genomic Health, ran it for him free, using a tiny grain of tissue left over from his biopsy. The results indicated there was an 81 percent probability that Mr. Woska’s tumor would not spread beyond the prostate.
On an aggressiveness scale of zero to 100, the tumor was an indolent 15.
The STHLM3 tests will be available in Sweden in March 2016 and we will now start
4Kscore Test for aggressive prostate cancer (PC) was chosen by an expert panel of the European Association of Urology (EAU) to be included in the 2016 EAU Guidelines for Prostate Cancer. The panel decided that 4Kscore, a blood test, showed greater specificity than the prostate-specific antigen (PSA) test in determining the probability of high-grade prostate cancer, and its use was indicated prior to a first biopsy or after a negative biopsy.

Monday, June 27, 2016
11:03 PM

CRE TEST for resistance
Thursday, June 30, 2016

The test, called the Xpert Carba-R Assay (Cepheid), checks patient specimens, usually obtained by rectal swabs, for the presence of five different genetic markers associated with carbapenemase. This is the enzyme produced by CRE that disables carbapenem-class antibiotics, widely used in hospitals to treat severe infections.

Mood and gut bacteria
Friday, July 1, 2016
For the first time, scientists have determined that there are bacteria in the human gut which depend on chemicals from our brain for survival. The discovery of this relationship between the gut biome and brain chemistry could lead the way to new treatments for depression and a host of other disorders.
New Scientist said Friday that scientists at Boston’s Northwest University have isolated a group of bacteria that depend upon the brain chemical gamma-aminobutyric acid or GABA — a molecule that the brain uses to calm itself — to survive.
Researcher Philip Strandwitz explained that the fact that the newly discovered bacteria — named KLE1738 — appear to eat GABA to live could explain the newly emerging link between gut microbiome health and mental health.

Gerd herb
Monday, July 4, 2016

Rikkunshito a Japanese herb for resistant GERD is part of the guidelines in Rx in Japan

Smoking and autoimmune diseases
Saturday, July 9, 2016

Cigarette smoking has been causally linked to the development of multiple autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, Graves’ hyperthyroidism, and primary biliary cirrhosis, among others.

Monday, July 11, 2016

Urolithin A in the fruit helps fight dysfunctional mitochondria

Hara hachi bu
Tuesday, July 12, 2016

Japanese diet – eat only 80 %

Tuesday, July 12, 2016

Nodular regenerative hyperplasia. A rare cause

Wednesday, July 13, 2016

Connecting two senses together this gives some superior talents. For example seeing a guitar you smell wood
Or connecting visual and auditory cues you see vibration

Ssa polyps
Monday, July 18, 2016

The Present and Future of Inflammatory Bowel Disease Treatment
Wednesday, July 27, 2016

DDW 2018 update
Saturday, June 23, 2018
12:11 PM

DDW update 2018

• EASL update
• Baclofen for alcohol prevention and withdrawal symptoms. Dose 60 mg in three doses 20 tid and safe even in cirrhosis
• Use of non selective beta blockers – is it safe in patients with ascites. Does it cause increased mortality. Hgiher mortality only in patients with low cardiac output, higher child pugh. Avoid in cirrhotic cardiomyopathy
• ACLF is organ failure with chronic liver disease. Decompensatiuon is worsening of liver without any organ failure. Metagenomic information is a scientific way of looking at gut microbiota. Two types of decompensation – normal and acute. Acute decompensation and ACLF is from less gene diversity in gut flora, especially for ACLF
• Treatment for ACLF – plasma exchange improves survival. (Study from delhi, retrospecrtive). ACLF is an inflammatory process. Plasma exchange is better than liver dialysis (26% versus 9%) mortality
• CLIF consortium fororgan failure – bilirubin more than 12, cr more than 12, HE stage 3-4, INIR more than 2.5, on vasopressor and Paox or Fi)2 less than 200 or Sp02/FiO2 less than 214
Biliary and Pancreatic update
• 2 types of pancreatitis – interstitial 80% and necrotizing 20%. (defined by CT – fluid collection is necrotic in necrotizing pancreatitis). Asynptomatic walled of necrosis 2/3 have benign course and 1/3 can have pseudoaneurysm, rupture into GI tract etc
• Consider sphincterotomy while waiting for cholecystectomy in patients with Necrotizing pancreatitis
• EDGE procedure (transgastric ERCP using EUS). (endoscopic directed gastric ERCP – EDGE)
IBD update
• 33% of the IBD flare up patients gets dependent on opoids
• Use Therapuetic drug monitoring for active IBD but not indicated for inactive IBD
• Opiate use is associated with bad outcome in IBD
• Therapeutic infliximab level is 5
• If therapeutic drug level is there, and no response, CONSIDERCHANGE CLASS, do not add immunomodulators. In some cases, you can increase dose also
• If low drug level and Ab present, switch in class or add immunomodulator
• For adalimumab the level is 7.5
• CZP level is 20 as therapeutic (certolizumab
• NUDT15 variants causes myelosuppression in patients on thiopurine. 22 times
• Oral anti TNF in phse 2 study OPRX-106 is a plant cel expressed recombinant anti TNF fusion protein, 67% clinical remission
• Tofacitinib safety (octave 1 and 2 trials), Risk is herpes, GI perforation, check myelosuppressionk chck lipids, liver enzymes, reliable contraception, avoid live vaccines, check for tb, lymphoma and other malignancies
• Vedolizumab is the safest
DDW esophagus and stomach update
• EoE update. Increasing incidence. PPI has anti inflammatory properties for EoE. Simplified 2 food elimination diet, . Updated diagnostic criteria. Eos more than 15, Rule out secondary causes of eosinophilia Prevalence is 55/100,000. It is an allergic disorder. Can show exudates, edema, furrows, stricture,and rings. Edema is pallor Long term causes supepithelial fibrosis (but they need steroids).. Use elemental diet 91% success ..Use amino acid based formulas. Directed eleimination is 46% success. Start with steps. First 2, elimination – milk and wheat.. IF that fails, add eggs and soy / legumes. If that failes add nuts and sewafood a. Patients who respond reintroduce one food at a time and repeat EGD and bx. Topical steroids. It is immune mediates, allergen, activates T helper cell and increases IL. Eotaxin 3 is where PPI acts. Options of steroids are fluticasone inahaler, oral viscous budesonide and fluticasone diskus
• Non obese NAFLD is associated with Erosive esophagitis
• High reslultion manometry can distinguish true NERD from functional reflux as confirmed by impedence.
• See table. Functiuonal HB have high EGJ resting pressure, higher peak DCI,
EASL Liver talk
• PBSC PPAR- delta and tropifexor (FXR agonist)in trials. Bezurso (bezafibrate) in NEJM 2018. Use in addition to urso
• Statins help PSC
• PEG vs lactulose for HE (Saudi arabia). HESA (hepatic encephalopathy scoring algorithm). PEG work
• FMT is treatment of choice with second episode of C diff. Colonoscopy is cost effective over capsules 30 capsules in 90 min Capsule lower cure rate than colonoscopy

• Safe in organ transplant patient but lower cure rate. Generally do 2 FMT. For best results in all patients. FMT can cause flare of crohns dis

Mercy 2018
Wednesday, June 27, 2018
3:36 PM

DDW update 2018

• EASL update
• Baclofen for alcohol prevention and withdrawal symptoms. Dose 60 mg in three doses 20 tid and safe even in cirrhosis
• Use of non selective beta blockers – is it safe in patients with ascites. Does it cause increased mortality. Hgiher mortality only in patients with low cardiac output, higher child pugh. Avoid in cirrhotic cardiomyopathy
• ACLF is organ failure with chronic liver disease. Decompensatiuon is worsening of liver without any organ failure. Metagenomic information is a scientific way of looking at gut microbiota. Two types of decompensation – normal and acute. Acute decompensation and ACLF is from less gene diversity in gut flora, especially for ACLF
• Treatment for ACLF – plasma exchange improves survival. (Study from delhi, retrospecrtive). ACLF is an inflammatory process. Plasma exchange is better than liver dialysis (26% versus 9%) mortality
• CLIF consortium fororgan failure – bilirubin more than 12, cr more than 12, HE stage 3-4, INIR more than 2.5, on vasopressor and Paox or Fi)2 less than 200 or Sp02/FiO2 less than 214
Biliary and Pancreatic update
• 2 types of pancreatitis – interstitial 80% and necrotizing 20%. (defined by CT – fluid collection is necrotic in necrotizing pancreatitis). Asynptomatic walled of necrosis 2/3 have benign course and 1/3 can have pseudoaneurysm, rupture into GI tract etc
• Consider sphincterotomy while waiting for cholecystectomy in patients with Necrotizing pancreatitis
• EDGE procedure (transgastric ERCP using EUS). (endoscopic directed gastric ERCP – EDGE)
IBD update
• 33% of the IBD flare up patients gets dependent on opoids
• Use Therapuetic drug monitoring for active IBD but not indicated for inactive IBD
• Opiate use is associated with bad outcome in IBD
• Therapeutic infliximab level is 5
• If therapeutic drug level is there, and no response, CONSIDERCHANGE CLASS, do not add immunomodulators. In some cases, you can increase dose also
• If low drug level and Ab present, switch in class or add immunomodulator
• For adalimumab the level is 7.5
• CZP level is 20 as therapeutic (certolizumab
• NUDT15 variants causes myelosuppression in patients on thiopurine. 22 times
• Oral anti TNF in phse 2 study OPRX-106 is a plant cel expressed recombinant anti TNF fusion protein, 67% clinical remission
• Tofacitinib safety (octave 1 and 2 trials), Risk is herpes, GI perforation, check myelosuppressionk chck lipids, liver enzymes, reliable contraception, avoid live vaccines, check for tb, lymphoma and other malignancies
• Vedolizumab is the safest
DDW esophagus and stomach update
• EoE update. Increasing incidence. PPI has anti inflammatory properties for EoE. Simplified 2 food elimination diet, . Updated diagnostic criteria. Eos more than 15, Rule out secondary causes of eosinophilia Prevalence is 55/100,000. It is an allergic disorder. Can show exudates, edema, furrows, stricture,and rings. Edema is pallor Long term causes supepithelial fibrosis (but they need steroids).. Use elemental diet 91% success ..Use amino acid based formulas. Directed eleimination is 46% success. Start with steps. First 2, elimination – milk and wheat.. IF that fails, add eggs and soy / legumes. If that failes add nuts and sewafood a. Patients who respond reintroduce one food at a time and repeat EGD and bx. Topical steroids. It is immune mediates, allergen, activates T helper cell and increases IL. Eotaxin 3 is where PPI acts. Options of steroids are fluticasone inahaler, oral viscous budesonide and fluticasone diskus
• Non obese NAFLD is associated with Erosive esophagitis
• High reslultion manometry can distinguish true NERD from functional reflux as confirmed by impedence.
• See table. Functiuonal HB have high EGJ resting pressure, higher peak DCI,
EASL Liver talk
• PBSC PPAR- delta and tropifexor (FXR agonist)in trials. Bezurso (bezafibrate) in NEJM 2018. Use in addition to urso
• Statins help PSC
• PEG vs lactulose for HE (Saudi arabia). HESA (hepatic encephalopathy scoring algorithm). PEG work
• FMT is treatment of choice with second episode of C diff. Colonoscopy is cost effective over capsules 30 capsules in 90 min Capsule lower cure rate than colonoscopy
• Safe in organ transplant patient but lower cure rate. Generally do 2 FMT. For best results in all patients
• Can cause flareup of crohns

Lugdunin for MRSA
Thursday, July 28, 2016
1:53 PM

University in Germany discovered Lugdunin which is secreted by Staph in the nose and eleminates MRSA and VRE

Friday, July 29, 2016

Dr Connor writes that the strength of the association of alcohol as a cause of cancer varies by bodily site. The evidence is “particularly strong” for cancer of the mouth, pharynx, and esophagus (relative risk, ~4-7 for ≥50 g/day of alcohol compared with no drinking) but is less so for colorectal cancer and liver and breast cancer 1.5 RR
Also possibly pancreatic and melanoma

Cancer immunotherapy
Saturday, July 30, 2016


TIA stroke reduction
Sunday, July 31, 2016

Commentary: In the first 90 days after presentation with a TIA or minor stroke, the risk of recurrent stroke is 10 to 15%, with approximately two-thirds of this risk falling within the first 10 days. Treatment with aspirin decreases the risk of recurrent stroke by about 20%.1 Ticagrelor is a potent antiplatelet agent which reversibly inhibits the P2Y12 receptor on the platelet. Contrary to expectations, this study shows that ticagrelor does not provide additional benefit in decreasing the risk of stroke or MI in patients who have experienced a stroke or TIA. —Neil Skolnik, MD

Sunday, July 31, 2016

Harnessing the Immune System to Fight Cancer

Asthma pill
Sunday, August 7, 2016

Fevipiprant. Lancet. Works for moderate to severe allergic asthma

Physical activity
Wednesday, August 10, 2016

Results 174 articles were identified: 35 for breast cancer, 19 for colon cancer, 55 for diabetes, 43 for ischemic heart disease, and 26 for ischemic stroke (some articles included multiple outcomes). Although higher levels of total physical activity were significantly associated with lower risk for all outcomes, major gains occurred at lower levels of activity (up to 3000-4000 metabolic equivalent (MET) minutes/week). For example, individuals with a total activity level of 600 MET minutes/week (the minimum recommended level) had a 2% lower risk of diabetes compared with those reporting no physical activity. An increase from 600 to 3600 MET minutes/week reduced the risk by an additional 19%. The same amount of increase yielded much smaller returns at higher levels of activity: an increase of total activity from 9000 to 12 000 MET minutes/week reduced the risk of diabetes by only 0.6%. Compared with insufficiently active individuals (total activity <600 MET minutes/week), the risk reduction for those in the highly active category (≥8000 MET minutes/week) was 14% (relative risk 0.863, 95% uncertainty interval 0.829 to 0.900) for breast cancer; 21% (0.789, 0.735 to 0.850) for colon cancer; 28% (0.722, 0.678 to 0.768) for diabetes; 25% (0.754, 0.704 to 0.809) for ischemic heart disease; and 26% (0.736, 0.659 to 0.811) for ischemic stroke.

Saturday, August 13, 2016

with an unhealthy lifestyle. Each 3% increase in calories from plant protein was associated with a 10% lower risk for death. Conversely, each 10% increase in the proportion of calories from animal protein was associated with a 2% higher risk for death from any cause and an 8% increased risk for death from cardiovascular disease.

Duodenal villous atrophy
Saturday, August 13, 2016

DVA. Occurs in patients with solid organ transplant and causes diarrhea. Usually it is from mycophonolic acid. Diarrhea after organ transplant can also be from giardia in duodenum and azatioprine

Hyperkinetic GBEF
Friday, June 10, 2016
9:26 AM

A total of 28 (44%) of 63 patients with high ejection fractions received a cholecystectomy. Twenty-seven (97%) of 28 patients indicated that they had improvement in their symptoms after the procedure, and 22 (79%) of 28 patients said they had total resolution of their symptoms. One patient did not respond to the procedure. Investigators did not gather data on those patients who did not receive a cholecystectomy.


EF elevation in GB is more than 80%

Gut microbiome
Thursday, August 18, 2016

In conclusion, these researchers demonstrated for the first time that an acute increase in gut microbiota-produced colonic propionate significantly reduced anticipatory hedonic responses to food in the human brain regions associated with reward processing and hedonic eating behaviour.

Inulin and inulin propionate ester are prebiotic. IPE stimulates colon bacteria to produce propionate which converts to butyrate. This reduces hedonic response and appetite

Obesity cancer
Thursday, August 25, 2016

The New York Times (8/24, Bakalar) “Well” blog reports that a reviewpublished in The New England Journal of Medicine “found solid evidence that being overweight or obese increases the risk for at least 13 types of cancer.” The blog points out that “strong evidence was already available to link five cancers to being overweight or obese: adenocarcinoma of the esophagus; colorectal cancer; breast cancer in postmenopausal women; and uterine and kidney cancers.” The “new review…links an additional eight cancers to excess fat: gastric cardia…liver cancer; gallbladder cancer; pancreatic cancer; thyroid cancer; ovarian cancer; meningioma…and multiple myeloma.”

Stents. Xience V
Friday, August 26, 2016

The popular, conventional Xience stent is a thin-strut (81 μm) device, which some have argued is an advantage over the Absorb bioresorbable vascular scaffold’s current 157-μm strut thickness.

Tick borne Crimean-Congo hemorrhagic fever (CCHF)
Friday, September 2, 2016

According to the World Health Organization, CCHF’s mortality rate is about 30 percent and it is endemic to Africa, the Balkans and Ukraine, the Middle East and Central Asia.
It is viral
Tick bite or from dead animals
Human to human transmission possible

Dietary Fat
Friday, September 2, 2016
Hazard Ratios (HRs) for the Highest Intake of Fat Category vs the Same Amount of Calories in Carbohydrates
Category HR for total mortality 95% CI P for trend
Saturated fat 1.08 1.03–1.14 < .001
Trans fat 1.13 1.07–1.18 < .001
PUFAs 0.81 0.78–0.84 < .001
MUFAs 0.89 0.84–0.94 < .001
Replacing just 5% of saturated fat calories with PUFAs and MUFAs reduced overall mortality by 27% and 13% (HR, 0.73 and 0.87, respectively).
Consumption of ω-6 PUFAs, especially plant-derived linoleic acid, was associated with reduced risk of death from most major causes. Eating fish-derived ω-3 PUFAs was linked to a modest reduction in overall death (HR comparing extreme quintiles, 0.96; P = .002 for trend).

Renal failure in HCV
Tuesday, September 13, 2016
Antiphospholipase A2 receptor antibodies

Cytoplasmic antineutrophil cytoplasmic anti

body is seen in granulomatosis with polyangiitis,
while antiphospholipid A2 receptor antibodies
are seen in idiopathic membranous nephritis.

Low serum complement levels are frequent

ly found in membranoproliferative glomerulo

nephritis. It is believed that immune complex
deposition leads to glomerular damage through
activation of the complement pathway and the
subsequent influx of inflammatory cells, release

of cytokines and proteases, and damage to cap

illary walls. When repair ensues, new mesangial
matrix and basement membrane are deposited,
leading to mesangial expansion and duplicated
basement membrane.

In cryoglobulinemic membranoprolifera

tive glomerulonephritis, the complement C4
level is often much lower than C3, but in
noncryoglobulinemic forms C3 is lower. A
mnemonic to remember nephritic syndromes
with low complement levels is “hy-PO-CO-
MP-L-EM-ents”; PO for postinfectious, CO
for cryoglobulins, MP for membranoprolifera

Viral versus bacterial
Wednesday, September 14, 2016

RNA-expression biosignatures derived from the patient’s peripheral blood distinguish bacterial from viral causes of fever in young children, according to two separate preliminary studies published online Aug. 23 in JAMA.

Friday, September 16, 2016

Older patients prescribed citalopram had almost 12-fold higher odds of hip osteoporosis, compared with those prescribed fluoxetine, according to a large retrospective study at a tertiary bone health clinic. Patients on fluoxetine… »»

Cardiovascular benefits
Friday, September 16, 2016

Novo Nordisk’s experimental injectable diabetes drug semaglutide reduced cardiovascular risk by 26 percent,

Empaliflozin is another Jardiance

Victoza also has same benefit ( the rate of the first occurrence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke among patients with type 2 diabetes mellitus was lower with liraglutide than with placebo. )

Antibiotic resistance
Saturday, September 17, 2016
This is the first time researchers have tailored one of these synthetic compounds, part of a class called PPMOs or peptide-conjugated phosphorodiamidate morpholino oligomers, to target a specific efflux pump found in bacterial cell walls, said Dr. David Greenberg, Associate Professor of Internal Medicine and Microbiology at UT Southwestern and a senior author of the study.

Read more at:

Saturday, September 17, 2016

Patients with galll stones have a higher incidence of heart disease. No cause or effect. Confounding factor. Even after eliminating common things like obesity etc

Wednesday, September 21, 2016
Candida tropicalis works alongside two other bacteria to cause the debilitating bowel condition, experts found.
It fuses together with E. coli and S. marcescens to produce a layer of microorganisms in the intestines which can cause symptoms of Crohn’s disease.

Anti obesity drug
Saturday, September 24, 2016

newer antiobesity medications, though all entered the market around the same time. Those newer agents include lorcaserin (Belviq®), combination phentermine/topiramate (Qsymia®), and combination naltrexone/bupropion (Contrave®).

Thursday, September 29, 2016

Miraca lab does cimzia drug level

Mercy Conference 2017 september update
Saturday, October 1, 2016


Mercy Conference 2017 september update

Hepatitis C Dr Eugene Schiff
• Fatigue is related to HCV viremia
• Hepatitis C Ag is on the horizon – ELISA test
• Resurgence of HCV.- the prevalence dropped in 2004 and now in 2014 the incidence is back to 2/1000,000. This is due to heroin on the street
• Heroin is cheaper than oxycontin
• 80% of people were born between 45 to 65. (in the past)
• NS3/4A meds are simeprevir, partaprevir, grazoprevir. Future asunaprevir, vedroprevir sovaprevir.
• NS5A meds Ledipasvir, Ombitasvir, Daclatasvir, Elbasvir. Future Velpatasvir, Odalasvir, PPI-668
• NS5B inhibitor Sofosbuvir
• Non nucleoside NS5B inhibitor Dasabuvir
• Cyclophilin Inhibitor SCY-635
• HCV treatment Path App
• Hardest to treat is cirrhotic GT3 that has relapsed or failed treatment
• Fibroscan : can be misleading in CHF patients
Alcoholic hepatitis Paul Thuluvath

• 3.3 million people die from alcohol related problems
• Increased risk when intake is more than 30 grams/day. 1% if they drink 30-60 grams and 6% if intake is more than 120 gm.
• 1 drink is 14 grams – 360 ml of beer, 150 ml of wine,
• Obesity, female viral hepatitis, genetic predisposition are more likely to develop alcohol liver disease
• 90% of alcoholic develop fatty liver and 20% alcoholic hepatitis and 15% cirrhosis
• Two types – fast acetylation or slow acetylation.
• ADH and ALDH enzymes in acetylation
• Adiponutrin on chromosome 22 increases risk
• Alcohol macrocytosis is from alcotohol toxicity, B 12 def, and increased lipid on RBC
• Other features besides macrocytosis are AST:ALT more than 2, increased INR, increased WBC, decreased lymphocytosis, high ESR, low plt and Hb
• Liver biopsy can show fatty liver, hepatitis, fibrosis or cirrhosis
• Symptoms of alcohol hepatitis – low grade fever, anorexia, RUQ pain, abdominal distension, proximal muscle weakness or confusion. Signs are jaundice, hepatomegaly, ascites, proximal myopathy or asterxis. Rarely malnutrition
• Prevent recevidism by using baclofen, gabapentin, naltrexone, acamprosate
• 50% of patients with alcohol hepatitis will have cirrhosis
• Recidivism is 70%
• Scores for outcome – DF more than 32,(30% 30 day mortality) MELD score more than 21 has 20% 90 day mortality and Lille score after 7 days of prednisolone
• Lille score is based on bilirubin – if after 7 days it does not improve after prednisone, they wont get better
• Lille score mortality if more than 0.45 is 75% at 6 months and if less than 0.45 mortality is 15%
• Alcoholic hepatitis Histologic Score (AHHS). 0-3, 4-5, 6-9 score has mortality of 3, 19 and 55% at 90 days
• 20% misdiagnosis in Alcohol hepatitis. So if in doubt consider liver biopsy
• Cause of death in alcoholic hepatitis liver failure 55%, GI bleed 21%, sepsis 7% and others
• Dose of prednisone is 40 mg a day. Encourage good nutrition, high protein .1.5 g/kg, high calories 35-40Kcal/kg, thiamine, folate, magnesium, phosphate and pyridoxine supplement.
• Rule out sepsis
• Pentoxyfylline is not helpful except if they have hepatorenal syndrome.
• Prednisone only had a 28 day mortality benefit.
• Steroid and pentoxyfylline is not helpful.
• Unproven benefit with GCSF or metadoxine (anti oxidant)
• Severe AH – prednisone for 28 days plus NAC for 5 days. Dose of NAC is Day 1 150 mg/kg in 30 min followed by 50/kg in 4 hours and then 100 mg/kgfor 16 hours
• Day 2-5 100 mg/kg. All is in D5W
• If lille score more than0.56 stop treatment and if Lille score more than 0.45 consider OLT

NAFLD Dr. Younoussi

• Treatment options are
• Weight loss
• Statins and fibrates
• Antioxidants
• Vitamin E/C
• Betaine
• Lecithin
• Silymarin
• Beta carotene
• Treatment of IR
• PPRA agonist (perixosome proliferator-activated receptor agonist
• Anti TNF like pentoxyfylline
• ACE or ARB
• Caspase inhibitors
• Bile acid Ursodeoxcyholic acid
• NAFLD is a phenotype (a diverse pathologic process from multiple other diseases)
• NASH is fat, liver injury and inflammation. Must exclude HCV and alcohol
• Middle east has highest incidence
• Obesity,, DM, metabolic syndrome, increased lipid or TG
• Lean NAFLD : 3.7 % had NASH even if BMI less than 25 They have insulin resistance and DM
• NASH is an independent risk factor for cardiac disease
• NASH and HCC. If NASH is present, higher mortality for HCC
• Highest mortality for NASH is in age and DM
• New NAFLD regimens are
• OCA (famesoid X recept agonist) Used for PBC. FLINT study fibrosis improvement and caused increased lipid profile.
• Simtuzumab (anti lysyl oxidase like 2 monoclonal Ab)
• Fatty acid / bile acid conjugate – Aramchol
• Dual inhibitor of CCR2 and CCR5 – cenicriviroc
• Dual peroxisome proliferator activated receptor – GFT 505 Elafibrinor
• Probiotics – VSL #3 Probably not helpful
• Ballooning and portal inflammation and fibrosis will develop cirrhosis. This is the advantage of liver biopsy. Fibrosis was the most significant indicator
• Cost of NAFLD is 100 billion dollars per year for USA
• Obesity, insulin resistance (IR) or T2D with second hit (oxidative stress from mitochondria and CYP 450 OR adipokines) leads to inflammation and necrosis. BOTH PATHWAYS NEEDED.
• Fibroscan and MR elastography are very helpful
• APRI score, Fib -4, bARD, BAAT, fibrotest, NAFLD fibrosis score.
• HAIR, NASH test, NPI
• Fibrosure is not good. NASH – CK-18 is another score
• Fib-4 –
• BARD score
• NAFLD score –
• HOMA score for insulin resistance
• DM plus morbidly obese – restrictive surgery
• Vitamin E helps in non diabetic NASH. Start with 400 , monitor LFT. Vitamin E – cardiovascular disease
• DM is an independent risk factor for HCC
HCC and surgery Dr. Hanish
• Sorafenib – no difference
• Resection – If normal liver, resect. But 80% of patients have cirrhosis or advanced fibrosis and plt less than 150,000 makes resection unsafe. Must have at least 50% functional liver reserve . In other words, plt more than 150, MELD less than 10, portal pressure less than 10 and 50% functional liver – RESECTION if lesion is solitary and less than 5 cm BUT 67 % tumor resection at 5 years and 83% recurrence at 10 years
• Local therapy – DEB-TACE, Y90, cryoablation, RFA, microwave, Ire
• Transplant
• Chemical ablation
• RFA improved survival benefit if lesion more than 2 cm, Not helpful if 5 cm lesion.
• RFA works by heating tumor to more than 100 celcsius. Sometimes it can cause rupture
• Microwave heats it up too but there is NO HEAT sink. There is no renal failure which occurs with RFA
• Bland ablation shows 2 year survival benefit.
• TACE 2 year survival is 63%. Drug eluting beads has improved outcomes.
• Y90 radioembolization – beta emitors and downsizes tumor. Have to wait for 6 weeks after Y90. It is most effective for portal vein thrombosis.
HPylori Dr Lisa Pichai

• Flagyl, tetracycline, Rifabutin, Furzolidone, Levofloxacin, Chlarithromycin, Amoxicillin
• Standard treatment in the past was triple therapy
• Hp has 2 states replicating and non replicating states
• Easier to kill when it is replicating and pH is 6-8. In non replicating, pH is less than 6. Most drugs break down in acidic environment
• 5 strains of Hp
• In USA flagyl resistance is common
• There is a lot of point mutation in Hp
• Changes in Hp forms – spiral to coccoid forms. Coccoid forms are resistant.
• They have plasmid mediated resistance
• India high flagyl resitance and some tetracycline
• In USA Biaxin resistance is 17%
• MUST TREAT 14 days.
• PBMT is option for first line OR PAMC either option.
• RESTRICT triple therapy.- PAC, PMC, PAM
• Against use of levofloxacin as first level. PAL is second line
• FAILED TREAT – PBMT with higher dose of tetra OR PAL.
• IF THEY have failed levo or amoxicillin in either regimen failed first time
• RIFABUTIN causes myelotoxicity. — USE ONLY IF THEY FAILED 3 other regimens and check Hp for sensitivity
• ADJUVANT – add probiotics.
gastric lesions – dr. kantsevoy

• MUST DO ENDOSCOPIC LIFT. This is 100% sensitive and 99% specific
Gluten sensitivity – Richard desi

• Gluten is a mixture of protein found in barley, rye, oat, spelt, kamut, triticale and wheat
• Prevalence 1:70 to 1:300 in most countries
• Neurological symptoms, osteoporosis, arthritis and rash
• Signs are vitamin def, osteoporosis, iron def, anemia
• Oral glutenase is being studied
• 1 in 5 is on a gluten free diet
• NCGS : people believe it can cause brain fog? Fatigue? Depression? Numbness in the hand, eczema and fatigue
• Gluten sensitivity maybe an immune mechanism

Opportunistic infection dr. harris

• HSV – type 1 or 2.
• Crusted lesions not infectious
• Acute phase – painful ulcers
• Stress, sun exposure reactivates hsv virus. Usual outbreaks are 3-4/year
• It can spread from one part of the body by auto touching. Ophthalmic involvement is worrisome
• Rx famciclovoir and acylovoir.
• Amino acid lysine can be helpful
• Varicella zoster
• Dermatological infection
• Often Trigeminnal involvement
• Use attenuated zoster immunization.
• It is live attenuated virus
• Give immunization – 3 weeks before biologic. Or must be off immunomodulater for 6 months before giving the live virus
• Look up paper on opportunistic diseasesin IBD review by Manish
• CMV can occur in immunocompetent patients also
• EBV – causes infectious mono, nasopharyngeal ca, burkitts lymphoma and B cell lymphoma
• HPV : 99% cervical ca have HPV DNA (type 16 or 18)
• HPV can occur in mouth also (tonsillar cancer)
• TB :
• Listeriosis _ occurs from contaminated food. Young, elderly and pregnant. S/S are headache, stiff neck, meningitits. Contaminated vegatables, milk, Incubation periodis 1 month
• Histoplasmosis and Apergillosis : Endemic here
• Anisayakasis (sushi )

Biologics in IBD in 2016 – Dr. Ray Cross

• Biologics modify the natural history of IBD
• Early biologic gives endoscopic healing at 2 years – higher rates (80% at 2 years ) and those who heal remain healed for 2 more years and just on azathioprine after that
• SONIC trial (combination is better for both UC or CD)
• AGA pathway – care pathway 2 steps Low risk versus high risk
• High risk are those with deep ulcers, extensive involvement, age less than 30, perianal disease, rectal disease, complicated behavior and prior surgery (for CD)
• High risk give anti TNF
• Low risk use budesonide or AZA or both
• UC – High risk – young age, deep ulcers, high CRP, steroid at time of diagnosis, C diff or CMV infection or extensive colitis.
• Low risk oral 5 ASA, budesonide or rectal steroids.
• High risk – entyvio or anti TNF
• Non responders are due to – IBS, psychiatric disease, look for stricture, bile salt diarrhea, bacterial overgrowth, celiac, short bowel, deep seated or intractable disease, smoking and other drugs
• Stricture is the biggest reason in non responders
• Stricture score – mass or abscess, mesenteric stranding, prox dilatation of colon more than 3 cm, SBO, fistula. If 1-5 score, most of them will need surgery. 1 point for each of the above points
• Anti drug Ab are bad
• Immunosuppresants improved outcome
• High baseline TNF better outcome
• Low albumin, worse outcome faster clearance
• High CRP drug clears faster
• Body size – higher BMI clears drug faster,
• Males have a faster clearance
• Switch to different anti TNF if antibody present. If Ab present 20% response. Change medicine 90% medicine
• Do drug level twice a year
• TAILORIX study :
• Entyvio : Alpha 4 beta 7 and madcam-1 blocked. Give at 0,2, 6
• Vedolizumab every 4-8 weeks
• 1/3 patients need it every 4 weeks per Dr. Cross in his practice
• Ustekinumab : Stelara Approved for Psoriasis IL-23 inhibitor. Study is UNITI-1. Treatment refractory group.. 50% had failed 2 different regimens. 6 mg/kg
• Response rate is 21% healing and response is 40%
• IM-UNITI study : dose is 90 q 8
• Monotherapy is reasonable for some patients
• Age more than 60 avoid 6 MP.
• Recent malignancy, avoid combination therapy
• Drug level is part of practice guidelines
• Entyvio onset is slow 6-8 weeks, no drug level and costlier. So second line
biomarkers in ibd. dr matilda hagan

• CRP. It is produced by hepatocytes from IL-6, TNF-alpha, IL-1B and mesenteric adipocytes in CD pt. Half life is19 hours
• Fecal calprotectin S 1008A8 protein and calcium and zinc binding
• Fecal lactoferrin
• Fecal calprotectin is more sensitive than CRP and suggests mucosal healing
• IBD versus non IBD tesing : no fecal marker can do it.
• Low crp (less than 0.5) and low calprotectin less than 1 % of IBD
• FC predicts disease relapse
• Clinical endpoint should be FC less than 50, which shows mucosal relapse
• If FC less than 50, after anti TNF 84% remained disease free
• ASCA and ANCA markers –
• ASCA is present in normal upto 5% 60^ of CD and 10% UC
• ASCA + and ANCA neg CD
• ANCA + – UC
• Anti-CBir1 is associated with development of CD of the pouch after IPAA
• Anti-Omp C in UC associated with colectomy
• CD with ANCA + are less likely to have complications
• Novel markers are anti Flagellin Ab, ALCA and ACCA
• Monitoring of IBD
• If 6 TGN is more than 235 more likely to respond
• Infliximab level should be more than 3-4 mcg/ml
• TAXIT – get therapeutic levels
Mucosal healing dr. harris

Deep remission : clinical, histological and biomarker resolution
UC use Mayo score : 0-3. Normal, to mild erythema
Scores : Rutgeerts score : 0 ulcers, less than 5 ulcers, more than 5 ulcers, ulcers without intervening normal structure and last is cobblestone with stricture. This is for Crohns
In clinical studies – for CD is looking for transmural healing now

Microscopic colitis
MC is LC and CC. Only histological differences
Female predominance
Age usually more than 65
Theory is related bile acids, increased NO and Pg, impaired electrolyte absorbtion and autoimmune from luminal Ag all lead to MC
Chronic diarrhea, dehydration, weight loss and abd. Pain
PPI, NSAIDs, ASA, ranitidine, SSRi, ticlid, ascarbose and statins. Other factors are smoking and auto immune disease
9 mg uceris for 8 weeks – Budesonide First line of therapy now
Follow up colon is not needed
Budesonide superior to Mesalamine
Maintenance for budesonide 6 mg for 6 months
Boswellia serrata for MC
Probiotics no difference with placebo
Mesalamine plus questran is same as Mesalamine
Azathioprine can be used but only 28% remission rate . This is for resistant patients. Other option is methotrexate
Get right side cold bx
Other use includes BSS and bile acid resins (bismuth sub salicylase) BSS – 2-3 tablets 3 or 4 times a day 262 mg each
eosinophilic esophagitis dr. richard desi

EoE 15 per HPF but not been validated
Diseases associated with Eosinophilia of esophagus, PPI- EE, CD, infection, achalasia, drugs hypersensitivity, vasculitis etc
Blood eos may or may not be present
Male 3:1
More in urban setting
Higher in cold and arid zones
EoE decreased after 45
Feline esophagus, strictures in 21%, whitish papules, linear furrows 48%, whitish papules 27% (microabscess)
PPI for 8 weeks repeat bx. If no eos, then probably not EoE
Budesonide / fluticasone trial if EoE
Six week elimination diet
If all fails, elemental diet
Allergiest referral

noac in endoscopy – dr. maheshwari

• neuroendocrine tumors dr. vadim guschinh. This is rare and is associated with high mortality
• Type 1 resect antrum
• Type 2 sandostatin and surgery for large tumors
• Type 3 gastrectomy with LN dissection

• Frequent liver and LN meds, subcm tumors
• Multiple
• Severe desmoplastic reaction
• Abdominal pain, diarrhea and carcinoid

• Simultaneous liver resection
• Survival 65% 5 year disease and 50% if metastatic

Neuroendocrine – second most common after colo rectal cancer
1000,000 patients in US
Increasing incidence
Tumor sites GI tract, then adrenal and then lung, merkle, medullary
Ki-67 index – less than 3, 3-20 and more than 20 is well differentiated moderately differentiated and poorly differentiated
Non functioning tumors can cause pain, weight loss,
Rectum neuroendocrine present with bleeding and local problems
68 Ga Octreotide or use 68 Ga octreotide with PET/CT scan
Debulking is beneficial
Primary tumor can be occult
3 types of hypergastrinemia
• Type 1 is auto immune gastritis

Rectal NET

• Small 1-2 cm good prognosis
• Larger than 2 cm have 60% node positivity and 25% liver mets. N. Multiple small tumors throughtout stomach
• Type 2 ZE
• Type 3 similar to adenoca of stomach. This is rare and is associated with high mortality
• Type 1 resect antrum
• Type 2 sandostatin and surgery for large tumors
• Type 3 gastrectomy with LN dissection
• eeds APR. Poor prognosis if conservative management

Drugs are MIBG, PRRT, cheomotherapy

liver imaging. dr. ankur gupta

US – increased echogenicity meaSB NET
• Frequent liver and LN meds, subcm tumors
• Multiple
• Severe desmoplastic reaction
• Abdominal pain, diarrhea and carcinoid
ns fatty liver

US – increased echogenicity means fatty liver, cirrhosis
• DD is iron deposition, cirrhosis, infiltrative neoSimultaneous liver resection
• Survival 65% 5 year disease and 50% if metastatic
• plasm, sarcoidosis, wilsons disease, glycogent storage and infection

US can prRectal NET
• ove if it iSmall 1-2 cm good prognosis
• Larger than 2 cm have 60% node positivity and 25% liver mets. Needs APR. Poor prognosis if conservative management
s cyst or not a cyst. Looks black
Hemangioma on US shows posterior acoustic enhancement, no color flow
Hemangioma on US shows posterior acoustiDrugs are MIBG, PRRT, cheomotherapy
liver imaging. dr. ankur gupta

enhancement, no color flow, hypoechoic center with hyperechoic periphery
The DUS – increased echogenicity means fatty liver, cirrhosis
• DD is iron deposition, cirrhosis, infiltrative neoplasm, sarcoidosis, wilsons disease, glycogent storage and infection
• D includes FNH, adenoma etc

HCC – Stage 0 to stage C
Milan criteria
US sensitivity is 65%
US sensitivity is 65%
4 phase CT – no conUS can prove if it is cyst or not a cyst. Looks black
trast, early arterial and late arterial, portal venous and then equilibirium 3 min plus
MRI T2 weighted sequences and diffusHemangioma on US shows posterior acoustic enhancement, no color flow, hypoechoic center with hyperechoic periphery
• The DD includes FNH, adenoma etc
ion DWI

HCC nodules. If less tIf adenoma more than 5 cm, surgical MRI DO NOT — USE GAD. It can cause developmental anomaly in lung or GI tract of fetus
resection since it grows in pregnancy
Unique diseases are hyperemesis gravidarum, IntPropofol is cat B, meperidine is Cat C, benzo is cat D and small doses midazolam is ok. Defer till secondaHyperecohic lesions are metastatic or malignant
HCC – Stage 0 to stage C
Milan criteria
n 1 cm, repeat MRI in 3 months.
If between 1-2, get CT or MRI
US sensitivity is 65%
4 phase CT – no First through 20 weeks, IHCP in second and third, AFLP in third and the eclampsia and HELLP in 20 to 22 weeks onwards
• ICHP, 5 % pruritis, abnormal LFT, unconjugated hyperbilirubinemia,
• Eclampsia upto 7.5%, HTN proteinuria, peripheral edema and seizures. Liver abnormality is uncommon and non specific. RUQ pain due to swelling of liver,striking transaminases, hematoma below glissons capsule. Cause is ischemia, . Maternal mortality is 1%, Hypertensive crisis, renal damage, neuro complications
• HELLP : 0.5% of all pregnancyies It is advanced form of pre eclampsia.
• Advanced age, nulliparous and multiparity. RUQ pain, hemolysis, TTP, low platelet, microangiopathic hemolytic syndrome. Mortality for mother is 1-3 %, hepatic infarction subcapsular hematoma, intra parenchymal hemorrhage. Fibrin deposition causes infarction.. If less than 34 weeks consider glucocorticoids. Missippi protocol, use Mg sulfate, BP control and use steroids. Recurrence with subsequent 3-27%
• AFLP : autosomal recessive – faty acid oxidation disorder in fetus and it crosses placenta and then causes fatty liver in mother. This causes fatty liver. Needs abnormal genetic in both mother and father. Occurs in 1.1000, third trimester, nausea, vomiting, abd. Pain, anorexia, jaundice. Fetal def of LCHAD. High complication rate. Rx delivery. Use Swansea diagnostic criteria for AFLP 6 or more present.
• HSV – high mortality rate in 74% . Rx empiric acyclovoir
• HBV high mother to child transmission – Tenofovir or telbivudine use in 3rd trimester. Esp if high viral load. Cat B drug
• No HCV treatment a few months before conception
• Cirrhosis in Pregnancy, Get rid of varices. Do EGD.

update on barretts dr. greenwald

• Norman Barrett from Australia first discovered it
• Do not biopsy less than 1 cm of z line variability
• Prague classification – C and M and location of diaphragm and GEJ
• Even if no intestinal metaplasia. Repeat EGD in 1-2 years
• 17% intestinal metaplasia of GEJ / cardia. Risk of cancer is same as general population.
• Partially deflate stomach and then get GEJ location.
• Screening for Barretts if reflux for more than 5 cm,age more than50, Caucasian, central obesity, tobacco use, FH of BE/eso cancer
• Don’t screen women.
• Don’t screen with short life expectancy
• Consider unsedated trans nasal endoscopy.
• If dysplasia then change to 4 quad in 1 cm.
• Don’t biopsy esophagitis
• Offer EMR
• Maximum 8 specimens in 1 jar
• Risk of cancer progression is lower than we were taught. It is 0.2% per patient per year
• Most patients of Barretts die from something else
• ? role of aspirin for prevention. PPI once a day unless bid for reflux control
• RFA is treatment of choice
• Nodules – remove with EMR
• HGD risk of cancer is 6%/patient/year
• Ablation helps prevent LGD from going to cancer
• RFA success rate is 91% RFA treated versus control 1% cancer versus 9% in untreated
• Even after RFA, needs repeat EGD and survellience
• Rigorous seattle protocol must be followed
• WATS 3D brushings
• Volume Laser endomicroscopy – – VLE.
• Liquid cryotherapy – Patient on Coumadin and needs nodule resection
• NO cryotherapy. – Mimi Canto from Hopkins uses it
acute pancreatitis from mayo clinic dr santhi vege

• 1% mortality of Pancreatitis – IN mayo mortality is 2-3% mortality
• Interstitial or mild and Severe.
• In Mayo – three types, Mild, moderate and severe
• Moderate is local complications
• Mild just interstitial edema
• Severe is necrotizing with organ failure – cardiac, renal and respiratory
• Revised atlantic 2012 classification
• Now 2 phase is First phase 1-2 weeks. Here there is systemic complications from inflammation. People die usually in first 2 weeks. Second phase at week 3-4 week usually causes morbitity but no death
• SIRS defined by pulse more than 90,
• Type of necrosis Two types. Pure pancreatic necrosis is extremely. Peripancreatic necrosis is second. Third the worst is necrosis both in pancreas and peripancreatic
• Acute necrotic collections or acute peri-pancreatic fluid collections
• Pseudocyst is rare. Most often is walled off necrotic collection.
• Critical pancreatits – infected necrosis plus persistent organ failure
• Day 1 US.
• MRI or EUS is rarely
• Perfusion CT – lesser volume
• Subtraction color map CT. Less radiation and easier procedure compared to perfusion CT
• Etiology : gallstones and microlithiasis. If ALT is more than 3 x UNL 90% PPV for biliary case. (stones or microlithiasis)
• If ALT is less than 3 UNL, and gallstones – get cholecystectomy is ok
• Badalov class 1 -4 for drug induced pancreatitis.
• Usually drug started in 6 months of pancreatitis
• TG has to be more than 1000
• AIP is rare cause of AP
• Main duct and side branch of IPMN
• Younger patients with idiopathic AP – genes
Systemic Inflammatory Response Syndrome (SIRS) Score
• SIRSdefinedby≥2ofthefollowing: Pulse > 90 /min
Resp > 20 / min or PaCO2 < 32 mm Hg Temp > 38 or < 36° C WBC count > 12,000 or < 4,000 / mm3
Fenagles Law
• CRP more than 150, necrosis on CT, age, comorbidity, increased BMI, persistent SIRS at 48 hours, persistant organ failure at 48 hours are poor predictors
• PPV for severity is only 50%
• Rx. Most important is IVF. 250 ml – 350 ml/hour, use lactated ringer. No strong evidence of using more than 4.5 liters
• Compartment syndrome with too much fluid
• No role of prophylactic antibiotics. Maybe helpful in necrosis involved organ failure
• Urgent ERCP is only if patient has cholangitis
• Oral intake early
• Enteral nutrition is better than TPN. Usually between 3-5 days
• NO TPN, NO TPN NO TPN uncles he cannot tolerate enteral supplement
• Infected necrosis usually at 1 week
• Walled off necrosis (WON)
• Necrotizing pancreatitis – preferably do it at 4 weeks and not before otherwise high mortality. Intervention is needed only infected. Sterile if SBO etc.
• WON – antibiotics, catheter drainage,..10 different management. Look up on slide
• Percutaneous drainage is the best, then endoscopic drainage and then laproscopic. OPEN not done. Hybrid is becoming popular
• Portal vein thrombosis – anticoagulants for 3 months
• Pseudoaneurysms needs embolization
• Pentoxifylline may be helpful.
• Chronic pancreatitis – genetic, alcohol and smoking. 50% idiopathic. The 1 % of alcoholics who develop pancreatitis have abnormal gene
• Hyper lipase syndrome – chronically goes up and down. Study in asymptomatic in Italy. Also elevated lipase occurs in CKD, bililary, intestinal issues etc. It is NON SPECIFIC.
AIP auto immune pancreatitis – Dr. Raina

• IgG4 has limitations
• Has frequent presentation of obstructive jaundice, with or without mass, lymphocytic infiltrate and responds to steroids
• Abundant IgG4 laden plasma cells infiltration in other organs also.
• IgG4 might be a systemic disease
• IgG4-related sclerosisg disease. Variable serum IgG4 levels
• Very rare – 1.4 , 100,000 incidence ins pancreas
• Two types – Type 1 and Type 2 . Type 1 is classic. Type 2 is a gel lesion or idiopathic duct pancreatitis. Type 1 is called LPSP is part of systemic syndrome. Lymphoplasmacytic sclerosing pancreatitis.
• Usually elderly male, systemic disease that can affect nearly any organ system and responds to steroids.
• Type 2 is IDCP or idiopathic duct centric pancreatitis. Granulocytic epithelial lesion (GEL) on bx. No IgG4 elevation and is associated ot UC. Occurs at 50-60 while type 1 is 70’s
• No pseudocyst seen with AIP
• The can have steatorrhea, weight loss, diabetes, obstructive jaundice.
• Sausage shaped pancreas is mostly poster ! The typical The head is prominent but duct is not dilated.
• Focal AIP – Just in head or tail. IgG4 is more than 280 mg and Ca 19-9 less than 85 probably focal AIP
• Extra pancreatic manifestation of LPSP – biliary tree, salivary grland, prostate, kidney, retroperitoneum, thyroid,, lymph nodes, colonic pseudotumor.
• IgG4 cholangiopathy –mostly around central hepatic duct !
• 6 cardinal things storiform fibrosis is another feature besides the others mentioned above
• IgG4 level more than 2 ULN is type 1 and 1-2 ULN in type 2.
• IgG4 gets elevated in skin disorders and parasitic disorders also
• Severe alcoholic hepatitis and PSC can also increase IgG4
• IgG4 does not bind to complement.
• Example bee hive workers IgG4 goes up progressively to attenuate response to bee stings
• UC subtype – possibly patients with UC and high IgG4 on biopsy possibly have a higher chance of getting PSC

pancreatic cysts dr jagannath

• Current Guidelines
• Increasing incidenctal pancreatic cysts lesions IPCL.
• IPMN – 3 types. Branc chain, main duct and mixed.
• Usually in 7 or 8th decade, equal M and F, 70% asymptomatic.
• If symptomatic cystic lesion with pain is a bad prognostic sign. More likely to be malignancy
• Cyst more than 3, solid component, abrupt change in PD, lymphadenopathy, thick cyst wall, dilated main PD more than 5-9 mm

Management of esophageal stricture Dr. michael kochman

• Dilatation .1 to .3% perforation rate for dilation and 0.2% bleeding
• Complex stricture – unable to pass endoscope, more than 2 cm and angulation
• Can use bronchoscopy.
• Tissue biopsy is not a contraindication to doing dilatation.
• Can do EGD through the PEG and then do dilatation through it
• Retrograde dilation and access
• Wire guided dilation – must have proximal and distal control. Savory or balloon – no difference
• Cannot use Maloney dilators into complex strictures
• Balloons preferred for epidermolysis bullosa, trachea-esophageal prostehses, anastomotic strictures, lach of mechanical advantage for savary, planned passage of endoscopy subsequent to dilatation
• Savary can coil in pharynx – especially in very tight strictures
• Refractory and recurrent. 14 mm. is target. Recurrent is if it closes after being patent for 4 weeks.
• pPeptic and schatzkis ring just one dilation. Schatzkis ring dilate with single dilator 18 mm
• Post surgical or radiation requires generally at least 3 dilations
• If length is more than 5 and requires multiple dilatations
• Kenalog 10 mg/ml in each 4 quadrants with sclera needls in the middle of stricture. Dilate after injection. Use for recurrent scar
• Polyflex – it is not definitive solution. It is only temporizing. Migration is 52%
• Off label use of endoprosthesis. Braided endoprosthesis, fully covered is preferred. Laser cut SHOULD NOT BE — USED Must be removed in a few months
• Self bouginage is a consideration
• Can use scissors to cut some strictures
• Endoprosthesis do not fix transmural process
• Schatzkis ring savory 18 mm one pass.
• EoE stricture – probably not safe to dilate.
• EoE stricture use balloon. Do not go more than 14 mmg
• Cricopharyngeal bars – can use 18-20 mm dilator savory. It gives short term relief and botox does not work. Refer to ENT?
• After dilatation, air translocation occurs but true perforation is is barium is shown to leak
Recurrent CDAD Dr.Jagannath

• Stool is a biologically active complex mixture of living organisms
• Human : mammalian and microbial cells. We have more microbials than mammalian cells Ratio is 10:1
• 3.3 million microbial genes
• Archae –Is the link between single cell and eukaryocytes
• 36,000 bacterial species are in our GI tract. Most of them are anaerobic.
• 4 major phyla Bacteroiodetes, Fermecitis,(these 2 or 90%) then actinobacteria, proteobacteria.
• Functions are – metabolism of polysacherides, vitamins, development of immune system, protect against pathological organisms
• B and F – increase in pro-inflammatory bacteria. . Gut dysbiosis – more yeasts, parasites
• C diff is a world wide epidemic.
• At risk population is IBD, peri-partum, antibiotics, compromised immune systems,
• NAP1/B1/027 produces toxin A, B and binary toxin. Binary toxin makes A and B toxins more virulent
• Phylogenetic diversity is lost when patients become C diff positive.
• 20% recurrent rate
• After each recurrent, your recurrence goes up by 20%
• Severe C diff DO NOT flagyl.
• Fulminant C diff – low bp, ileus, Vancomycin 500 m qid
• Fidaxomicin 88% cure rate. Lower recurrence rate
• Third recurrence, consider FMT
• After 3rd recurrence use FMT. ACG guidelines
• Use non toxin C diff to prevent toxin C diff (NTCD)
• Recurrence rate is lower in patients who have CDA1 and CDB1 antibodies
• Modify 1 and 2 trials for Zinplava – Actoxumab and bezlotoxumab (antibody to toxin A and B respectively)
• Only antibody to toxin b works.
• Vaccine for C diff. Partially purified toxoid A and B. Phase 3 trials underway.
• FMT capsule G 3 and Rebiotix are two different capsules
• Could do cecostomy and deposit stool 60 cc at a time

HCV relapse Dr. Paul Thuluvath

• RAS –Q80K for GT1a with cirrhosis If mutation cure rate is 10% lower
• NS5A –RAS mutation if you use grazoprevir/elbasvir combination for GT1a
• Q80K mutation is 13% incidence
• If you fail viekera or harvoni – will have NS5A mutations
• Drug resistant mutations are Q30H/R with ledipasvir, L31M is 4%,Y93H is 2 percent multiple is 5%
• NS5B no mutations noted with sofosbuvir
• Viekira pack – does not impact mutation since there are 3 drugs
• Zepetier (grazoprevir/elbasvir) NS5A RAS but no effect on NS3 RAS
• Harvoni failures Sofosbuvir plus simeprevir plus ribavirin for 12 weeks or 24 weeks for cirrhosis
• Sofosbuvir plus zepetier for viekira pack failures
post ercp pancreatitis. dr. kochman

• If amylase is less than 1.5 ULN in 4 hours of ERCP, unlikely to develop pancreatitis
• Modifiable risk –
• PEP (post ercp pancreatitis)
• Things we cannot modify are gender, age, prior PEP, ercp
• Prior PEP 8.7 odds ratio for developing pancreatitis
• Difficult cannulation – cannulate within 10 min or change technique
• Risk is 3, 8 and 15 percent based on cannulation attempts less than 5, more than 6 or more than 15 attempts
• Balloon sphincteroplasty should NOT be done unless sphincterotomy was done first
• PD stent may decrease risk
• Failure to place PD stent will cause pancreatitis if you try it and fail
• Needs 100 cases per year and 1000 cases in training
• Indocin or diclofenac to decrease pancreatitis
• 20 cc/kg bolus and then 3 cc/kg/hour for 8 hours with LR
• 100 mg indomethacin dose rectally

Cirrhosis check list dr. anurag maheshwari

• 1 out of 3 patients with cirrhosis will be readmitted after initial discharge in 1 month
• Ascites :Low albumin, is an indicator for SBP prophylaxis
• Lactulose every 2 hours till he wakes up. Use NGT even if varices present
• Use Rifaximin – universal use for all HE patients
• DVT prophylaxis – SQ lovenox and use of heparin should be used because cirrhosis is a risk factor for DVT x 2 normal population THERE IS NO SUCH THING AS AUTO ANTICOAGULATION
• Coreg 3.125 in primary prophylaxis or 6.25 bid for secondary prophylaxis to titrate to HR of 55.
• FFP prior to procedure is not needed if INR is upto 1.9
ppi in 2016

• CKD 11.8% versus 8.5 % in patients on PPI
• Tell patients – the information is retrospective. It is an association and not cause and effect. Impossible to adjust confounding factors
• Increased CV mortality is 2.2 compared to no use of PPI. 4000 use of PPI one has MI
• B 12 or iron def. anemia – no clear data

Monday, October 3, 2016

Reticare : phenylephrine and lidocaine for hemorrhoid

Hep B and HCV 2016
Wednesday, October 5, 2016

Mutant is – hep b e Ag neg, high ALT and HBV DNA more than 2000 Rx

Hep B eAg positive, high ALT and hbv DNA more than 20,000 Rx

Hep BsAg pos, hep B c Ab pos, low DNA less than 2000 – age more than 40 Rx. Less than age 40 – liver Bx or observe

Hep C GT 1a : NS5A resistance positive zepetier plus ribavarin for 16 weeks
NS5A negative zepetier 12 weeks
Viekera plus ribavarin if cirrhosis 24 weeks. If no cirrhosis 12 weeks

Ribavarin is always weight based. Weight more than 75 kg 1200 mg and less than 75 1000 mg

HVV GT 1B : viekera pack or zepetier 12 weeks – both cirrhosis or non cirrhosis

Type 2 : epclusa 12 weeks or sofusbuvir plus ribavarin 12 weeks

Type 3 : non cirrhotic : epclusa 12 weeks or dac plus sofusbuvir 12 weeks
If cirrhotic add weight based ribavarin

Use of statin
Saturday, October 8, 2016

During the 10-year follow-up period, patients with baseline coronary artery calcium scores of 400 or higher had a cardiac event rate of 12.6%. But when baseline scores were less than 100, the chance of a cardiac event decreased to just over 3%.

Sunday, October 9, 2016

Statin myopathy
Sunday, October 9, 2016

Curcumin is turmeric counters effects of myopathy by allowing to reduce dose

Ace plus bactrim
Sunday, October 9, 2016

Higher mortality

Monday, October 17, 2016
But bit by bit, vindication has come creeping in. This July, an international team of researchers found that people with self-reported non-celiac wheat sensitivity (NCWS) were indeed sickened by eating wheat. Their intestinal lining was damaged, and blood tests showed higher levels of systemic inflammation. Gluten or no, something was messing them up.

Another group of researchers suspected that something might be another protein. They started looking at a group called amylase-trypsin inhibitors, or ATIs. The ATIs are a small group, representing about 4 percent of wheat proteins, but they’re powerful.

(Vienna, October 17, 2016) Scientists have discovered that a protein in wheat triggers the inflammation of chronic health conditions, such as multiple sclerosis, asthma and rheumatoid arthritis, and also contributes towards the development of non-coeliac gluten sensitivity.
With past studies commonly focusing on gluten and its impact on digestive health, this new research, presented at UEG Week 2016, turns the spotlight onto a different family of proteins found in wheat called amylase-trypsin inhibitors (ATIs). The study shows that the consumption of ATIs can lead to the development of inflammation in tissues beyond the gut, including the lymph nodes, kidneys, spleen and brain. Evidence suggests that ATIs can worsen the symptoms of rheumatoid arthritis, multiple sclerosis, asthma, lupus and non-alcoholic fatty liver disease, as well as inflammatory bowel disease.

Fodmap foods
Monday, October 17, 2016

Foods high in FODMAP

Foods High in FODMAPs
Milk, evaporated/condensed milk, ice cream, margarine, powdered milk, soft and unripened cheese (ricotta, cottage, cream, mascarpone), soy milk, yogurt.
Apples, apricots, blackberries, boysenberries, cherries, figs, lychees, mangoes, nectarines, peaches, pears, plums, prunes, watermelon.
Barley, rye, wheat (in large amounts), fructo-oligosaccharides, inulin.
Baked beans, bortolotti beans, kidney beans, chickpeas, lentils, soybeans, soy flour.
Agave, corn syrup solids, high-fructose corn syrup, honey, isomalt, maltitol, mannitol, sorbitol, xylitol.
Artichokes, avocados, asparagus, beetroot, cauliflower, chicory, dandelion leaves, garlic, green pepper, leek, mushrooms, onions, pumpkin, radicchio lettuce, spring onions (white part), snow peas.

Celiac versus NCGS
Monday, October 17, 2016

Currently, the best approach would be to include all serological testing (TG2, TG6, anti-endomysium antibodies, AGA) for patients suspected of having GRD.

CD – TG2 positive
NCGS – TG6 positive and TG2 NEGATIVE

TG6 is associated with neurological symptoms

Saturday, October 22, 2016

New medication for sedation better than versed / midazolam

Tuesday, October 25, 2016

About 11% of people with infectious enteritis go on to develop irritable bowel syndrome, a new study found.

Wednesday, October 26, 2016
Researchers said the study by the University of Manchester, King’s College London and Newcastle University showed the first ever long-term effect of an early intervention for autism.
Lead author Prof Jonathan Green, Professor of Child & Adolescent Psychiatry, Division of Neuroscience and Experimental Psychology, University of Manchester described the results as “pretty remarkable”.
“Our findings are encouraging, as they represent an improvement in the core symptoms of autism previously thought very resistant to change,” he said, with scores showing significant improvements in communication skills and reduced repetitive behaviour.
Autism spectrum disorder is a developmental disorder that affects about 1 in 100 people.

Gluten compliance
Saturday, November 5, 2016

The American Journal of Gastroenterology, Dr. Carolina Sousa of the University of Seville and colleagues report on their experience using the iVYLISA GIP-S kit (Biomedal) that detects and quantifies GIP in stool samples. 98% specific sensitive

Gluten free diet downside
Saturday, November 5, 2016

First, it is an expensive diet, estimated to increase your food costs by about a third. It is not cheap. Second, as Alessio referred to, it is higher in calories. If you compare equivalent foods that are gluten-free as opposed to gluten-containing, there are more calories generally. It is also higher in sodium. Third, it is low in fiber and also lacks calcium, iron, and certain B group vitamins.

Friday, November 11, 2016

In the retrospective study of over 3.5 million veterans, those with constipation had a 13% higher likelihood of developing CKD, and a 9% higher likelihood of developing kidney failure compared with those without constipation, reported Csaba Kovesdy, MD, of University of Tennessee Health Science Center and Memphis VA Medical Center, and colleagues in the Journal of the American Society of Nephrology.

Tuesday, November 15, 2016

inc levels are often supplemented with oral zinc sulfate capsules dosed at 30-60 mg daily, he added. Patients with liver disease often have low zinc levels, which continue to drop as liver disease progresses, he noted. In a previous study he helped conduct, average serum zinc levels were 85 mcg/dL in healthy controls, 63 mcg/dL in patients with chronic hepatitis, and 55 mcg/dL in

Incidence of HCC WAS 9% if zinc taken. Control 25% over 3 years

Wednesday, November 16, 2016

Both have low levels of orexin a brain protein

GI update
Saturday, November 19, 2016
WASHINGTON – The American Gastroenterological Association, the Food and Drug Administration, pharmaceutical companies, and patient advocacy groups came together for a first-of-its-kind meeting, a program of the AGA Center for Diagnostics and Therapeutics, to discuss new and emerging drugs for the treatment of four key GI diseases, highlighting the promise that these treatments show and the hurdles they face to gain approval.
“If we look at the AGA’s Burden of GI Disease Survey, published a few years ago in Gastroenterology, [you] can see that there are millions of visits to primary care and specialists for a variety of upper gastrointestinal symptoms, so clearly upper GI disorders still pose a major burden to our health care environment,” explained Colin W. Howden, MD, AGAF, chair of the AGA Center for Diagnostics and Therapeutics from the University of Tennessee in Memphis.

121642_dyspepsia panel_web.jpg

Deepak Chitnis/Frontline Medical News
From left: Dr. Michael Camilleri, Dr. Juli Tomaino, Ms. Robyn Carson, Dr. Jessica Lee, Dr. Nimish B. Vakil, Tom McCourt, Dr. Paul Moayyedi, Dr. Colin W. Howden, and Dr. Jan Tack
Speakers at the meeting focused on gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), gastroparesis, and functional dyspepsia. In the GERD session, Marcelo F. Vela, MD, of the Mayo Clinic in Phoenix, talked about what to expect on the horizon to manage one of the most common GI diseases.

While proton pump inhibitors (PPIs) continue to be the first line of management for GERD, severe cases often require a stronger approach. Alternatives that are being investigated include potassium-competitive acid blockers, for which there have been clinical trials. However, no advantage over PPIs was demonstrated in any trials. Another alternative is bile salt binders, for which at least one trial is currently underway. Dr. Vela was unable to say when findings are expected to be published.

Another approach to managing GERD is to treat the acid pocket itself by using alginate. A randomized study by Rohof et al. investigated this in 2013, comparing Gaviscon and antacid; although the population size was small (n = 16), investigators concluded that “alginate-antacid raft localizes to the postprandial acid pocket and displaces it below the diaphragm to reduce postprandial acid reflux [making it] an appropriate therapy for postprandial acid reflux.”

Another new drug is lesogaberan, a GABA-B agonist that was examined in a 2010 randomized, double-blind crossover study by Boeckxstaens et al. While also a small trial (n = 21), the findings indicated that the drug is a good option for those with only partial response to PPIs, as it decreased the number of transient lower esophageal sphincter relaxations (TLESRs) and reflux episodes, and increased LES pressure [in] patients with reflux symptoms. Work to inhibit transient LES relaxations also is being done, but so far lesogaberan, arbaclofen, and ADX 10059 (an mGluR5 modulator) programs have all been halted because of side effects or insufficient efficacy findings.

Prokinetics are also being looked at, with drugs such as metoclopramide being examined for efficacy, although to this point, the drug has shown “no improvement in acid exposure or esophageal clearance [when] compared to placebo,” according to Dr. Vela. Other drugs that are available outside the United States include domperidone, itopride, and mosapride, but Dr. Vela, who led a 2014 report on these therapies, stated that benefits offered by these are modest, and studies investigating them are limited in number.

Also being looked at are rebamipide, which can be used a cytoprotective agent that increases prostaglandin production. A 2010 study by Yoshida et al. found that lansoprazole (15 mg/day), combined with 300 mg/day of rebamipide, was significantly better at preventing relapse within a year than was just the former medication taken on its own. Additionally, there are conceptual studies examining topical protection to maintain mucosal integrity, nociceptor blockades, and imipramine.

Regarding trials for GERD, Robyn Carson, director of health economics & outcomes research at Allergan stated that the company recently redefined what constitutes GERD in order to help refocus what its drugs were trying to do.

“I think we’ve operationalized it very recently in terms of exclusion and GERD,” she explained. “The way we define it is ‘active GERD’ with two or more episodes a week of heartburn, so it was very much focused on the heartburn and PPI use was acceptable.”

Following the GERD discussion, panelists talked about what’s coming up in the realm of EoE. Stuart J. Spechler, MD, of the University of Texas Southwestern in Dallas, discussed ongoing research into treating EoE as an antigen-driven disorder, noting that about half of all EoE patients have a history of atopic disease – such as rhinitis, asthma, and atopic dermatitis – and exhibit sensitization to food or other aeroallergens. Furthermore, about 3% of patients who undergo oral immunotherapy to treat a food allergy develop EoE.

But in terms of what to take EoE research forward, Dr. Spechler called for a shift away from trying to distinguish between EoE and GERD, arguing that GERD contributes to EoE pathogenesis, and vice versa. PPIs can and should be used in EoE for the same reasons that they’re used to treat GERD, he explained.

“We need a shift in focus [because] I don’t think it’s likely to be that productive a line of research,” Dr. Spechler said. “The two diseases often coexist.”

To attack gastroparesis, P. Jay Pasricha, MDexplained that a number of trials examining several drugs have shown that they are either ineffective or “do not correlate with improvement in gastric emptying.” These drugs include cisapride, tegaserod, botulinum toxin, mitemcinal, camcinal, TZP 102, and relamorelin.

“I’m not going to talk about emerging biomarkers because there isn’t a lot to talk about with biomarkers that hasn’t already been said,” stated Dr. Pasricha of Johns Hopkins University in Baltimore adding that his focus would largely be focused on emerging therapies and treatment targets.

A 2013 study by Parkman et al. investigated the effects of nortriptyline on mitigating idiopathic gastroparesis symptoms, finding that there was no significant difference in symptoms among patients who took the drug, versus those who took a placebo. In terms of using antinauseants to alleviate symptoms, dopamine receptor antagonists continue to be commonly prescribed, but they have their limitations. Metoclopramide, though approved since 1986, can be used for only 12 weeks, has acute and chronic side effects such as mood and irreversible movement disorders, and a black box warning imposed on it by the FDA in 2009 for tardive dyskinesia. One drug approved in India, though not by the FDA, is domperidone, which has no side effects to the central nervous system but does raise cardiovascular concerns in patients with “mild hERG affinity.”

Currently, the APRON trial is investigating the efficacy of aprepitant to relieve chronic nausea and vomiting in gastroparesis patients. Those enrolled in the study are all at least 18 years old, have undergone gastric-emptying scintigraphy, and either a normal upper endoscopy or an upper GI series within the 2 years prior to enrollment, have symptoms of chronic nausea or vomiting consistent with a functional gastric disorder for at least 6 months before enrollment, and nausea defined as “significant” by a visual analog scale score of at least 25 mm.

“Continuing to focus solely on accelerating gastric emptying is a failed strategy,” said Dr. Pasricha, adding that research needs to focus on the unique aspects of the disease’s biology, including pathogenic similarities with functional dyspepsia.

To that end, the final disease covered was functional dyspepsia. In terms of ongoing or planned clinical studies, Jan Tack, MD, from the University of Leuven (Belgium), mentioned three. Two of them are multicenter controlled trials investigating acotiamide, one in Europe and the other in India, for the management of functional dyspepsia and postprandial distress syndrome, while the other is a multicenter study examining rikkunshito, a traditional Japanese medicine. Additionally, ongoing or planned mechanistic studies include single-center controlled trials in Belgium on the efficacy of acotiamide and rikkunshito for intragastric pressure, as well as another Belgian study analyzing the impact of monoacylglycerol lipase inhibitors on intragastric pressure in patients that have functional dyspepsia with “impaired accommodation.”

Meal-related symptoms, nutrient challenge tests, and intragastric pressure measurements should all become short-term pathophysiology and efficacy markers, said Dr. Tack, adding that it’s also important for new therapeutic targets to include gastric emptying, hypersensitivity, and duodenal alterations, if necessary.

Hurdles persist in getting drugs through the approval process, however. Juli Tomaino, MD, of the FDA’s Center for Drug Evaluation and Research, explained where many proposed drugs run into issues in the regulatory process.

“We really have to know what we’re diagnosing, so the regulatory pathway to any of these approvals will really depend on the independent patient population, it will depend on the mechanism of action of the drug, what the drug is able to do and not do, and how you’re going to design that trial to target whatever that drug can do,” Dr. Tomaino said.

The issue of labeling also factors in, according to her. “We know that patients with acid-mediated heartburn do well on PPIs, but if they’re having different symptoms due to different mechanisms of action, then you have to design that drug with that patient population in mind, and that’s what the labeling would look like,” she explained. “So I’m not saying that it would necessarily have to list all the enrollment criteria, all the enrichment techniques that we use in that trial, but it would be a description of the intended patient population and what the drug would do.”

Mrs. Carson also chimed in on the topic of trial difficulties, saying that “[Irritable bowel syndrome] and [chronic idiopathic constipation] became quite an impediment to recruitment, and I think as we get farther away from the complete overlapping conditions, I think that’s where in discussions with the [Qualification Review Team] at FDA, they recognize that [we should] track that and let this evidence drive the next step,” adding that “we’ll have data on that shortly.”

Hepatitis B Vemlidy
Saturday, November 26, 2016
The FDA has approved tenofovir alafenamide (TAF), to be sold as Vemlidy, for adults with chronic hepatitis B infection with compensated liver disease, said manufacturer Gilead Sciences on Thursday.
TAF is a prodrug for tenofovir, an antiviral agent previously approved under the name Viread for HIV and HBV infection.

Portal hypertension
Wednesday, December 7, 2016

Coreg 6.25 bid and Simvastatin 40 mg

Sarcopenia : muscle loss. Occurs in cirrhosis
CT at L3 level get score. Less than 39 poor outcome
Twice mortality

Tuesday, December 27, 2016

We report that the anticancer activity of the widely used diabetic drug metformin is strongly potentiated by syrosingopine. Synthetic lethality elicited by combining the two drugs is synergistic and specific to transformed cells. This effect is unrelated to syrosingopine’s known role as an inhibitor of the vesicular monoamine transporters. Syrosingopine binds to the glycolytic enzyme α-enolase in vitro, and the expression of the γ-enolase isoform correlates with nonresponsiveness to the drug combination. Syrosingopine sensitized cancer cells to metformin and its more potent derivative phenformin far below the individual toxic threshold of each compound. Thus, combining syrosingopine and codrugs is a promising therapeutic strategy for clinical application for the treatment of cancer.

Crispr Cas9
Monday, January 2, 2017
CRISPR technology in a nutshell

Late 1980’s : scientists discover bacteria have genomic code that has no value

Bacteria are constantly attacked by viruses

In 2008 – scientists discover that bacteria creates splicer / scissors to split viral Dna / rna

The memory of specific splicer is retained in the genomic area that we thought in 1980’s was of no value

2012 / 2013 : scientist discover that bacteria can be tricked into creating splicer / scissors specific for our use this is the Cas9

2016 : now we can manipulate any part of any DNA /RNA of anything. Humans animals or plants or any organ

2016 : legal war between California and Chinese scientist who actually developed the skill to trick bacteria.
Only a couple of billion dollars at stake here and Nobel prize and fame

Today : Good Morning frankenstein !

Saturday, January 14, 2017

And finally, clinicians may soon have a new term to use in the medical diagnosis of obesity: adiposity-based chronic disease (ABCD).

Gayatri mantra
Tuesday, January 24, 2017

The study suggests that blue light specifically, within the visible light spectrum, may directly activate key immune cells and increase their motility. The researchers studied both human and mouse T lymphocytes after exposure to blue light. They found that the blue light triggered the synthesis of hydrogen peroxide, which in turn activated key signaling pathways that led to increased movement and motility of the T cells.

High plant protein diet helps NAFLD and insulin resistance
Wednesday, January 25, 2017

Remarkably, diets restricted in methionine were shown to prevent the development of insulin resistance and of the metabolic syndrome in animal models [so] the type of protein may elicit different metabolic responses depending on the amino acid composition,” Dr. Markova and her coinvestigators noted. “It is therefore hypothesized that high-plant-protein diets exert favorable effects on hepatic fat content and metabolic responses as compared to high intake of animal protein rich in BCAA [branched-chain amino acids] and methionine,” both of which can be found in suitably low levels via plant protein.

Pill for lactose intolerance
Sunday, January 22, 2017

Ritter Pharmaceuticals

highly purified (more than 95%) short-chain galactooligosaccharide (GOS) was given to 42 adults with a self-reported history of lactose intolerance, confirmed by a hydrogen breath test administered after a 25-g lactose challenge.

a significant increase in the lactose-fermenting Bifidobacterium, Faecalibacterium, and Lactobacillus species. T

Sunday, January 22, 2017

unprocessed red meat, but not processed red meat, was the primary driver for the association between total red meat and risk of diverticulitis,”

Asthma drug and hepatic veno-occlusive disease drug
Thursday, January 26, 2017
10:19 PM

Saturday, January 28, 2017

GIE 2016 VOLUME 83

Saturday, January 28, 2017

Olympus or erbe cautery
Place pad on flank
Indigo carmine better than methylene blue
Voluven or saline plus methylcellulose
Hybrid knife use normal saline
Favor dual knife. Hook for fibrotic knife
IT KNIFE – IT nano for colon. IT 2 FOR stomach
Scissors knife :
Fuji caps
Coagulation forceps
Tension pneumoperitoneum is rare
Dilumen is over tube and 2 balloons
Lumen R

Pathology sections should be every 2 mm
European guidelines gastric intestinal metaplasis : every 3 years EGD
cases : eso cancer 16,000 a year versus gastric 26,000

ESD for 2 cm. Less recurrence compared to EMR
Piece meal EMR and cancer. Needs surgery. Not curative
Paris clarification
Depression of flat lesson – ESD. Ulcerative lesion surgery
Pit pattern : use BING clarification for barretts
Gastric cancer : see Wallace slides
JNET classification for colon polyps

Do not remove if on dependent area
Clip easier if on left side of screen vessel
Can use clip as tamponade

Soft coag with coag grasper 60-100 watts

PRECUT EMR. Cut around polyp.
Hybrid is when you start cutting around and dissect under polyp and then convert to ESD and then use stiff snare or spiral.snare.

Hypromellose or
Elleview ( starch poloxamer and Tg) injections

Good judgement come from experience and experience comes from poor judgement. Surgical quote

Markings and coag grasper : soft coag effect 5 watts 80
Mucosal incision and trimming : end cut q effect 3 cut duration 1 interval 1
Avulsion : hot bx forceps : endocut I effect 2 , time 1 duration 1
Use boston syringe for injection
Needle length 4 mm sclerotherapy

Forced coag setting : effect 2 watts 50

Dry cut for colon : effect 3 watts 100

Forced coag : effect 2 watts 50

Ercp endocut I effect 2
Polyp : effect 3

Endocut : q 750 volts and I 550 volts
Effect is degree of coagulation higher number more coag

Trimming is using multiple dual knife to cute below lip up to 3 times to negotiate cap under polyp

Standard hood short hood or ST hood

Statin alternatives
Saturday, January 28, 2017

Inclisiran represents a new class of cholesterol lowering medications that work by inhibiting PCSK9. PCSK9 is the enzyme that clears the LDL-C receptor from the liver. When PCSK9 is inhibited, the LDL-C receptor is cleared more slowly so there are more LDL-C receptors available to clear LDL-C from the circulation, and serum LDL-C decreases. This is the mechanism for inclisiran as well as for the recently approved PCSK9 inhibitors alirocumab (Praluent) and evolocumab (Repatha), which are monoclonal antibodies that target PCSK9. The difference is that inclisiran is not a monoclonal antibody, but rather from a new class of medication that targets RNA directly to silence the RNA of the target and stop the production of the PCSK9 enzyme before it is built. This class of medication has a long duration of action, 6-12 months, and is apparently much easier to manufacture than monoclonal antibodies.1

Ldl is cleared by LDL-C RECEPTORS
PCSK 9 destroys LDL C receptors
PCDK9 can be inhibited by repatha or praluent which are monoclonal Ab
Inhibiting Production of PCSK9 at RNA LEVEL

Plavix resistance
Saturday, January 28, 2017
• Carriers of CYP2C19 loss-of-function alleles were at increased risk of stroke vs noncarriers (12.0% vs 5.8%; RR, 1.92).
• Composite vascular events were also more frequent in carriers of CYP2C19 loss-of-function alleles vs noncarriers (13.7% vs 9.4%; RR, 1.51); however, bleeding rates were similar.

AS and IBD
Saturday, February 4, 2017

Baseline level of fecal calprotectin among AS patients who had been diagnosed with Crohn’s disease 5 years later was higher, at 570 mg/kg, compared with 85 mg/kg (P=0.014) among those who did not develop the inflammatory bowel disease (IBD), according to Eva Klingberg, MD, PhD, of the University of Gothenburg, and colleagues.

Alcoholism – carbohydrate deficient transferrin
Saturday, February 4, 2017

combination of GGT and CDT compared with GGT or CDT alone shows a higher diagnostic sensitivity, a higher diagnostic specificity, and a stronger correlation with the actual amounts of alcohol consumption. Combination GGT/CDT values appear to increase after the daily alcohol consumption exceeds a threshold of 40 g. This approach is cost-effective, easy to manage in hospital laboratories, and should be suitable for routine clinical care.

Sunday, February 5, 2017

ORITAVANCIN orbactiv. Glycoprotein similar to vancomycin but effective in 15 min. Attached to bacteria by brute force. 1200 mg IV

Monday, February 6, 2017
Without further ado, here are the qualities the panel thought categorized a good night sleep:

  1. It takes you no more than 30 minutes to fall asleep.
  2. You wake up no more than once.
  3. When you do wake up in the night, you’re awake for no more than 20 minutes.
  4. You’re asleep at least 85 percent of the time you’re in bed.

Pre diabetes
Friday, February 10, 2017
Result A1C
Normal less than 5.7%
Prediabetes 5.7% to 6.4%
Diabetes 6.5% or higher

Fasting Plasma Glucose (FPG)
This test checks your fasting blood glucose levels. Fasting means after not having anything to eat or drink (except water) for at least 8 hours before the test. This test is usually done first thing in the morning, before breakfast.
• Diabetes is diagnosed at fasting blood glucose of greater than or equal to 126 mg/dl

Result Fasting Plasma Glucose (FPG)
Normal less than 100 mg/dl
Prediabetes 100 mg/dl to 125 mg/dl
Diabetes 126 mg/dl or higher

Research shows that you can lower your risk for type 2 diabetes by 58% by:
• Losing 7% of your body weight (or 15 pounds if you weigh 200 pounds)
• Exercising moderately (such as brisk walking) 30 minutes a day, five days a week
Don’t worry if you can’t get to your ideal body weight. Losing even 10 to 15 pounds can make a huge difference.

  • See more at:
  • See more at:

ACG guidelines for Liver
Sunday, February 12, 2017
9:23 PM

• 29 to 33 IU/L represents a normal, healthy ALT range for males.
• 19 to 25 IU/L is normal for females.
• The diagnostic workup for hepatocellular injury should include testing for viral hepatitis A, B, and C, nonalcoholic fatty liver, and alcoholic liver disease, among other possibilities.
• Advise patients to abstain from alcohol since that’s the cornerstone of treatment for the disorder.
• Perform blood, urine, and ascites cultures in patients with jaundice and suspected alcoholic hepatitis.
• Admit jaundiced patients with alcoholic hepatitis to the hospital to improve their nutritional status, encourage abstinence, and to rule out serious infections.
• Perform hepatic imaging but exercise caution when giving iodinated contrast dye since it increases the risk of acute renal injury.
OLT patients
Occult hepatitis C infection (HVC) may still exist in some patients with abnormal aminotransferase levels despite the fact that they have had a sustained virologic response 12 weeks after a course of treatment with direct acting antiviral agents, a recent study found. To reach that conclusion, researchers conducted a prospective analysis of 134 patients with recurrent HCV infection after liver transplantation who had received direct acting agents with or without ribavirin. They found that:
• More than 10% of patients (n=14) with a sustained response had serum aminotransferase levels that did not normalize—or normalized transiently—during or after antiviral therapy.
• 9/14 patients were evaluated for occult HCV with reverse transcription quantitative polymerase chain reaction.
• 5 patients had occult infection, with negative strand viral genome indicating viral replication.

Magnetic resonance elastography (MRE) is more accurate than ultrasound-based transient elastography (TE) for detecting stage 1 and higher liver fibrosis and steatosis in patients with non-alcoholic fatty liver disease, according to a recent study. Similarly, MRI-based proton-density fact fraction (MRI-PDFF) is more accurate than TE-based controlled attenuation parameter (CAP) for diagnosing all grades of steatosis in these patients. More specifically, the study found:
• MRE detected fibrosis with an area under the receiver operating characteristic curve (AUROC) of 0.82, compared to 0.67 for TE.
• MRI-PDFF revealed steatosis with an AUROC of 0.99, vs 0.85 for CAP.
• MRE detected stage 2, 3, or 4 fibrosis with AUROC values of 0.89, 0.87, and 0.87, respectively, while TE’s AUROC values were 0.86, 0.80, and 0.69.

Complicated appendicitis
Sunday, February 12, 2017
9:52 PM
Age more than 10
Prolonged duration of symptoms
Wider diameter of appendix

Adrenal adenoma
Monday, February 13, 2017
2:07 PM

The evaluation in apparently asymptomatic patients has been debated. Even in asymptomatic patients, the European Network for the Study of Adrenal Tumors (ENSAT) recommends performing the following tests to determine the secretory activity of the tumor: fasting blood glucose, serum potassium, cortisol, corticotropin (ACTH), 24-hour urinary free cortisol, fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasone at bedtime, adrenal androgens (dehydroepiandrosterone-sulfate [DHEA-S], androstenedione, testosterone, 17-OH progesterone), and serum estradiol in men and postmenopausal women [76].

Adrenal carcinomas are typically inefficient steroid producers, but they secrete excessive amounts of adrenal steroid precursors due to decreased expression of several steroidogenic enzymes (which also results in diminished cortisol production). Even in patients with adrenal carcinomas who presumably did not produce excess steroids, more sensitive methods such as gas chromatography/mass spectrometry identify increased urinary metabolites of several steroids and precursors of androgens (pregnenediol, pregnenetriol, androsterone, etiocholanolone) or glucocorticoids (17-hydroxyproesterone, tetrahydro-11-deoxycortisol, cortisol, 6-hydroxy-cortisol, tetrahydrocortisol, and a-cortol); this is different from cortisol secreting adenomas which produce cortisol, but little androgens [77]. Low serum aldosterone concentrations, but normal or high serum or urinary concentrations of aldosterone precursors (ie, deoxycorticosterone, 18-hydroxydeoxycorticosterone, corticosterone, and 18-hydroxycorticosterone, tetrahydro-11-deoxycorticosterone (THDOC), and 5 alpha-THDOC) are found in most adrenal carcinomas, but not in adrenal adenomas [77,78].

The European Network for the Study of Adrenal Tumors (ENSAT) also recommends that plasma metanephrines or urinary metanephrines and catecholamines be obtained in all patients to exclude pheochromocytoma, and that plasma aldosterone and renin be obtained in patients with hypertension and/or hypokalemia (see “Establishing the cause of Cushing’s syndrome” and “Adrenal hyperandrogenism” and “Pathophysiology and clinical features of primary aldosteronism” and “The adrenal incidentaloma”). Hormonal evaluation may help in establishing the adrenal origin of the tumor and provide tumor markers that can be useful during follow-up to estimate the presence of residual tumor or tumor recurrence after surgery.

Hcv and T2D
Tuesday, February 14, 2017

According to a review published in Liver International, “[a]lthough many of the extrahepatic effects of HCV are caused by an interaction between HCV and the immune response leading to cryoglobulinemia, the link between T2DM [type 2 diabetes mellitus] and HCV does not occur through this mechanism. T2DM is secondary to HCV proteins interacting with key regulatory steps involved in glucose metabolism within hepatocytes causing insulin resistance (IR). The HCV core protein has been specifically identified as involved in this process. Extrahepatic sites involved in glucose metabolism, such as the skeletal muscles also exhibit IR in patients with chronic HCV.”

According to a review published in Liver International, “[i]nsulin resistance occurs in approximately 30%-70% of persons with chronic HCV but in only 10%-25% of the general population. IR is more common in patients with chronic HCV than in those with other liver diseases and develops before fibrosis. IR is a necessary precursor for T2DM and develops before overt T2DM in patients with HCV.”

According to a review published in Liver International, “[a]n estimated 47 million individuals worldwide have T2DM secondary to chronic HCV. T2DM is four times more common in patients with HCV than in control patients without liver disease or in patients with other liver disorders.”

published in Liver International, “[h]epatic steatosis in patients with chronic HCV can be a direct result of HCV genotype 3 or from IR and T2DM in those with other genotypes. Eradication of HCV RNA in patients with genotype 3 is associated with resolution of hepatic steatosis.

Wednesday, February 15, 2017
7:53 PM

NOAC circulation 2017
Tuesday, February 21, 2017
• In most situations, the time of last drug ingestion combined with a recent assessment of creatinine clearance (CrCl) should enable appropriate clinical decision making.
• In patients who are on dabigatran who have minor bleeding, supportive care and careful observation are recommended. For major bleeding, intravenous idarucizumab (Praxbind), will reverse the anticoagulant effect of dabigatran within minutes.
• For procedures with an extremely low risk of bleeding such as minor dental, dermatologic, or ophthalmologic procedures, anticoagulation may be safely continued without interruption.
• In patients with a moderate to high procedural risk of bleeding, the thromboembolic risk should be evaluated. For patients with low to moderate thromboembolic risk, NOAC therapy can be stopped sufficiently ahead of the procedure and bridging low-molecular-weight heparin is not recommended as it does not prevent thrombotic events and increases the risk of bleeding.
• Prior to surgery when NOAC is going to be held, dabigatran should be held for at least 24 hours if CrCl ≥50 mL/min; for at least 72 hours if CrCL <50 mL/min; rivaroxaban, apixaban, and edoxaban should be held for at least 24 hours.
Four NOACs have been approved in the US for prevention of stroke in the setting of nonvalvular atrial fibrillation (AF), as well as the prevention and treatment of VTE. Approved agents are dabigatran etexilate (Pradaxa); rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa).

Alcohol and appetite
Tuesday, February 21, 2017
Alcohol has a complex interaction with your body, but that “drunk hunger” is partly due to a neuropeptide called AgRP (agoti-related protein), which makes you want to eat even if you’re not hungry. At the same time, it’s believed to suppress your appetite-regulating hormone leptin so you never quite feel full either.

What’s more, the effects of alcohol can change how your brain processes the taste, texture, and overall palatability of foods. That means you might find yourself craving a cold, floppy pizza that you wouldn’t normally eat and thinking it tastes like something that Gordon Ramsay lovingly prepared for you. Also, your tendency to eat horrible foods when you drink is a big reason why excessive drinking leads to weight gain, so check out this article on how to drink alcohol without messing up your weight loss

MAGE for diabetes monitoring
Wednesday, February 22, 2017

Glycemic excursions were assessed as mean amplitude of glycemic excursions (MAGE) with 72-h ambulatory continuous glucose monitoring. Treatment efficacy was evaluated as relative HbA1c reduction (%), calculated as (baseline HbA1c – post-treatment HbA1c)/baseline HbA1c × 100.

Bcp cancer
Thursday, February 23, 2017

women who have ever used combined oral contraceptives see an increased risk of breast and cervical cancer, the risk disappears within about 5 years after stopping, but a protective effect against colorectal, endometrial, and ovarian cancer persists for more than 30 years.

Hp 2017 guidelines
Thursday, February 23, 2017
2:35 PM

To that end, ACG recently provided recommendations to help clinicians choose the best antibiotic regimen and to avoid common treatment errors. Among its recommendations:
• Ask patients if they have received previous treatment for the infection and incorporate that information into the decision making process.
• Only prescribe clarithromycin triple therapy as first line therapy to patients who have not been exposed to macrolides and who live in areas where resistance to the antibiotic is low.
• Prescribe bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole to most patients as first line therapy.
• For patients who don’t respond to first line treatment with clarithromycin, the best approach is bismuth quadruple therapy or levofloxacin.


Low CVD risk diet / low MI
Friday, February 24, 2017

If an ingredients list describes any oils at all, you don’t eat it. You don’t add oils, nor cook with them. Between this, and the vegan directive, you’ve covered most of Dr. Esselstyn’s plan. Add to this a directive of whole grain/whole food, instead of processed.

Procalcitonin sepsis
Friday, February 24, 2017
High levels of PCT suggest a bacterial infection, whereas low levels suggest a viral infection or noninfectious causes, the FDA says. Clinicians may be able to use PCT levels and other information to safely withhold or discontinue antibiotics. PCT may indicate the presence of a variety of bacterial infections, but it does not detect the exact cause of a patient’s symptoms.
The Vidas Brahms PCT assay is already approved by the FDA to help clinicians better predict a patient’s risk of dying from sepsis or of their condition worsening.

GFD implications
Friday, February 24, 2017
5:47 PM

Gluten-free diets related to high levels of arsenic, mercury However no data to support it is harmful

Tuesday, February 28, 2017
Green urine is a highly uncommon and unusual finding, generally associated with recent surgery requiring high doses of propofol infusion.[29] The discoloration may result from quinol derivatives following glucuroconjugation and excretion of the parent drug.

Carcinoid diarrhea
Wednesday, March 1, 2017
10:20 AM

The FDA approved telotristat ethyl (Xermelo) on Tuesday for treatment of carcinoid syndrome diarrhea, the agency announced.

Obesity cancers
Wednesday, March 1, 2017
10:21 AM

the strongest evidence was seen for cancers of the gastric cardia, colon, rectum, biliary tract system, pancreas, breast, endometrium, ovary, kidney, esophageal adenocarcinoma, and multiple myeloma, reported Maria Kyrgiou, PhD, of Imperial College London, and colleagues.

NASH drugs
Wednesday, March 1, 2017
4:30 PM

Obetechoic acid, tocotrienol

Trulance constipation
Thursday, March 2, 2017

Chronic idiopathic constipation. New medicine

IBS genetics
Friday, March 3, 2017

One severe IBS-C case with a highly penetrating SCN5A loss-of-function mutation was successfully treated with mexiletine (Mexitil), a cardiac antiarrhythmic that restores NaV1.5 channel function.

New Hepatitis B
Wednesday, January 4, 2017
6:38 PM

Vemlidy : Tenofovir alafenamide 25 mg once a day.

Advantage over Viread : (viread causes renal toxicity and bone loss)

Four mutations for RAV : 28, 30, 31 and 93 mutations : these mutations confer resistance. If present add ribavarin.

Pre op evaluation for cirrhosis : Patrick Kamath : Mayo clinic paper. If MELD Na less than 8 acceptable operative risk
8-11 score : higher risk but acceptable (risk of decompensation or variceal bleed)
12 or higher : high risk : get listed for transplant before major surgery
Glue emboliztion occurs in 5 %

Erbe unit simplified
Wednesday, March 8, 2017
12:11 PM

Erbe unit simplified


Thursday, March 9, 2017

Lysosomal acid lipase 402300. Lab corp

Thursday, March 9, 2017

the PhenoTest BC Kit, performed on the manufacturer’s Pheno system, can identify 14 different species of bacteria or two species of yeast from a positive blood culture in about 90 minutes. In another 6 to 7 hours, it delivers results on antibiotic susceptibility. The test also picks up on two indicators of antibiotic resistance.

Marijuana or cannabis
Sunday, March 12, 2017

Major finding: Cannabis users showed 26% increased risk (OR, 1.24) of stroke and 10% increased risk (OR, 1.1) of heart failure.

CHS : cannabis hyperemesis syndrome

Candida auris,
Sunday, March 12, 2017

Candida auris,

this one causes serious bloodstream infections, spreads easily from person to person in health-care settings, and survives for months on skin and for weeks on bed rails, chairs and other hospital equipment. Some strains are resistant to all three major classes of antifungal drugs. Based on information from a limited number of patients, up to 60 percent of people with these infection have died. Many of them also had other serious underlying illnesses.
Read more here:

Colonoscopy performance
Friday, March 17, 2017

We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 Rate of adequate bowel preparation (minimum standard 90 %); 2 Cecal intubation rate (minimum standard 90 %); 3 Adenoma detection rate (minimum standard 25 %); 4 Appropriate polypectomy technique (minimum standard 80 %); 5 Complication rate (minimum standard not set); 6 Patient experience (minimum standard not set); 7 Appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.

PPI management
Friday, March 17, 2017

Gastroenterological Association has reviewed these recommendations. Best Practice Advice 1: Patients with GERD and acid-related complications (ie, erosive esophagitis or peptic stricture) should take a PPI for short-term healing, maintenance of healing, and long-term symptom control. Best Practice Advice 2: Patients with uncomplicated GERD who respond to short-term PPIs should subsequently attempt to stop or reduce them. Patients who cannot reduce PPIs should consider ambulatory esophageal pH/impedance monitoring before committing to lifelong PPIs to help distinguish GERD from a functional syndrome. The best candidates for this strategy may be patients with predominantly atypical symptoms or those who lack an obvious predisposition to GERD (eg, central obesity, large hiatal hernia). Best Practice Advice 3: Patients with Barrett’s esophagus and symptomatic GERD should take a long-term PPI. Best Practice Advice 4: Asymptomatic patients with Barrett’s esophagus should consider a long-term PPI. Best Practice Advice 5: Patients at high risk for ulcer-related bleeding from NSAIDs should take a PPI if they continue to take NSAIDs. Best Practice Advice 6: The dose of long-term PPIs should be periodically reevaluated so that the lowest effective PPI dose can be prescribed to manage the condition. Best Practice Advice 7: Long-term PPI users should not routinely use probiotics to prevent infection. Best Practice Advice 8: Long-term PPI users should not routinely raise their intake of calcium, vitamin B12, or magnesium beyond the Recommended Dietary Allowance (RDA). Best Practice Advice 9: Long-term PPI users should not routinely screen or monitor bone mineral density, serum creatinine, magnesium, or vitamin B12. Best Practice Advice 10: Specific PPI formulations should not be selected based on potential risks.

Friday, March 17, 2017

team of researchers from Germany found that rodents with a deficiency of the SPRED2 protein engaged in excessive grooming rituals. This protein generally inhibits signals from sliding along a pathway called the Ras/ERK-MAP kinase cascade. Without SPRED2, signal pathways become overactive.
Drugs that inhibit the Ras/ERK-MAP kinase cascade are already on the market for treating cancer. So, it’s possible that a more effective method for OCD may already be in existence — and hopefully on the way sooner rather than later.

Hypercoagulable causes
Sunday, March 19, 2017
Hypercoagulable states such as:
●Factor V Leiden
●Prothrombin gene mutation
●Protein C deficiency
●Protein S deficiency
●Antithrombin deficiency
●Increased factor VIII levels

Acquired conditions such as: ●Philadelphia-chromosome negative chronic myeloproliferative disorders (polycythemia vera, essential thrombocythemia, idiopathic myelofibrosis, unclassifiable myeloproliferative disorders)
●Paroxysmal nocturnal hemoglobinuria
●Behçet’s syndrome
●Abdominal inflammatory lesions including infection, pancreatitis, and inflammatory bowel disease

Thus would recommend pursuing full hypercoagulable work-up including flow cytometry for PNH. Would also check Jak2 mutation, FISH for BCR/ABL.

Bloating causes
Monday, March 20, 2017
3:16 PM
The DD for bloating is long. It includes, reflux, PUD, biliary disease, NUD, SIBO, lactose, frutose, GSID, EPI, NCGS, food alergies, constipation,and diet.

Colon polyp. NbI
Thursday, March 23, 2017

Types 1, 2A, and 3 of the JNET classification were very reliable indicators for HP/SSP, LGD, and SM-d carcinoma, respectively. However, the specificity and positive predictive value of Type 2B were relatively lower than those of others. Therefore, an additional examination such as pit pattern diagnosis using chromoagents is necessary for accurate diagnosis of Type 2B lesions.

Friday, March 24, 2017

found that 5% of cancer-causing mutations can be linked to inherited genetic risk.” Meanwhile, “an additional 29% of malignancy-promoting mutations can be attributed to ‘modifiable’ factors…such as wearing sunscreen and vaccinating ourselves against cancer-causing viruses.” The other “66% of genetic mutations known to give cancer a foothold are random transcription errors in DNA.”

Saturday, April 1, 2017

According to this meta-analysis, approximately 1 in 6 patients with unexplained exacerbations of COPD have a pulmonary embolus as a primary cause or important contributions

Friday, April 7, 2017

Once the diagnosis has been made, there are numerous therapeutic options, but the top three are “diet, diet, and diet,” according to Dr. Lembo. In his review of prokinetic drugs, such as metoclopramide and motilin agonists, he cautioned that there is often a delicate balance between risk and benefit. New options on the horizon include a ghrelin agonist that showed promise in a phase III trial, but he noted that many patients with severe unremitting symptoms are prepared to try almost anything.

Rule out cyclic vomiting rumination syndrome and chronic cannabinoid use

Friday, April 7, 2017
10:10 AM

Saturday, April 8, 2017

Reovirus may trigger celiac or other autoimmune disease

Hp treatment
Monday, April 10, 2017
4:14 PM

Regimen Drugs (doses) Dosing frequency Duration (days) FDA approval
Clarithromycin triple PPI (standard or double dose) BID 14 Yesa
Clarithromycin (500 mg)
Amoxicillin (1 grm) or Metronidazole (500 mg TID)
Bismuth quadruple PPI (standard dose) BID 10–14 Nob
Bismuth subcitrate (120–300 mg) or subsalicylate (300 mg) QID
Tetracycline (500 mg) QID
Metronidazole (250–500 mg) QID (250)
TID to QID (500)
Concomitant PPI (standard dose) BID 10–14 No
Clarithromycin (500 mg)
Amoxicillin (1 grm)
Nitroimidazole (500 mg)c
Sequential PPI (standard dose)+Amoxicillin (1 grm) BID 5–7 No
PPI, Clarithromycin (500 mg)+Nitroimidazole (500 mg)c BID 5–7
Hybrid PPI (standard dose)+Amox (1 grm) BID 7 No
PPI, Amox, Clarithromycin (500 mg), Nitroimidazole (500 mg)c BID 7
Levofloxacin triple PPI (standard dose) BID 10–14 No
Levofloxacin (500 mg) QD
Amox (1 grm) BID
Levofloxacin sequential PPI (standard or double dose)+Amox (1 grm) BID 5–7 No
PPI, Amox, Levofloxacin (500 mg QD), Nitroimidazole (500 mg)c BID 5–7
LOAD Levofloxacin (250 mg) QD 7–10 No
PPI (double dose) QD
Nitazoxanide (500 mg) BID
Doxycycline (100 mg) QD
BID, twice daily; FDA, Food and Drug Administration; PPI, proton pump inhibitor; TID, three times daily; QD, once daily; QID, four times daily.
a Several PPI, clarithromycin, and amoxicillin combinations have achieved FDA approval. PPI, clarithromycin and metronidazole is not an FDA-approved treatment regimen.
b PPI, bismuth, tetracycline, and metronidazole prescribed separately is not an FDA-approved treatment regimen. However, Pylera, a combination product containing bismuth subcitrate, tetracycline, and metronidazole combined with a PPI for 10 days is an FDA-approved treatment regimen.
c Metronidazole or tinidazole.
Table 2. Recommended first-line therapies for H pylori infection

Aspiration management
Wednesday, April 12, 2017
10:15 AM

  1. Swallowing with tongue on roof of mouth
  2. Holding tongue out and swallowing
  3. Keep pronouncing words ending in K like block,crock
    Chin tuck
    Do not use straws
  4. Swallowing with tongue on roof of mouth
  5. Holding tongue out and swallowing
  6. Keep pronouncing words ending in K like block,crock
  7. Chin tuck
  8. D not use straws

Aspiration handout
Wednesday, April 12, 2017


Tuesday, April 18, 2017

consensus statement and recommendations to assist health care providers with appropriate management of patients with biallelic mismatch repair deficiency (BMMRD) syndrome, also called constitutional mismatch repair deficiency syndrome.

The major challenge is that BMMRD is rare, limiting the ability to accumulate unbiased data and develop controlled prospective trials. The formation of effective international consortia that collaborate and share data is proposed to accelerate our understanding of this disease. A computer-aided search of MEDLINE from 1999 to March 2016 was performed focusing on biallelic mismatch repair deficiency (BMMRD) syndrome and constitutional mismatch repair deficiency (CMMRD) syndrome. The search was restricted to English language articles. In addition, a search was conducted using references from accessed articles. Publications were retrieved, and the authors synthesized and assessed the available data. There were no controlled trials in BMMRD. Experts pooled their collective experiences to develop consensus guidelines as an initial attempt to produce more uniform approaches to patient management, and prioritize areas in greatest need of research. The Multi-Society Task Force is composed of gastroenterology specialists with a special interest in CRC, representing the following major gastroenterology professional organizations: American College of Gastroenterology, the American Gastroenterological Association Institute, and the American Society for Gastrointestinal Endoscopy. The North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, and representatives of the Collaborative Group of the Americas on Inherited Colorectal Cancer also reviewed this article. This document was approved by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition. LS is the autosomal-dominant disease caused by a monoallelic germline mutation in a DNA mismatch repair (MMR) or EPCAM gene, and is the most common cause of inherited CRC.5 LS is caused by a large number of heterozygous germline mutations in MLH1, MSH2, MSH6, PMS2, and EPCAM, and the tumor DNA is characterized by microsatellite instability (microsatellite instability–high [MSI-H], or, by convention, MSI). Penetrance for cancer is incomplete in LS; the cumulative lifetime risk of CRC is variable depending on the gene mutated and sex, and ranges from 40% to 70% for women and men, respectively, for the genes MSH2, MLH1, and MSH6.5 Penetrance for CRC is reduced substantially for LS associated with mutations in PMS2, ranging from 10% to 20%.6-8 Patients with LS also are predisposed to extracolonic malignancies, primarily endometrial cancer (40% in women with mutations in MSH2 and MLH1), and, to a lesser extent, other gastrointestinal and genitourinary cancers. These syndromes can be managed adequately by annual colonoscopy and appropriate gynecologic surgery.1 BMMRD is an under-recognized syndrome with pleiotropic presentations. Clues to guide clinicians to suspect BMMRD and increase recognition of BMMRD are included in Table 2. Patients may be children or young adults diagnosed with early onset CRC, brain tumors, leukemias, lymphomas, or uterine cancer. Any child or young adult with cancer plus parental consanguinity or features of neurofibromatosis not explained by other confirmed germline mutations should be suspected. Raising awareness among gastroenterologists, oncologists, dermatologists, internists, gynecologists, and pediatricians is paramount for improving the characterization of BMMRD patients and outcomes for patients and families with this disorder. The management of BMMRD is based on the current estimates of neoplasia risk and the early age of onset for the cancers (Table 1), which have led to tentative guidelines for the management of these patients (Table 3). Evidence-based CRC screening and surveillance recommendations in LS were developed based on prospective but uncontrolled trials with large numbers of patients. Colorectal screening with colonoscopy decreases the CRC mortality in patients with LS.29-31 Frequent colonoscopy screening (every 1 or 2 years) was associated with earlier-stage diagnosis of CRC and a reduction in the number of CRCs in LS patients. Guidelines recommend that patients at risk for LS, or with confirmed LS, undergo colonoscopy every 1–2 years, beginning between ages 20–25 years or 2–5 years before the youngest age at diagnosis of CRC in the family if diagnosed before age 25 years.1,32 Once polyps are identified, colonoscopy every 6 months is recommended. Weak recommendation, low-quality evidence. Patients with BMMRD are at increased risk of very early onset small-bowel cancers. The median age at diagnosis of small-bowel cancer was 28 years, with a range of 11–42 years.12,22 The prevalence of small-bowel cancer ranges from 10% to 16% in BMMRD patients.33 Prospective data are scant, but insights have been derived from single kindreds followed up for extended periods. Malignant tumors have included an asymptomatic jejunal cancer amenable to complete resection and the other identified lesions showed low-grade to high-grade dysplasia. This kindred continues in the surveillance program, and 2 malignancies (duodenal and jejunal cancers) have been diagnosed over the past 5 years, after a total of 15 years of surveillance. Monitoring of hemoglobin levels every 6 months also is suggested, beginning at 8 years of age. Weak recommendation, very low quality evidence. Brain tumors are frequent among BMMRD patients, and often diagnosed in the first decade of life. The penetrance for these tumors is unknown. High-grade gliomas are most common, followed by primitive neuroectodermal tumors and medulloblastoma. Similar to gastrointestinal adenomas, the rate of progression among BMMRD individuals appears to be rapid in the brain tumors. The median age at diagnosis in patients with BMMRD is 9 years (range, 2-40 y).22 Surveillance magnetic resonance imaging (MRI) identified an asymptomatic anaplastic astrocytoma amenable to complete resection with long-term disease-free survival.15,35 Prognosis depends on the possibility of complete resection, making early detection paramount. Asymptomatic low-grade tumors have been identified on MRI and completely resected.15 Weak recommendation, low-quality evidence. All major types of leukemias and lymphomas occur in BMMRD. However, there is a high prevalence of lymphoid malignancies, most commonly T-cell non-Hodgkin lymphomas. Currently, no proven surveillance modalities for leukemia or lymphoma have been identified. Data collected by the International BMRRD consortium and other case series expand the tumor spectrum of BMMRD to include osteosarcoma and tumors of embryonal tissue origin such as neuroblastoma, Wilms tumor, and rhabdomyosarcoma.40 The natural history of these tumors in BMMRD patients is unknown. Weak recommendation, very low quality evidence. Endometrial cancer is the second most common cancer occurring in LS, with a cumulative lifetime risk ranging from 10% to 70% related to the specific gene mutation.1 Expert consensus recommends offering screening for endometrial cancer in LS by pelvic examination and endometrial sampling annually starting at age 30–35 years.1 Endometrial cancer has been reported in fewer than 10 BMMRD individuals diagnosed between 19 and 44 years.22,41 Currently, the prevalence of endometrial cancer among BMMRD patients appears to be low but may increase as these patients live longer. Weak recommendation, very low quality evidence. Patients with LS are at risk of transitional cell carcinomas of the ureter, renal pelvis, and bladder.1 The risk is greatest in males with MSH2 mutations. The evidence for effectiveness in screening the urinary tract in LS patients is weak. Urinalysis starting at age 30–35 years is recommended.1 Urinary cytology examinations are of no value for screening in high-risk individuals.42,43 Among BMMRD patients reported to date, fewer than 10 individuals have been reported with urinary tract tumors. The age at diagnosis has ranged from 10 to 22 years. As patients with BMMRD transition into adulthood, we recommend annual urinalysis starting at 10 years of age and consideration of MRI. Weak recommendation, very low quality evidence. Hepatic adenomas were reported in 3 unrelated patients with BMMRD.44 Awareness of the association of hepatic adenoma with BMMRD is important so that benign adenomas are not misdiagnosed as metastatic disease, resulting in inappropriate interventions, including surgery or chemotherapy. Hepatic imaging techniques including abdominal MRI should be used to differentiate liver metastases from hepatic adenomas. Hepatic adenomatosis may occur in BMMRD with nodules up to 5 cm, but the natural history of this situation is not yet understood. Weak recommendation, very low quality evidence. In contrast to other cancer predisposition syndromes, the majority of BMMRD kindreds have no immediate family history of LS-related cancers and most parents are clinically unaffected. In contrast to typical LS, PMS2 mutations are the most common mutations identified among BMMRD patients. PMS2 mutations in the heterozygous state have low penetrance, which probably explains the paucity of LS cancers in the extended family. Consequently, asymptomatic parents may receive a diagnosis of LS after the diagnosis of BMMRD is made in a child. Therefore, we recommend that all heterozygous family members follow the LS screening guidelines.1 Weak recommendation, moderate-quality evidence. Because patients with BMMRD undergo intensive surveillance programs, malignancies will be detected and treated, and patients will enjoy longer lives. It is unclear what tumor spectrum will emerge among adults with BMMRD. No specific recommendations for adults with BMMRD exist, and it is not certain whether particular tumors will continue to increase with age among BMMRD survivors. In addition, clinical heterogeneity related to different mutations in the 4 DNA-MMR genes is likely, but currently undefined. Synchronous gastrointestinal and/or extraintestinal cancers occur frequently in BMMRD. Therefore, oncologists and gastroenterologists managing BMMRD patients need to assess the entire gastrointestinal tract for synchronous tumors before determining treatment plans. In one review, 20% of patients had multiple synchronous CRCs, ranging from 2 to 10 malignancies.33 Similarly, synchronous small-bowel cancers commonly occur in BMMRD. Among 17 BMMRD patients reported with small-bowel cancers by consortia, approximately one third had multiple synchronous small-bowel tumors.12,33 BMMRD patients with concomitant extraintestinal cancers are reported, including rectal cancer with mediastinal non-Hodgkin lymphoma diagnosed during preoperative staging. The risk of metachronous CRC in monoallelic LS after partial colectomy is substantial (10-year cumulative risk, 16%–19%). Consequently, colectomy with ileorectal anastomosis is the primary treatment for patients known to be affected with LS who have CRC or colonic neoplasia not amenable to resection at endoscopy.1 Given the greater risk of CRC among BMMRD individuals and the high prevalence of metachronous gastrointestinal cancers, an aggressive management approach is recommended. In BMMRD patients with colonic polyps containing high-grade dysplasia or cancer, or when there are too many polyps to remove endoscopically, total or subtotal colectomy with ileorectal anastomosis is recommended, although proctocolectomy with ileal pouch–anal anastomosis may be necessary in the case of rectal cancer. Close monitoring of the rectum with endoscopy every 6–12 months is crucial after ileorectal anastomosis. Studies have shown that LS patients experience a significant reduction in the risk of CRC and possibly other noncolonic LS-related cancers by taking aspirin.46 The initial prospective placebo-controlled studies were conducted in Europe using 600 mg of aspirin per day in adults, and those who took the aspirin for at least 2 years had a reduction in CRC incidence of >60%. The median age of the treated patients was 45 years, and there was no excess aspirin-related toxicity in the treatment group compared with patients taking placebo. It is unknown whether a beneficial pharmacologic effect will be seen in individuals with BMMRD because the biology of this disease is different from that in ordinary LS. However, it would seem reasonable to propose a controlled prevention trial of aspirin in BMMRD patients. CRCs with MSI generate a large number of frame-shift neopeptides that are immunogenic.47-49 This may explain the large number of tumor-infiltrating lymphocytes in CRCs with MSI and the large number and size of regional lymph nodes in resection specimens of patients undergoing surgery for CRC in LS. The clinical survival in patients with CRC in LS is significantly better than that for sporadic CRCs.45,50,51 One interpretation of this is that the immunologic response to antigenic neopeptides helps contain the CRC and limits metastasis. Patients with CRCs in the setting of LS may develop metastases and die of their cancer despite this, because some tumors manage to escape immunologic containment. Young patients diagnosed with cancer always should raise the suspicion of a possible underlying cancer predisposition. Any young patient with cancer plus consanguinity and/or features of neurofibromatosis should be evaluated for an underlying BMMRD. Clues to guide clinicians to suspect BMMRD are included in Table 2. Genetic counseling plays a crucial role in the management of kindreds with BMMRD. Genetic counseling can offer support and education for this complex diagnosis that has implications for the entire family. Siblings of the proband would be at risk of having BMMRD, Lynch syndrome, or neither condition, and testing is required to determine the surveillance protocol, which differs in the type of screening and the age to start. Both parents of the proband have Lynch syndrome, and a genetic counselor can review cancer risk and surveillance recommendations for what most often are lower penetrance LS genes. A counselor also can identify other family members at risk (grandparents, aunts, uncles, cousins), as well as offer options such as prenatal and preimplantation genetic diagnosis for future children who may be at risk. As life expectancy increases for patients with BMMRD, family planning considerations based on risk of LS for the children should be reviewed. Over time, as BMMRD becomes better recognized and more patients are characterized and enter surveillance programs, systematic data collection will allow for a more comprehensive understanding of the cancer spectrum, and genotype–phenotype correlations. Surveillance of adult BMMRD survivors may expand the tumor spectrum in BMMRD, and additional LS-associated tumors may emerge among adults with BMMRD. As we intervene clinically in this disease, the natural history will change and evolve. The authors disclose no conflicts. This work was supported in part by the National Institutes of Health (CA72851). The authors gratefully acknowledge the input of Melyssa Aronson, Senior Genetic Counselor, The Zane Cohen Center, Mount Sinai Hospital, The University of Toronto, Toronto, Ontario, Canada.
BMMRD (biallelic mismatch repair deficiency), CMMRD (constitutional mismatch repair deficiency), CRC (colorectal cancer), GRADE (Grades of Recommendation, Assessment, Development and Evaluation), LS (Lynch syndrome), MLH (Mut L homolog 1), MSH2 (Mut S homolog 2), MSH6 (Mut S homolog 6), MMR (mismatch repair), MRI (magnetic resonance imaging), MSI (microsatellite instability–high), PD (programmed death), PD-1 (programmed death-1), PD-L1 (programmed death-ligand 1), PMS2 (post meiotic segregation 2), VCE (video capsule endoscopy)
This article is being published jointly in Gastrointestinal Endoscopy, Gastroenterology, The American Journal of Gastroenterology, and The Journal of Pediatric Gastroenterology and Nutrition.
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kPA on MRE conversion
Wednesday, April 19, 2017
10:03 AM

F0 2.8-3.08
F1 3.08-3.58
F2 3.58-5.31
F3 5.3-6.35
F4 more than 6.35

Monday, April 24, 2017
2:44 PM

Take once a day after
Family pharmacy global a japanese company Cost is 40$ a month if you take it 3 times a day.

AN-PEP for celiac sprue
Friday, May 26, 2017
12:03 PM

Tolerase G on amazon for celiac

HSV now known as HHV
Monday, May 29, 2017
5:57 PM

Human herpesvirus types 1-8
6 and 7 pediatrics seizures
8 Kaposis sarcoma

Tuesday, April 25, 2017

Tenofovir alafenamide (TAF, sold as Vemlidy) was as effective as the older tenofovir disoproxil fumarate (TDF) formulation in keeping hepatitis B

Hepatitis B patients who switched to a new formulation of tenofovir showed improvements in bone and kidney safety in a pair of long-running studies, researchers reported here.

Ibs hormone therapy
Friday, April 28, 2017

n addition, further back, a small 1994 trial, by John Mathias, MD, et al, randomized 28 women with moderate to severe functional bowel disease to leuprolide (depot) or placebo for 12 weeks. Symptoms improved so significantly that all patients were allowed to continue on non-depot leuprolide for an additional 40 weeks, with all receiving estrogen replacement and 89% completed 52 weeks of treatment. Continued use of leuprolide at the maximum therapeutic dosage produced even more striking changes, with significant improvements in abdominal pain and distention, early satiety, anorexia, nausea, and vomiting.

Vitamin d
Sunday, April 30, 2017

Normalizing vitamin D levels correlated with lower insulin resistance and decreased adipose fibrosis in obese patients, according to a study presented at the Eastern regional meeting of the American Federation for Medical Research.

Wednesday, May 3, 2017

Ingrezza newly approved drug

Neuro degeneration
Saturday, May 6, 2017

. They searched for drugs that had the potential to prevent brain cells from shutting down in the presence of faulty proteins, and found two: trazodone, a drug that’s already being used to treat patients with depression, and DBM, a compound found in licorice that’s currently being tested to see if it can treat cancer. After infecting mice with a disease that can cause neurodegeneration, the researchers treated them with one or the other of these drugs.

Saturday, May 6, 2017

Effect varies by type of NSAID

ASPIRIN efficacy lost, MI, CHF and stroke

Sunday, May 7, 2017

Recent studies have shown serum intestinal fatty acid binding protein (I-FABP) to be a sensitive marker of enterocyte damage in celiac disease.

The enzyme, A. niger-derived prolyl endoprotease (AN-PEP), has demonstrated the ability to degrade gluten into nonimmunogenic compounds in vivo in healthy subjects, according to Julia König, PhD, of the School of Medical Sciences, Örebro (Sweden) University and her colleagues. The researchers tested the enzyme at two separate doses in 18 adults with self-reported gluten sensitivity.

Hcv cirrhosis
Sunday, May 7, 2017

Cirrhosis patients with the rs738409 CG/GG genotype experienced worse outcomes, including a slower recovery of encephalopathy, ascites, and bilirubin, compared with those without this CG/GG genotype, based on data from a prospective study.

Monday, May 8, 2017

such as concomitant use of anticoagulation and low dose aspirin, indefinite proton pump inhibitor therapy is recommended. “In these patients the risk of death from bleeding is greater than the risk from any of the other adverse events mentioned in the medical literature,” Kurlander said. “With upper gastrointestinal bleeding, the risk of death in the hospital is between 2% and 5%. That is a very real risk.”

Monday, May 8, 2017
Rebleeding was seen in 80% of patients with scores of at least 4 on ORBIT’s 7-point scale, Gonçalves said at Digestive Disease Week 2017, compared with 37% in those scored as low or intermediate risk (P=0.003).
But ORBIT was less successful in predicting which patients would show small-bowel lesions on capsule endoscopy that could become future bleeding sites, Gonçalves said. There were no significant differences in diagnostic yields among the ORBIT-scored risk groups, and actually the high-risk group had the lowest rate of such lesions.
ORBIT is an acronym for the five components contributing to the score (ORBIT also happens to be the name of the registry that supplied the original data validating the system):
• Older age (75 or greater)
• Reduced hemoglobin/hematocrit
• Bleeding history
• Insufficient kidney function
• Treatment with antiplatelets
Anemia and bleeding history are scored at two points each; the other components each get one.

Tuesday, May 9, 2017

The three most common methods are in phase-opposed phase, Dixon method and the spectral-spatial excitation techniques.” MRI

Thursday, May 11, 2017
Two pivotal phase III studies yielded mixed results for mepolizumab (Nucala) as an add-on treatment for patients with eosinophilic phenotype chronic obstructive pulmonary disease (COPD), according to initial results released by drugmaker GlaxoSmithKline (GSK).
The trials were designed to examine whether adding the biologic therapy to optimal standard-of-care treatment would decrease the frequency of moderate to severe exacerbations in this high-risk COPD group. The drug, an interleukin-5 inhibitor, is currently approved as add-on therapy for severe asthma.

Healing SB ulcers
Saturday, May 13, 2017

In an 8-week, double-blind, randomized trial, misoprostol was better at promoting mucosal healing than placebo in patients taking continuous aspirin for cardiothrombotic illness, according to Francis Chan, MD

Pancreatitis severity
Saturday, May 13, 2017

In a prospective study in over 300 patients, about 81% of patients who had severe acute pancreatitis consumed less than three portions of fresh fruit and vegetables per day compared with 58.6% of patients who had mild bouts of acute pancreatitis (P=0.003), reported Amir Gougol, MD, of the University of Pittsburgh Medical Center, and colleagues.

Underwater colonoscopy
Saturday, May 13, 2017

Patients undergoing the procedure — sometimes called “underwater” or water-exchange colonoscopy — at the University of California Irvine (UCI) from 2012 to 2016 had an SSA detection rate for the entire colon of 11.1%, compared with 7.9% with air insufflation (P<0.05), said UCI’s Anish Patel, MD, at

C diff prevention
Saturday, May 13, 2017

In a Phase IIb randomized clinical trial, the drug ribaxamase reduced the incidence of CDI by more than 70% compared with placebo, according to John Kokai-Kun, PhD, of Synthetic Biologics Inc.,

Mullish reviewed earlier work, including the Naturepaper and others, showing that certain players in bile acid metabolism, such as taurocholate, deoxycholate, and glycine, help to promote germination of C. diff spores whereas others including chenodoxycholate tend to discourage it.
One way in which antibiotics have the unwanted effect of promoting C. diff is by killing gut bacteria that act as a brake on C. diff via their actions on bile acids, Mullish explained.

Thursday, May 18, 2017
• Fluorescence patterns were detected on Hep-2 cells that suggested the presence of PBC antibodies among PBC patients. Patients with suspected of PBC and controls were included for comparison.
• EliA-M2 testing and the multiplexed line-blot Autoimmune Liver Disease Profile Euroline were performed on blood samples.
• 100% agreement was found between EliA-M2 testing and multiplexed line-blot for the detection of anti-mitochondrial antibodies.
• EliA-M2 and multiplexed blot testing were able to accurately diagnose PBC, and an association between Eli-M2 and disease activity was detected.

Thursday, May 18, 2017

The descriptive term HFpEF is clinically and therapeutically useless. The term metabolic-senile cardiovascular disease distinguishes a circumscribed disease and pathological process, beginning before the clinical expression of HF, which should more aptly direct future therapeutic investigations. LV volume measurement is useful in assessing SV and characterizing LV remodeling, but let’s focus on the underlying disease in considering novel

Pulse ox
Sunday, May 21, 2017

. Severe leukocytosis like 100 K Carboxyhemoglobin, Methemoglobin, Finger nail polish, Anemia, The patient is in cardiac arrest or shock, Cold hand, Venous pulsations, Have taken vascular activity medicine, Motion artifact and Cyanosis.

Tuesday, May 23, 2017

Patients with TLL1 VARIANT in liver biopsy patients are more likely to develop post eradication of HCV HCC

Tuesday, May 23, 2017

Prospective studies have shown that 3% to 36% of such infections lead to persistent new IBS symptoms that may last for 10 years or more. The outcome depends on the organism: Whereas viral gastroenteritis seems to have only short-term effects, bacterial, protozoan, and helminth infections can be followed by prolonged post-infective IBS (PI-IBS).

Bacterial toxins that promote intestinal inflammation include those of Campylobacter jejuni and Escherichia coli, as well as Salmonella and Shigella strains. Spiller and Lam noted that C. jejuni infection is one of the commonest causes of gastroenteritis, leading to PI-IBS in 9% to 13% of cases.

Thursday, May 25, 2017
• Approximately 1 in 4 patients with acute pancreatitis have false negative test results.
• Serum amylase, serum lipase, and urinary trypsinogen-2 share similar accuracy in diagnosing the disorder.
• As acute pancreatitis progresses over time, the value of these tests diminishes.
• Approximately 1 in 10 patients who do not have the disorder may be misdiagnosed with acute pancreatitis.

Why dieting fails
Monday, May 29, 2017

This brain region contains a group of neurons called “agouti-related neuropeptides” (AGRP), which play a key role in regulating appetite. When AGRP neurons are “on,” we want to eat, but when these neurons are deactivated, they can make us stop eating almost completely. AGRP neurons have the same effect in animals.

If food is available, they make us eat, and if food is scarce, they turn our body into saving mode and stop us from burning fat.”

My interpretation
So best is to fool the brain by eating but not enough. Smaller portions even if all day ???!

Insulin sensitivity
Wednesday, May 31, 2017

when a gene called PPARD (read PPAR delta) was permanently activated in mice, they gained greater endurance, insulin sensitivity, and resistance to weight gain. Basically, they became furry little athletes. The researchers activated that gene through genetic engineering, but they found that they could administer the aforementioned GW1516 (GW) compound to mice to activate the gene, too. U

Orthorexia nervosa
Wednesday, May 31, 2017

Obsession with eating healthy

Wednesday, June 14, 2017
A recent randomized controlled trial was designed to compare a low FODMAP with high FODMAP diet in patients with IBS to provide a mechanistic understanding of the disease. The results revealed that histamine levels and the microbiota of participants were altered, which may, in turn, modify patient symptoms.4 Another study evaluated a histamine receptor H1 (HRH1) antagonist after HRH1 was linked to visceral hypersensitivity, and results were positive for abdominal and overall pain relief.5 These results may provide a novel means for patient selection in the future. The detection of histamine in urine or other samples could be used to select patients who respond to HRH1 antagonists highlighting the need to identify biomarkers if progress in IBS treatment is to move forward.1
“Advances in neurobiology of pain sensation and tissue expression provide clues to potential targets for future medical treatments of IBS. Until now, the targets thought to be genetic include SCN5A, which has rarely been reported in association with increased visceral pain or sensitivity, due to changes in the ion channel NAV 1.5,” said Dr. Camilleri. Given the increased exposure of patients to cannabinoids in search of pain relief, it is relevant that preliminary studies also suggest an association between the genes mediating cannabinoid 1 receptor function or cannabinoid metabolism, with colonic transit and pain sensation during acute colonic distensions.

M͎e͎t͎o͎p͎r͎o͎l͎o͎l͎ a͎c͎t͎i͎o͎n͎ i͎n͎ M͎I͎
Thursday, June 15, 2017

The β1-adrenergic-receptor (ADRB1) antagonist metoprolol reduces infarct size in acute myocardial infarction (AMI) patients. The prevailing view has been that metoprolol acts mainly on cardiomyocytes. Here, we demonstrate that metoprolol reduces reperfusion injury by targeting the haematopoietic compartment. Metoprolol inhibits neutrophil migration in an ADRB1-dependent manner. Metoprolol acts during early phases of neutrophil recruitment by impairing structural and functional rearrangements needed for productive engagement of circulating platelets, resulting in erratic intravascular dynamics and blunted inflammation. Depletion of neutrophils, ablation of Adrb1 in haematopoietic cells, or blockade of PSGL-1, the receptor involved in neutrophil–platelet interactions, fully abrogated metoprolol’s infarct-limiting effects. The association between neutrophil count and microvascular obstruction is abolished in metoprolol-treated AMI patients. Metoprolol inhibits neutrophil–platelet interactions in AMI patients by targeting neutrophils. Identification of the relevant role of ADRB1 in haematopoietic cells during acute injury and the protective role upon its modulation offers potential for developing new therapeutic strategies.

P͎A͎S͎S͎ P͎A͎N͎C͎R͎E͎A͎T͎I͎C͎ A͎S͎S͎E͎S͎S͎M͎E͎N͎T͎ S͎C͎O͎R͎I͎N͎G͎ S͎Y͎S͎T͎E͎M͎ F͎O͎R͎ P͎A͎N͎C͎R͎E͎A͎T͎I͎T͎I͎S͎
Thursday, June 15, 2017

  • patients with self-limited disease presented with lower scores and experienced a more rapid decline in score;
  • patients with prolonged illness presented with higher scores at baseline and exhibited persistent elevation in scores during the initial stage of hospitalization;
  • patients who went on to experience multiple or persistent organ failure had increased baseline PASS scores that remained elevated during the initial phase of hospitalization.

Deceptive patients
Thursday, June 15, 2017
According to Bettes, both verbal and non-verbal deceptive behaviors are exhibited when people are being deceptive. About 27 deceptive behaviors are considered reliable indicators of deception, the most common of which include:
• Failing to answer the question.
• Using attack behaviors that discredit interviews or abandon the line of questioning.
• Using qualifiers to carve out information that may be detrimental.
• Hiding the mouth and/or eyes (to shield the truth).
• Clearing the throat before answering questions.
• Moving major body parts when responding to questions.
• Using grooming gestures to tidy up one’s self, fidgeting, or making frequent adjustments.
• Exhibiting verbal disconnect with behavior.
• Frequently repeating questions in an attempt to buy time before answering questions.
• Providing too much information or overly specific responses.

PARP inhibitor
Saturday, June 17, 2017

Works in ovarian cancer, breast cancer and early studies indicate can help in stroke and MI

Tuesday, June 20, 2017

  • Patients should be counseled that hair washing and styling will not expedite loss.
  • Patients should also be informed that 6 months to a year of treatment may be necessary before results are seen.
  • Baseline photographs of the scalp for both men and women should be taken at the time of initial visit for comparison at return appointments.
  • FDA approved therapies: topical minoxidil and oral finasteride
  • Minoxidil is available in 2% and 5% topical solutions and a more cosmetically appealing 5% foam vehicle. Minoxidil should be applied directly to the scalp, not to the hair itself. Minoxidil is best at maintaining the current density of hair, and reports show that 40% of men will experience at least moderate regrowth. If the drug is discontinued, its benefits will be lost in 3 to 6 months. Minoxidil is not effective in treating regression of the bitemporal hairline. The most common side effect is scalp irritation, which generally improves with repeated applications.
  • Finasteride 1mg by mouth daily. Reports show that 90% of men will maintain the hair they have, and approximately 67% will see regrowth. Like topical minoxidil, a 6-month trial of treatment is warranted before declaring treatment failure. If the drug is stopped, benefits will be lost within a year. Males over the age of 40 years need a baseline PSA level. Finasteride will decrease the PSA level by 1/2. Sexual side effects such as impotence are rare and often improve with treatment continuation. However, there are rare cases where decreased libido may not improve and appropriate referral is warranted for further investigation.


  • Minoxidil 2% solution is the only FDA-approved treatment for female pattern hair loss. Minoxidil is most effective at slowing the progression of hair thinning and in approximately 40% of cases improvement in density is expected after 4 months of treatment. Seven percent of women using minoxidil can develop symmetrical facial hypertrichosis that readily reverses once the medication is stopped. Scalp irritation can develop but often improves with continued treatment.
    Some clinicians recommend 5% solution to use daily, but this is off label and should be appropriately discussed with the patient. Most of my female patients use the 5% minoxidil foam on a nightly basis. The foam is less messy compared to the solution and once-daily application promotes compliance. This is an off-label use of this over-the-counter medication.
  • Antiandrogen therapy is particularly important in cases where systemic androgen excess is associated with female pattern hair loss, but may also be used in conjunction with topical minoxidil in resistant cases. Spironolactone is prescribed at a dose of 50-100mg twice daily. In order to avoid the two most common side effects of spironolactone, breast tenderness and menstrual irregularity, an oral contraceptive should be prescribed concomitantly. Results should be expected in 6 months.
    Female patients must not become pregnant on spironolactone. In addition, if there is a personal or family history of breast cancer in a first degree relative, I recommend consultation with the primary care physician or gynecologist. However, there is not a clear link between spironolactone use and increased risk of breast cancer.
  • The goal of treatment is maintenance and/or improvement of hair density.
  • Follicular Unit hair transplant – Follicles from androgen insensitive regions such as the occiput and inferior temporal vicinity, are transplanted to affected areas. Patients must have sufficient density of hair in donor sites. The procedure is expensive but can achieve very cosmetically pleasing results. It is important to select the proper candidate, as females with diffuse thinning are not candidates.
  • Hair pieces – There are a variety of hair pieces available capable of achieving a natural appearance.

Friday, June 23, 2017

Cognitive training, hypertension management and physical exercise helps prevent it. NASEM data

Diabetes Broccoli victoza
Saturday, June 24, 2017
Glucose control with broccoli? A new study found the chemical sulforaphane, found in cruciferous vegetables like broccoli, lowered hepatic glucose production and was able to shift liver gene expression in rats with type 2 diabetes. (Science Translational Medicine)

newly published review examines management and treatment of both osteoporosis and type 2 diabetes in tandem. “Metformin, sulfonylureas, DPP-4 inhibitors and GLP1 receptor agonists — medications for T2D — should be the preferred treatment for T2D in patients who also have osteoporosis,” said lead author Stavroula Paschou, MD, PhD, in a press release. (Journal of Clinical Endocrinology & Metabolism)

Based on the findings of the LEADER trial, earlier this week an FDA advisory committee voted 17-2 in support of the label expansion of Novo Nordisk’s diabetes drug Victoza (liraglutide 1.8 mg) to include cardiovascular event prevention. (MedPage Today)

Excess vitamin D
Saturday, June 24, 2017

e American adults may be exceeding the “tolerable daily limit” of 4,000 IU of vitamin D, according to a new study. Intake of vitamin D supplementation increased from 1999 to 2014, mostly among seniors and non-Hispanic white females. Excess of 25-hydroxyvitamin D could pose risk such as increased risk of fractures, fall, kidney stones, and more. (JAMA)

ABG. Interpretation
Saturday, June 24, 2017

Saturday, June 24, 2017
By using colonoscopies in adults aged ≥50 years (4/09-12/14), we stratified endoscopists by high and low ADRs (<15%, 15%-<25%, 25%-<35%, ≥35%) to determine corresponding SDRs by using 2 SDR measures, for screening and surveillance colonoscopies separately: (1) Clinically significant SDR (CSSDR), meaning colonoscopies with any sessile serrated adenoma/polyp (SSA/P), traditional serrated adenoma (TSA), or hyperplastic polyp (HP) >1 cm anywhere in the colon or HP >5 mm in the proximal colon only divided by the total number of screening and surveillance colonoscopies, respectively. (2) Proximal SDR (PSDR) meaning colonoscopies with any serrated polyp (SSA/P, HP, TSA) of any size proximal to the sigmoid colon divided by the total number of oscreening and surveillance colonoscopies, respectively.
A total of 45,996 (29,960 screening) colonoscopies by 77 endoscopists (28 facilities) were included. Moderately strong positive correlation coefficients were observed for screening ADR/CSSDR (P = .69) and ADR/PSDR (P = .79) and a strong positive correlation (P = .82) for CSSDR/PSDR (P < .0001 for all) was observed. For ADR ≥25%, endoscopists’ median (interquartile range) screening CSSDR was 6.8% (4.3%-8.6%) and PSDR was 10.8% (8.6%-16.1%).
Derived from ADR, the primary colonoscopy quality indicator, our results suggest potential SDR benchmarks (CSSDR = 7% and PSDR = 11%) that may guide adequate serrated polyp detection. Because CSSDR and PSDR are strongly correlated, endoscopists could use the simpler PSDR calculation to assess quality.

Monday, June 26, 2017

Causes enteropathy spree celiac

Probiotics studied
Tuesday, June 27, 2017

Visibiome and VSL # 3
Kumbucha tea. Trader Joe. Tea.

Prudent diet
Wednesday, June 28, 2017

The U.S. Food and Drug Administration reports that a food item is considered low-fat when there is it contains 3 g or less of total fat per serving. A meal is low-fat when there are 3 g or less total fat per 100 g serving and 30 percent or less fewer calories are from fat. Low saturated fat guidelines allow for 1 g or less per serving and no more than 15 percent of calories. Low cholesterol signifies 20 mg or less cholesterol and 2 g or less saturated fat per serving. Low sodium is recognized as 140 mg or less per serving.

Food Items

A few food items on the prudent diet. Photo Credit seb_ra/iStock/Getty Images
Plain fruits, vegetables, legumes and whole intact grains, including oats, couscous, barley and quinoa, are generally low in fat, cholesterol and sodium. All animal products contain saturated fat and cholesterol. Animal products include red meat, poultry, pork, fish, eggs and dairy. Choose the lower fat and cholesterol options. Cheese is high in sodium. Prepackaged foods tend to be higher in trans fats and sodium. Read food labels carefully, and remember variety and moderation of foods.

Monday, July 3, 2017
research does suggest that some subset of Americans may be especially sensitive to salt and would benefit from consuming less. Among those are folks with ancestors from Sub-Saharan Africa. But for most people, the risk lies elsewhere.
A 2014 meta-analysis of more than two dozen relevant studies, published in the American Journal of Hypertension, concluded that risk of death appeared to be lowest among individuals consuming between 2,565 mg and 4,796 mg of sodium per day, with higher rates of death above and below that consumption range. As noted above, the FDA itself reports that average daily consumption is 3,400 mg—right in the middle of the ideal range.
In April, a new study by researchers at the Boston University School of Medicine, who followed more than 2,600 people for 16 years, once again debunked the dire claims about salt. “We saw no evidence that a diet lower in sodium had any long-term beneficial effects on blood pressure,” said lead researcher Lynn Moore. “Our findings add to growing evidence that current recommendations for sodium intake may be misguided.”
In fact, the authors found that study participants who consumed less than 2,500 mg a day had higher blood pressure than those who consumed more. They also pointed out that other research has also found that people who consume very high or very low amounts are both at greater cardiovascular risk. “Those with the lowest risk,” they noted, “had sodium intakes in the middle, which is the range consumed by most Americans.”

CRC screening
Monday, July 3, 2017

The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT–fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.

PPI death rate
Tuesday, July 4, 2017
Prolonged use of PPIs was associated with a 25 percent greater risk of death, compared with people taking H2 blockers, another class of acid reducers. H2 blockers are sold under brand names including Pepcid, Tagamet and Zantac, as well as generic names such as famotidine, cimetidine and ranitidine.
For the new report, researchers examined millions of military veterans’ prescription records that spanned an average of nearly six years. Their findings were published Monday in the journal BMJ Open; go to for the study. The senior author was Dr. Ziyad Al-Aly of the U.S. Department of Veterans Affairs’ health system in St. Louis.

Wednesday, July 5, 2017

Tofacitinib is the first in a new class of medicines called Janus kinase (JAK) inhibitors under investigation for the treatment of moderate to severe UC. Tofacitinib is a small molecule taken as a pill. It acts on specific inflammatory responses thought to play a role in the inflammation associated with UC.

Thursday, July 6, 2017
They found that on average, several risk factors were more common among individuals with type 2 diabetes, compared with the matched controls “many years before the diagnosis,” Dr. Malmström said. “In particular, BMI [body mass index], fasting triglycerides, fasting glucose, the apo B/apo A-I ratio and inflammatory markers were increased up to 25 years before the diagnosis.”

For example, 25 years before diagnosis, mean fasting plasma glucose in the type 2 diabetes group was higher than controls at 90 mg/dL vs. 86 mg/dL, respectively. By 10 years before diagnosis, that gap had widened to 98 mg/dL vs. 88 mg/dL. At 1 year before diagnosis, the levels were 106 mg/dl vs. 90 mg/dL.

As for fasting triglycerides, high levels earlier in life appeared to be especially risky: Individuals with levels over 124 mg/dL were more likely to develop type 2 diabetes 20 years later, even if they weren’t overweight or had elevated mean fasting glucose levels.

At 25 years before diagnosis, the type 2 diabetes group had mean fasting triglyceride levels of 120 mg/dL vs. 89 mg/dL in the control group. And at 1 year before diagnosis, the difference had widened to 146 mg/dL vs. 106 mg/dL.

Researchers found signs of higher levels of fructosamine – a marker of glycemic levels over an extended period of time (2-3 weeks) – at about 15 years before diagnosis. According to Dr. Malmström, this finding suggests that “glucose metabolism was starting to become more disturbed later than the changes in fasting glucose, but still many years before the type 2 diabetes diagnosis.”

Asthma sugar intake during pregnancy
Thursday, July 6, 2017

Women who eat too much sugar during pregnancy are doubling the chance of their child going on to develop asthma, new research suggests.

A study of almost 9,000 mother and child pairs starting in the 1990s found a link between free sugars, such as those found in fizzy drinks and processed food, and the inflammatory disease.

Researchers at Queen Mary, University of London compared the 20 per cent of mothers who consumed the most sugar, equivalent to more than five teaspoons a day, or two cans of full-fat coke, to the 20 per cent who had the least.

dpp-4 inhibitors mechanism of action – Google Search
Friday, July 7, 2017

Asthma IBD link
Friday, July 7, 2017

Same inflammatory pathway.

asthma/IBD susceptibility is breastfeeding, with breastfed children having lower risks of both, especially if they are breastfed for more than a year. “Maybe a shared environmental exposure early in life can be either protective or harmful in IBD and asthma,” Kaplan said. “These may be separate conditions, but certain factors that raise risk are shared.”
While breastfeeding is thought to affect the gut microbiome positively, use of antibiotics in the first year of life may disrupt it and increase susceptibility to inappropriate immune responses. That makes the pressure for judicious use of antibiotics even more important, and there is growing interest in postantibiotic “chasers,” such as prebiotics and probiotics to reset the microbiome after possible disruption by antimicrobial agents — “But this area is still in its infancy,” he said.

CHF markers
Monday, July 10, 2017
The statement summarizes the existing literature and provides guidance for the utility of currently available biomarkers associated with HF, including natriuretic peptides, soluble suppressor of tumorgenicity 2, highly sensitive troponin, galectin-3, midregional proadrenomedullin, cystatin-C, interlukin-6, procalcitonin, and others. Among the conclusions and recommendations:
• In community-based populations, measurement of natriuretic peptides (BNP or NT-proBNP) or markers of myocardial injury (TnI or TnT) alone adds prognostic information to standard risk factors for predicting new-onset HF.
• Measurement of several new biomarkers, including sST2, Gal-3, GDF-15, and markers of renal function, alone or in a multimarker strategy, may be useful for providing additional risk stratification.
• Measurement of BNP or NT-proBNP and cTn at the time of presentation is useful for establishing prognosis or disease severity in patients with acutely decompensated HF.
• Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis is reasonable for additive risk stratification in patients with acutely decompensated HF.
• Measurement of predischarge BNP or NT-proBNP during an HF hospitalization can be useful for establishing postdischarge prognosis.

A fib RF
Monday, July 10, 2017

hile genetics, metabolomics, and systems biology remain important research domains to improve our relatively elementary understanding of AF and its mechanisms, this paper serves as a reminder that, for the overwhelming majority of patients, addressing risk of AF and its sequelae should be more about reducing waist size (fitting into jeans) than being preoccupied with heritability (genes),” an accompanying editorial concluded.

BMI benefit in MI
Monday, July 10, 2017
Mortality among overweight and obese individuals was 14% lower at 30 days, 30% lower at 1 year, and 27% lower at 5 years compared with normal-weight individuals in the study of 345,192 participants from 2005 through 2013.
The associations were found across stable angina, unstable angina and non-ST and ST-segment elevation myocardial infarction.
“Factors underlying this phenomenon remain uncertain and controversial, and this study provides support for further exploration,” the researchers concluded, adding that the findings “should also highlight the potentially negative implication of low BMI, leading physicians to carefully dose medications and investigate weight loss or very low BMI.”

A fib
Tuesday, July 11, 2017

Percutaneous left atrial appendage closure with an Amplatzer device in patients with nonvalvular atrial fibrillation was associated with significantly lower rates of all-cause and cardiovascular mortality, compared with oral anticoagulation, in a large propensity score–matched observational registry study.

Left atrial appendage closure (LAAC) also bested oral anticoagulation (OAC) with warfarin or a novel oral anticoagulant (NOAC) in terms of net clinical benefit on the basis of the device therapy’s greater protection against stroke and systemic embolism coupled with a trend, albeit not statistically significant, for fewer bleeding events, Steffen Gloekler, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

Alcohol and brain
Tuesday, July 11, 2017
From 1985 to 2015, 550 community dwelling adult participants in the UK Whitehall II cohort imaging substudy underwent repeated measurements of cognitive performance and weekly alcohol intake, as well as multimodal MRI at study endpoint. At baseline, mean age was 43.0 ± 5.4 years, and no participants were alcohol-dependent, on the basis of the CAGE screening questionnaire. Incomplete or poor-quality MRI or clinical data or gross structural abnormality led to exclusion of 23 participants.
In a dose-dependent manner, higher alcohol consumption was associated with increased risk for hippocampal atrophy during the 30-year follow-up, after adjustment for confounding factors that included age, sex, education, social class, physical and social activity, smokin

Heart and fat
Wednesday, July 12, 2017
• Randomized clinical trials showed that polyunsaturated fat from vegetable oils replacing saturated fats from dairy and meat lowers CVD.
• A dietary strategy of reducing intake of total dietary fat, including saturated fat, and replacing the fats mainly with unspecified carbohydrates does not prevent CHD.
• Prospective observational studies in many populations showed that lower intake of saturated fat coupled with higher intake of polyunsaturated and monounsaturated fat is associated with lower rates of CVD and all-cause mortality.
• Saturated fat increases LDL cholesterol, a major cause of atherosclerosis and CVD, and replacing it with polyunsaturated or monounsaturated fat decreases LDL cholesterol.
• Replacing saturated with polyunsaturated or monounsaturated fat lowers blood triglyceride levels, an independent biomarker of risk for CVD.
• Replacing saturated with polyunsaturated fat prevents and regresses atherosclerosis in nonhuman primates.
• Overall, evidence supports the conclusion that polyunsaturated fat from vegetable oils (mainly n-6, linoleic acid) reduces CVD somewhat more than monounsaturated fat (mainly oleic acid) when replacing saturated fat.

Colon cancer chemo metastatic
Thursday, July 13, 2017

Epidermal growth factor receptor monoclonal antibody (EGFR Mab) drugs reduce disease progression and improve survival in patients with metastatic colorectal cancer, according to a recent review of the evidence published by the Cochrane Library. Details of the analysis include the following:
• When used in combination with standard treatment, EGFR Mabs are effective in patients whose tumors are KRAS wide type, ie, those that do not have mutations in the KRAS gene.
• KRAS wide type patients experience a 30% reduction in the risk of disease progression and a 12% reduced risk of death.
• EGFR tyrosine kinase inhibitors, which include agents such as erlotinib and gefitinib, do not improve clinical outcomes in patients with metastatic colorectal cancer.

COPD exacerbation based on eosinophils
Thursday, July 13, 2017
2:56 PM

In a post-hoc analysis of the WISDOM trial, COPD patients with elevated blood eosinophil levels – specifically counts of 4% or greater – were more likely than patients with lower eosinophil levels to experience exacerbations following inhaled corticosteroid withdrawal.
While Bafadhei and colleagues warned that caution is needed in interpreting the post-hoc findings from WISDOM and other trials, the analyses have consistently shown patients with elevated circulating eosinophil levels to have more exacerbations. They have also shown inhaled corticosteroids to be beneficial for reducing the occurrence of exacerbations in patients with elevated eosinophil counts.
“Elucidation of the role of eosinophils in the pathogenesis of COPD, or as a potential biomarker in the disease, will provide further insight into how we can predict the response of a patient to inhaled corticosteroids and the mechanisms that underlie this response,” Bafadhei and colleagues wrote.
Evidence is mounting that circulating eosinophil count during stable disease can be useful for predicting the risk of death and exacerbations in the COPD setting. It also appears that circulating eosinophils early in an exacerbation may be useful for identifying those at risk for worse outcomes, hospital re-admission, longer hospital stay, response to corticosteroids, and mortality.
“Stratification of the single or combined risk of death, lung function decline and exacerbations — modelled on circulating eosinophils, disease severity, and response to treatment — would be required to determine the utility of circulating eosinophils as a relevant and valid biomarker in COPD risk identification,” they wrote.


Markers for IBD and NASH
Thursday, July 13, 2017

50-50 joint venture established by the firms, Microbiome Diagnostics Partners, will incorporate two of Enterome’s proprietary biomarkers: IBD110 for tracking mucosal healing and MET210 for non-alcoholic fatty liver disease and steatohepatitis.

Pcsk 9 ldl-r
Thursday, July 13, 2017

Low-density lipoprotein receptors (LDL-R) in hepatocytes bind to LDL particles and remove them from the circulation. The LDL-R then return to the cell surface to repeat this process. PCSK9 functions as a binding protein; it is expressed primarily in hepatocytes and after secretion binds to the LDL-R and promotes their degradation. By blocking PCSK9, these drugs result in increased availability of LDL-R to remove LDL-C from the circulation.

Thursday, July 13, 2017

Conclusions All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction. Risk of myocardial infarction with celecoxib was comparable to that of traditional NSAIDS and was lower than for rofecoxib. Risk was greatest during the first month of NSAID use and with higher doses.
It is generally accepted that oral non-steroidal anti-inflammatory drugs (NSAIDs) can increase the risk of acute myocardial infarction. Randomised controlled trials of NSAIDs have been of limited use for assessing this rare adverse event, as they had small cohorts and poor generalisability.[1,2] The trials excluded those at highest cardiovascular risk or with established cardiovascular disease.[3,4] Network meta-analyses of randomised controlled trials of NSAIDs and myocardial infarction risk have attempted to improve statistical power, but the results of direct and indirect comparisons of NSAIDs and placebo remain imprecise and occasionally inconclusive.[3,4]
The Prospective Randomized Evaluation of Celecoxib Integrated Safety vs. Ibuprofen Or Naproxen (PRECISION) trial was a large randomised controlled trial (n=24 081) that filled some of these knowledge gaps. This trial’s conclusion of the non-inferiority of moderate dose celecoxib compared with ibuprofen and naproxen on a primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke in patients with arthritis at moderate cardiovascular risk has challenged the convention that all selective cyclo-oxygenase-2 (COX 2) inhibitors share the same heightened cardiovascular risk as rofecoxib and that naproxen has superior cardiovascular safety.[5]

Thursday, July 13, 2017
10:11 PM

Overall, the available data suggest that all NOACs can be used in patients with normal or mildly elevated transaminases (<3 ULN) and mild hepatic impairment (Child-Pugh A, Table 1), while dabigatran and apixaban may be used with caution in moderate liver disease (Child-Pugh B with normal transaminases levels). However, NOACs should be avoided in patients with severe liver impairment. Although idiosyncratic DILI occurs unpredictably, known liver disease is a risk factor, and regular re-assessment of liver function with prompt NOAC discontinuation in case of liver enzymes elevation could prevent severe potentially fatal DILI.
In warfarin users with chronic liver disease, a simple score based on the serum albumin (2.50–3.49 g/dL scoring 1, and <2.50 g/dL scoring 2 points) and creatine levels (1 point if 1.01–1.99 mg/dL, 2 points if ≥2.0 mg/dL) predicted both anticoagulation control and bleeding (with score=4, adjusted HR for bleeding was 5.17; 95% CI, 1.67 to 16.01).[10]Using a split-sample approach, Alonso et al[8] derived a prediction model for 1-year risk of OAC-specific liver injury hospitalisation, which had a modest predictivity in both derivation (c-statistic 0.67; 95% CI, 0.64 to 0.70) and validation sample (c-statistic 0.69; 95% CI, 0.66 to 0.73).
The risk model includes liver, gallbladder and kidney disease, heart failure, cancer, anaemia and alcoholism (all yes/no), and is intended to estimate 1-year risk of liver injury hospitalisation with the use of warfarin, dabigatran, rivaroxaban or apixaban. However, the model components are defined only by claim-based diagnostic codes, which is of little (if any) practical value to clinicians, while implementation of such model in various automated electronic environments bears the potential of underestimation or overestimation of the risk of DILI (dependent on the selected diagnostic codes). This could result in unjustified OAC (or NOACs) denial to eligible patients, or one drug could be favoured over others without firm clinical grounds. Further research is needed to optimise automated decision-making tools for OAC use.
Notwithstanding the limitations of observational postmarketing studies, new data presented by Alonso et al broadly confirm previous findings of lower DILI rates with all NOACs relative to warfarin. The lowest risk of DILI was observed with dabigatran, but other NOACs could also be used, particularly in case of concomitant renal disease. Clinical vigilance and regular follow-up of NOACs users are needed to prevent severe, potentially deleterious DILI, but there is no compelling evidence that any particular NOAC should be denied to most patients with AF at risk of stroke only to avoid a rare event such as DILI. However, more data are needed to inform optimal use of NOACs in patients with AF with liver dysfunction.

Coumadin and RF
Thursday, July 13, 2017
10:17 PM

Conclusions: Among older adults with AF, warfarin therapy initiation was associated with a significantly lower 1-year risk for the composite outcome across all strata of kidney function. The risk for major bleeding associated with warfarin use was increased only among those with eGFRs of 60 to 89 mL/min/1.73 m2.

Ocular allergies and asthma TC
Friday, July 14, 2017

Immune reactions, such as allergic conjunctivitis, occur as a series of cellular events, all of which represent points of therapeutic intervention. One of these points is the IgE receptor-triggered, mast-cell degranulation and histamine release that is catalyzed by spleen tyrosine kinase (Syk).2
Syk inhibitors have been touted as potential therapies for blood cell cancers, allergic asthma, and allergies in general. There are a number of small molecule, Syk-targeted compounds in clinical stage testing, and trials involving allergic disorders are expected in the near future.
Kinases are key metabolic regulators and it is not surprising that many kinase inhibitors have therapeutic potential. Drugs–such as Imatinib (Gleevec, Novartis), an important therapy for chronic leukemias and stromal tumors–recently were shown to be an effective inhibitor of mast-cell growth–and a potential treatment for allergic asthma and other allergic conditions.3
Another kinase in the crosshairs is IkK-beta, a key player in pro-inflammatory signaling. Inhibitors of this kinase, such as SAR113945 (Sanofi), have been tested as treatments for osteoarthritis. Similar compounds may have a role in chronic allergy therapy.
Lastly, there is the potential for ROCK kinases inhibitors and the MAP kinases. Both are therapies for different disorders from glaucoma to various neoplasias. The focus of these molecular compounds are best suited to an empirical assessment of efficacy in ocular allergy and inflammation.
On a different front, efforts to unravel the mechanisms of action for compounds derived from natural products used as allergy treatments (such as flavonoids, stilbenes, and curcuminoids)4have narrowed the focus to a common, mast-cell stabilization effect.
This was demonstrated by in vitro studies in basophilic cell lines. Given the common mechanism in several popular herbal preparations, a revival of interest in mast cell stabilizers may be on the horizon.
One anticipated therapeutic arrival in ocular allergy treatments came in 2013 and 2014, with approvals of sublingual timothy grass antigen extracts as a desensitizing approach to seasonal allergies. These approvals received a first-ever FDA indication for “allergic rhinitis with or without conjunctivitis,” opening the door to future treatments for rhino-conjunctivitis.

Viagra stents
Friday, July 14, 2017

Sildenafil (Viagra) reduced both platelet aggregation and a marker of restenosis, which could give it a potential edge over both bare metal stents and current-generation DES, reported Han-Mo Yang, MD, PhD, of Seoul National University Hospital in South Korea, and colleagues in a poster at the American Heart Association’s Basic Cardiovascular Sciences 2017 meeting.

The drug activates protein kinase G (PKG) and was found to reduce neointimal hyperplasia in rat carotid arteries. Furthermore, Yang’s group found that sildenafil reduced viability, cell cycle progression, and migration of vascular smooth muscle cells and inhibited their change from a contractile to a synthetic form.

Artificial sweeteners
Monday, July 17, 2017

in the Canadian Medical Association Journal, researchers analyzed 37 studies on artificial sweeteners to see if they were successful for weight management. The studies followed more than 400,000 people for about 10 years. Seven of the studies were randomized controlled trials, a type considered to be the gold standard in scientific research.

artificial sweeteners have been associated with health problems, experts have several working theories to explain the link. Some researchers speculate that the sweeteners interfere with a person’s microbiome, a collection of gut bacteria crucial for the absorption of nutrients. Regularly eating or drinking sugar substitutes may also cause people to crave sweeter foods more often. People may also believe that because they haven’t consumed calories, they have license to splurge elsewhere. Some researchers also believe that sweeteners may interfere with the body’s mechanisms for metabolizing sugar.

Pancreatic duct AC
Thursday, July 20, 2017

In a 337-person study, researchers found that a blood panel for the protein thrombospondin-2 (THBS2) and cancer antigen 19-9 (CA19-9), measured with a standard ELISA test, together detected pancreatic ductal adenocarcinoma (PDAC) with a specificity of 98% and a sensitivity of 87%. The test was effective at distinguishing patients with PDAC from controls and those with benign pancreatic disease across all stages of the cancer, wrote Kenneth Zaret, PhD, at the University of Pennsylvania, Philadelphia.

PPI deaths. BMJ 7/2017
Thursday, July 20, 2017

They found a 25% increased risk for death in the PPI group compared with the H2 blocker group. The researchers calculated that, for every 500 people taking PPIs for a year, there is one extra death that would not have otherwise occurred. Given the millions of people who take PPIs regularly, this could translate into thousands of excess deaths every year, Dr. Al-Aly said.

Dementia prevention
Thursday, July 20, 2017

three interventions — cognitive training, blood pressure management in those with hypertension, and increased physical activity — have “inconclusive but encouraging” evidence that they can help stave off dementia.

Exercise related gut damage
Thursday, July 20, 2017

Several strategies for preventing or reducing the severity of exercise-associated GI perturbations:
• Maintenance of euhydration
• Consumption of carbohydrate during exercise
• Dietary adaptation of the GI tract pre-exercise
• Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs)
• Dietary supplementation, such as antioxidants, glutamine, L-arginine, L-citrulline, bovine colostrum, and probiotics

as exercise intensity and duration increased, so did indices of intestinal injury, permeability and endotoxemia, as well as impairment of gastric emptying, slowing of small intestinal transit, and malabsorption.
Exercise stress of ≥2 hours at 60% VO2max appeared to be the threshold, while significant GI perturbations manifested, irrespective of fitness status. Running and exercising in hot ambient temperatures exacerbated the indicators of gastrointestinal disturbance, they added.
Additionally, low to moderate physical activity may be beneficial for patients who have irritable bowel syndrome or inflammatory bowel disease.

Bowel prep and missed polyp
Friday, July 21, 2017

Boston bowel prep score. C1 first colonoscopy

Overall, patients with inadequate bowel prep were significantly more likely than those with adequate prep to be male (71% vs. 60%) and younger (average age, 59 years vs. 61 years). In addition, patients with inadequate prep at C1 were significantly more likely to have C2 for an indication of screening, while patients with adequate prep at C1 were significantly more likely to undergo C2 for surveillance.

In a multivariate model, the risk of advanced polyps at C2 was significantly higher for patients who had advanced polyps at C1 (odds ratio, 3.5), but inadequate BBPS scores at C1 had no significant impact on advanced polyp risk at C2. The risk of advanced polyps at C2 increased slightly with each year of age (OR, 1.1), but was not impacted by sex or time between C1 and C2 visits.

In addition, polyps at C2 were significantly more likely in patients with inadequate examinations at C1 vs. adequate C1 exams (18% vs. 7%).

Newer C diff Rx investigational drug
Friday, July 21, 2017

Ridinilazole correlated with more sustained clinical responses across almost all subgroups as well, including with treatment differences (respectively) of 42.7%, 15.9%, 19.9%, and 8.9% for those over 75 years, with a more severe diagnosis, more than one previous CDI episode, and those taking other antibiotics before study participation, according to the investigators. Both groups saw similar rates of adverse events related to treatment.
Compared with vancomycin

Metabolic Alkalosis: Practice Essentials, Pathophysiology, Etiology
Friday, July 21, 2017

Metabolic alkalosis may be generated by one of the following mechanisms:
• Loss of hydrogen ions
• Shift of hydrogen ions into the intracellular space
• Alkali administration
• Contraction alkalosis
Hydrogen ions may be lost through the kidneys or the GI tract. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCl). Whenever a hydrogen ion is excreted, a bicarbonate ion is gained in the extracellular space.
Renal losses of hydrogen ions occur whenever the distal delivery of sodium increases in the presence of excess aldosterone, which stimulates the electrogenic epithelial sodium channel (ENaC) in the collecting duct. As this channel reabsorbs sodium ions, the tubular lumen becomes more negative, leading to the secretion of hydrogen ions and potassium ions into the lumen.
Shift of hydrogen ions into the intracellular space mainly develops with hypokalemia. As the extracellular potassium concentration decreases, potassium ions move out of the cells. To maintain neutrality, hydrogen ions move into the intracellular space.
Administration of sodium bicarbonate in amounts that exceed the capacity of the kidneys to excrete this excess bicarbonate may cause metabolic alkalosis. This capacity is reduced when a reduction in filtered bicarbonate occurs, as observed in renal failure, or when enhanced tubular reabsorption of bicarbonate occurs, as observed in volume depletion (see Maintenance of metabolic alkalosis).
Loss of bicarbonate-poor, chloride-rich extracellular fluid, as observed with thiazide diuretic or loop diuretic therapy or chloride diarrhea, leads to contraction of extracellular fluid volume. Because the original bicarbonate mass is now dissolved in a smaller volume of fluid, an increase in bicarbonate concentration occurs. This increase in bicarbonate causes, at most, a 2- to 4-mEq/L rise in bicarbonate concentration.

Causes of chloride-responsive alkalosis (urine chloride < 20 mEq/L) include the following: • Loss of gastric secretions – Vomiting, NG suction • Loss of colonic secretions – Congenital chloridorrhea, villous adenoma • Thiazides and loop diuretics (after discontinuation) • Posthypercapnia • Cystic fibrosis Causes of chloride-resistant alkalosis (urine chloride >20 mEq/L) with hypertension include the following:
o Primary hyperaldosteronism – Adrenal adenoma, bilateral adrenal hyperplasia, adrenal carcinoma, glucocorticoid-remediable hyperaldosteronism
o 11B-HSD2 – Genetic, licorice, chewing tobacco, carbenoxolone
o CAH – 11-Hydroxylase or 17-hydroxylase deficiency
o Current use of diuretics in hypertension
o Cushing syndrome
o Exogenous mineralocorticoids or glucocorticoids
o Liddle syndrome
o Renovascular hypertension
Causes of chloride-resistant alkalosis (urine chloride >20 mEq/L) without hypertension include the following:
• Bartter syndrome
• Gitelman syndrome
• Severe potassium depletion
• Current use of thiazides and loop diuretics
• Hypomagnesemia
Other causes include the following:
 Exogenous alkali administration – Sodium bicarbonate therapy in the presence of renal failure, metabolism of lactic acid or ketoacids
 Milk-alkali syndrome
 Hypercalcemia
 Intravenous penicillin
 Refeeding alkalosis
 Massive blood transfusion

Mortality rates have been reported as 45% in patients with an arterial blood pH of 7.55 and 80% when the pH was greater than 7.65. Prognosis also depends in part on the specific condition or circumstances that led to metabolic alkalosis.

Worm for septic shock ??
Tuesday, August 1, 2017
• Home
• Medical research
• July 31, 2017
The story of how a worm turned… into a bringer of medical miracles
July 31, 2017 by Wafaa Essalhi

Marine worms may hold the key to medical breakthroughs including speedier recovery from surgery and more blood transfusions
For centuries, the only use humans found for the lugworm—dark pink, slimy and inedible—was on the end of a fish hook.
But the invertebrates’ unappreciated status is about to change.
Their blood, say French researchers, has an extraordinary ability to load up with life-giving oxygen.
Harnessing it for human needs could transform medicine, providing a blood substitute that could save lives, speed recovery after surgery and help transplant patients, they say.
“The haemoglobin of the lugworm can transport 40 times more oxygen from the lungs to tissues than human haemoglobin,” says Gregory Raymond, a biologist at Aquastream, a fish-farming facility on the Brittany coastline.

New HBV vaccine
Thursday, August 3, 2017

Hepatitis B is a serious disease. A company (Dynavax) has a new hepatitis vaccine that induces hepatitis antibodies more vigorously than existing vaccines and does so after 2 doses (instead of the usual 3). The vaccine works through a unique adjuvant. The serological advantages of the Dynavax vaccine were demonstrated in a randomized trial of >8000 patients; about 5600 people received the new vaccine and about 2800 people received the existing standard.

Mavyret for HCV
Thursday, August 3, 2017
As so he grew into his larger self,
Humanity framed his movements less and less;
A greater being saw a greater world.
A fearless will for knowledge dared to erase
The lines of safety Reason draws that bar
Mind’s soar, soul’s dive into the Infinite.
Even his first steps broke our small earth-bounds
And loitered in a vaster freer air.
In hands sustained by a transfiguring Might
He caught up lightly like a giant’s bow
Left slumbering in a sealed and secret cave
The powers that sleep unused in man within.
He made of miracle a normal act
And turned to a common part of divine works,
Magnificently natural at this height,
Efforts that would shatter the strength of mortal hearts,
Pursued in a royalty of mighty ease
Aims too sublime for Nature’s daily will:
The gifts of the spirit crowding came to him;
They were his life’s pattern and his privilege.
A pure perception lent its lucent joy:
Its intimate vision waited not to think;
It enveloped all Nature in a single glance,
It looked into the very self of things;
Deceived no more by form he saw the soul.

Colon cancer genetics
Friday, August 4, 2017

If you have colon cancer genes how likely is it you will pass genes to children? Heritability is 40%

However there are autosomal dominant genes also that account for 10% of the genetics

Saturday, August 5, 2017

Exetenide a GLP drugs used in DM slows progression of Parkinson’s

Chf management
Wednesday, August 9, 2017
• Natriuretic peptide biomarker screening and early intervention may prevent HF.
• During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a postdischarge prognosis.
• In patients at increased risk, stage A HF, the optimal blood pressure in those with hypertension should be <130/80 mm Hg.
• In patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is <20%), intravenous iron replacement might be reasonable to improve functional status and QoL.
Patient deaths and re-hospitalizations could be reduced though the use of novel tests for heart failure (HF), which can better guide the diagnosis and management of HF, according to a new scientific statement from the American Heart Association (AHA). The statement summarizes the existing literature and provides guidance for the utility of currently available biomarkers associated with HF, including natriuretic peptides, soluble suppressor of tumorgenicity 2, highly sensitive troponin, galectin-3, midregional proadrenomedullin, cystatin-C, interlukin-6, procalcitonin, and others. Among the conclusions and recommendations:
• In community-based populations, measurement of natriuretic peptides (BNP or NT-proBNP) or markers of myocardial injury (TnI or TnT) alone adds prognostic information to standard risk factors for predicting new-onset HF.
• Measurement of several new biomarkers, including sST2, Gal-3, GDF-15, and markers of renal function, alone or in a multimarker strategy, may be useful for providing additional risk stratification.
• Measurement of BNP or NT-proBNP and cTn at the time of presentation is useful for establishing prognosis or disease severity in patients with acutely decompensated HF.
• Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis is reasonable for additive risk stratification in patients with acutely decompensated HF.
• Measurement of predischarge BNP or NT-proBNP during an HF hospitalization can be useful for establishing postdischarge prognosis.
Simpson said beta-blockers and angiotensin-receptor-blockers that can pass through the blood-brain barrier were successful at treating both the heart condition and diaphragm weakness.

CCY AND gallstone
Thursday, August 10, 2017

Approximately 20% of patients with gallstone disease have choledocholithiasis, mainly because gallstones can pass from the gallbladder into the common bile duct. After undergoing ERCP, such patients are typically referred for CCY, but there are no “societal guidelines” on timing the referral, the researchers said. Practice patterns remain “largely institution based and may be subject to the vagaries of surgeon availability and other institutional resource constraints.” One prior study linked a median 7-week wait time for CCY with a 20% rate of recurrent biliary events.

Early cancer detection
Thursday, August 17, 2017

Using a technique called targeted error correction sequencing, investigators identified 59% to 71% of stage I-II colorectal, breast, lung, and ovarian cancers. Retrospective comparison with tumor biopsy specimens showed good correlation between tissue and blood-test results, according to Victor Velculescu, MD, PhD, of Johns Hopkins in Baltimore, and colleagues.

Salt intake
Thursday, August 17, 2017

Lowest mortality is people who consume 3-5 Good morning/ day salt

There is an absence of robust evidence of significantly lower rates of CVD with low sodium intake, compared to moderate intake. When guidelines originally recommended a target of low sodium intake, conventional wisdom assumed that all approaches to reducing sodium intake would automatically translate into lower rates of CVD. While there are no randomized controlled trials demonstrating that low sodium intake (<2 g/day) is associated with lower rates of CVD than moderate (average) intake (3–5 g/day), the blood pressure reductions seen with reduced sodium intake in clinical trials has been considered to be the basis for recommendation for low sodium intake. It was also assumed that an adequate sodium intake, for physiological purposes, was about 0.5 g/day, creating a theoretical safe limit for salt consumption. However, in recent years, new evidence from large prospective cohort studies have reported an increased risk of CVD/mortality with sodium intakes that are either above 5 g/day or below 3 g/day, whereby moderate sodium intake is associated with the lowest CV risk. These data, and those from studies reporting an activation of the renin-angiotensin-aldosterone and sympathetic nervous systems with sodium intakes under 3 g/day, have challenged the wisdom of recommending low sodium intake for the entire population. It is suggested that optimal sodium intake is a delicate balance between levels sufficient to meet physiological requirements, which may vary by population and setting because of factors such as ambient temperature and thus salt loss through sweat, and avoidance of high sodium intake levels associated with a pathological effect on blood pressure and vascular health. Such an evolution in the evidence-base linking sodium intake and health has resulted in re-evaluation of current recommendations by some guideline groups. Whereas some institutions (e.g. WHO) have concluded that there should be no change to the current recommendations for low sodium intake, others (e.g. Institute of Medicine, USA) have concluded that available evidence is inadequate to support a recommendation for low sodium intake while recommending against high sodium intake.

Wednesday, August 23, 2017

The penchant of etomidate for not eroding hemodynamic and respiratory function makes it particularly attractive for patients with shock or significant cardiopulmonary disease. The agent does have its quirks, however. It inhibits the synthesis of both glucocorticoids and mineralocorticoids through blockage of 11-β-hydroxylation within the adrenal gland. In fact, a single dose can affect steroidogenesis for up to 72 hours. Myoclonus and postoperative nausea and vomiting are also common side effects.

Thursday, August 24, 2017


7C4 rest in BAAD

Saturday, August 26, 2017

he proposes the term schizophrenia “should be abolished.” In its place, he suggests the concept of a psychosis spectrum disorder.

Reduction in MI
Monday, August 28, 2017

Heart attack survivors given injections of a targeted anti-inflammatory drug called canakinumab had fewer attacks in the future, scientists found. Cancer deaths were also halved in those treated with the drug, which is normally used only for rare inflammatory conditions.

Newer drug for MI
Tuesday, August 29, 2017

The study randomized 30,449 patients with atherosclerosis to placebo or the cholesteryl ester transfer protein (CETP) inhibitor anacetrapib. After 4.1 years of followup a major coronary event occurred in 10.8% of patients in the anacetrapib group versus 11.8% of patients in the placebo group, a 9% reduction in risk (P=0.004).

Strange idioms
Wednesday, August 30, 2017
Strange But True….

1. In the 1400s a law was set forth in England that a man was allowed to beat his wife with a stick no thicker than his thumb. Hence we have ‘the rule of thumb.’

2. Many years ago in Scotland, a new game was invented. It was ruled ‘Gentlemen Only Ladies Forbidden’ and thus the word GOLF entered the poor bloody English language.

3. Each King in a deck of playing cards represents a great king from history:-
Spades – King David
Hearts – Charlemagne
Clubs – Alexander the Great
Diamonds – Julius Caesar

4. In Shakespeare’s time, mattresses were secured on bed frames by ropes. When you pulled on the ropes the mattress tightened, making the bed firmer to sleep on. Hence the phrase, ‘goodnight, sleep tight.’

5. It was the accepted practice in Babylon 4,000 years ago that for a month after the wedding, the bride’s father would supply his son-in-law with all the mead he could drink. Mead is a honey beer and because their calendar was lunar based, this period was called the honey month, which we know today as the ‘honeymoon’.

6. In English pubs, ale is ordered by pints and quarts. So in old England , when customers got unruly, the bartender would yell at them ‘Mind your pints and quarts, and settle down.’ It’s where we get the phrase ‘mind your P’s and Q’s’

7. Many years ago in England, pub frequenters had a whistle baked into the rim or handle of their ceramic cups. When they needed a refill, they used the whistle to get some service. ‘Wet your whistle’ is the phrase inspired by this practice.

Opioid gut
Friday, September 1, 2017
• Opioids can cause dysmotility in the esophagus.
• The drugs can cause a significant delay in gastric emptying, which in turn can precipitate postprandial nausea and early satiety.
• Following surgery, opioids can induce ileus.
• Another complication to consider is narcotic bowel syndrome, which may lead to chronic abdominal pain, nausea, and vomiting.
• The bowel function index can be of value in patients on these narcotics to help identify opioid induced chronic constipation.

UC flare up
Friday, September 1, 2017

Several fatty acids were linked to disease flare ups but the strongest association occurred in patients who consumed foods rich in myristic acid, which is common in palm oil, coconut oil, and dairy fats.

PBC – copy paste as patient ed
Friday, September 1, 2017
Pruritis, fatigue, and sicca complex are the most common symptoms of PBC and can significantly effect quality of life. Pruritis can be treated with cholestyramine or rifampicin. Clinicians should seek out and treat associated and alternate causes of fatigue and advise patients on strategies to avoid compounding fatigue problems. Sicca complex should be treated appropriately and, if patients develop refractory symptoms, referred to a specialist.

Complications of liver disease caused by PBC include osteoporosis, fat-soluble vitamin substitution, hyperlipidemia, varices, hepatocellular carcinoma, and need for liver transplant, though the need for liver transplant in PBC patient has decreased over time.

Cholecystectomy timing
Friday, September 1, 2017

Approximately 20% of patients with gallstone disease have choledocholithiasis, mainly because gallstones can pass from the gallbladder into the common bile duct.

Over 365 days of follow-up, 10% of patients who did not have a CCY had recurrent biliary events, compared with 1.3% of patients who underwent early or delayed CCY. Th

Barrett screen
Friday, September 1, 2017

Cytosponge is option when approved

MS linked to mono
Friday, September 1, 2017

while “mono consistently increases the risk of developing MS by two- to threefold” among whites, blacks and Hispanics saw a fourfold increased risk in the new study, said lead author Dr. Annette Langer-Gould. She is a neuroscience researcher with Southern California Permanente Medical Group.

Obesity increases cancer by crosstalk
Friday, September 1, 2017

certain fat cells – known as “adipose stromal cells” – were able to invade cancer lesions and then help spur the growth of tumors. The data also showed that obese people with prostate or breast cancer appeared to have more of these cells than thinner people.

Some types of fat cells are also more “metabolically active,” releasing more substances that promote tumor growth, the review found.

Also, fat may be white, brown or beige, Ulrich’s team noted. And these different types of fat each behave differently, depending on quantity and location in the body. For example, the review found that white fat tissue is linked with inflammation and worse outcomes for women with breast cancer.

Night shift and obesity
Saturday, September 2, 2017
Working night shifts derails your metabolism and can make it difficult to shift weight, new research shows.
Humans have one specific protein which harvests energy from fat and portions the rest into storage.
Like most metabolic pathways, this protein (NFIL3) relies on a regular night-day light cycle to function at its prime.
And now, a research team at The University of Texas Southwestern Medical Center has shown how disruptions to that rhythm – by working the night shift or traveling internationally – are more likely to be obese and develop conditions like diabetes.

Sunday, September 3, 2017

An epidemic of chronic kidney diseasenot associated with any of the usual risk factors, such as hypertension and diabetes, could be due to kidney damage related to recurrent dehydration, said an expert here at the European Renal Association and European Dialysis and Transplant Association 54th Congress

This enzyme system converts glucose into fructose, which is then metabolized by the fructokinase enzyme, releasing oxidative stress and uric acid, both of which can cause local tubular injury. The researchers point out that knockout mice that did not carry the fructokinase enzyme were protected from renal injury despite being exposed to recurrent dehydration.

Kiss the boo boo
Sunday, September 3, 2017

It turns out that histatin-1 does all of that. Not only does it make new skin cells migrate and attach themselves to the wound, but it actually helps to grow new blood vessels.

Sunday, September 3, 2017
Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.1 Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.2 Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.1 The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.
Mechanism of action
Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.3 Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.3
A wide range of adverse effects
Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.1 Alpha-PVP is known to cause rhabdomyolysis.4 Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.5 Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.5 Death may occur by cardiac arrest, renal damage, or suicide.

Case reports. The effects of α-PVP have been documented in the literature:
• A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.2
• ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.4
• In 2015, 18 deaths related to α-PVP use were reported in South Florida.5
• Deaths related to α-PVP use also have been reported in Japan and Australia.5

Age related melatonin drop
Sunday, September 3, 2017
Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.1
Romo-Nava et al2 had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo¬thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta¬bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.3

PBC survival
Monday, September 4, 2017

A retrospective analysis of 88 PBC patients hospitalized between June 2009 and January 2014 was performed for the study. NLR was a significant predictor of survival, with an odds ratio of 1.5, a sensitivity of 100%, and a specificity of 67.1%. A baseline NLR value of 2.18 was selected as the cutoff for 1-year mortality. Of the 33 patients above this value at initial hospitalization, 6 died, whereas none of the 55 patients below this value died.

Neutrophil to lymphocytes ratio

Monday, September 4, 2017
Timothy Gardner, MD, MS, focused on the management and treatment of sequelae in patients with acute pancreatitis. He provided support for the use of lactated Ringer’s as the fluid of choice, cautioning against over-resuscitation. He advised early oral feeds, without clear preference for nasogastric or nasojejunal administration. Dr. Gardner emphasized the importance of classifying type of fluid collection to optimize clinical decision making. Endoscopic techniques appear to be safer and as efficacious as surgical approaches. Regarding thrombosis, anticoagulation was recommended unless an absolute contraindication exists. He also recommended addressing symptomatic ductal disruptions.

Dr. Michelle K. Kim
Matthew J. DiMagno, MD, AGAF, provided important insights into chronic pancreatitis. He first advised classifying patients with recurrent attacks of pancreatitis. Also, pain patterns in chronic pancreatitis may be categorized into two groups: short, intermittent pain (type A) and constant pain (type B). The former can often be managed without invasive procedures, while the latter is often managed with interventions. When addressing the pain of chronic pancreatitis, clinicians need to establish the diagnosis, advise abstinence from alcohol and smoking, and advocate adequate nutrition and other treatments. The approach to constant pain requires exclusion of anatomic pathology and appropriate treatment of neuropathic and centralized pain. Assessment of duct morphology also impacts treatments; patients with dilated or large duct disease should undergo drainage procedures.

Salt intake
Monday, September 4, 2017
Participants in a recent study with the highest intake of sodium and potassium actually had significantly lower blood pressure, according to an analysis presented earlier this year at the American Society for Nutrition’s Scientific Sessions meeting in Chicago. The group with the lowest blood pressure averaged a daily sodium intake of 3.7 grams a day, far higher than the guidelines suggest.

The findings echo those of a 2016 study published in The Lancet. The largest of its kind, the review looked at sodium intake and blood pressure data in over 130,000 individuals from 49 countries with varying degrees of salt consumption. Low sodium intake was defined as up to 3 grams a day, just shy of the 3.4 grams a day that Americans average. Four and 5 grams a day was considered “moderate” intake, and 7 or more grams a day as “high” consumption.

The authors found that populations with very low sodium intake seemed to have a higher risk of cardiovascular disease and death than those with moderate intake. So did people on high-salt diets, but only those with high blood pressure in the first place. According to the data, moderate to high salt consumption in people with normal blood pressure did not appear to have the dire consequences that might have been presumed.

“In people with normal blood pressure, there doesn’t seem to be much of an association between salt intake increases in blood pressure,” says lead study author Andrew Mente, a nutritional epidemiologist at McMaster University in Hamilton, Ontario.

GAD IN LADA – diabetes
Tuesday, September 5, 2017

Autoantibodies to GAD also provide one of the critical definitions of latent autoimmune diabetes in adults (LADA). The definition of this disease has not been formalised, but criteria suggested by the Immunology of Diabetes Society include patients over 30 years old at diagnosis, positive for at least one islet autoantibody, and not treated with insulin within the first 6 months after diagnosis.

Music and HTN
Wednesday, September 6, 2017

Listen to Beethoven op 61 , second movement Larghetto. Reduces BP

Music helps treat insomnia

Thursday, September 7, 2017

Food and Drug Administration has approved Vabomere (meropenem and vaborbactam) for adults with complicated urinary tract infection (cUTI), including pyelonephritis caused by susceptible Enterobacteriaceae, the agency has announced.

Thursday, September 7, 2017

Total airway mucin concentrations show promise as an important biomarker for chronic bronchitis, which is a key component of chronic obstructive pulmonary disease (COPD), new research suggests.


Thursday, September 7, 2017

Tiotropium is a long-acting muscarinic antagonist (LAMA) approved to improve airflow in patients with moderate-to-severe COPD. Small trials and subgroup analyses have shown tiotropium therapy to improve lung function, measured by FEV1 and forced vital capacity (FVC) in patients with GOLD stage 1 and early stage 2 disease.

Thursday, September 7, 2017
break down into 4 total stages. Over time, COPD symptoms will worsen, and the stage numbers will increase.
• Stage 1: Very mild COPD with a FEV1 about 80 percent or more of normal.
• Stage 2: Moderate COPD with a FEV1 between 50 and 80 percent of normal.
• Stage 3: Severe emphysema with FEV1 between 30 and 50 percent of normal.
• Stage 4: Very severe COPD with a lower FEV1 than Stage 3, or those with Stage 3 FEV1 and low blood oxygen levels

Genetic marker for ibd cancer
Thursday, September 7, 2017
• Researchers looked at methylated miRNA levels, comparing patients with ulcerative colitis-associated colorectal cancer to those with colitis but no cancer.
• Methylation of miRNA was significantly higher in tissue samples from patients who had dysplasia or colorectal cancer, when compared to patients with colitis but no malignancy.
• One particular biomarker called MIR137, located in rectal mucosa, was found to be an independent risk factor for ulcerative colitis-related colorectal cancer.

Obesity causes
Thursday, September 7, 2017
Our fatty tissue produces leptin, which acts in opposite to the so-called “hunger” hormone, “ghrelin.” Leptin travels through the bloodstream, and binds to the brain’s hypothalamus, to make us feel full. But when fat is lost, the production of this hormone goes down, which makes us feel hungrier.

Viruses: A virus, known as Ad-36 can causeobesity. You may be unaware that you’ve caught it, but it can have lasting effects on your body .One study showed that 30 percent of obese subjects had been infected with it, versus 11 percent of those who were not obese – a 3-to-1 ratio.

Your microbiome: Depending on the distribution of the bacteria in your intestine, you may be thinner or fatter, as some gut microbes are more efficient at extracting calories from food than are others.

Diverticula bleed
Friday, September 8, 2017

Ligation therapy was more effective compared to clipping to avoid TAE or surgery. Coagulation, clipping, and ligation were equivocal in terms of effectiveness for initial hemostasis and preventing early recurrent bleeding.
Gastroendoscopy. Japanese study

Cirrhosis readmission
Friday, September 8, 2017
Patients with a CRP >10 mg/l at discharge had a significantly higher probability of being readmitted within 30 days (44% vs. 24%; P=0.007) and a significantly lower probability of 6-month survival (62% vs. 88%; P<0.001) than those with a CRP ≤10 mg/l.
CONCLUSIONS: CRP showed to be a strong predictor of early hospital readmission and 6-month mortality in patients with cirrhosis after hospitalization for bacterial and/or fungal infection. CRP values could be used both in the stewardship of antibiotic treatment and to identify fragile patients who deserve a strict surveillance program.Am J Gastroenterol advance online publication, 29 August 2017; doi:10.1038/ajg.2017.253.

Best polypectomy technique
Friday, September 8, 2017

There are several approaches to polypectomy for sessile polyps <20 mm and for pedunculated polyps. Recent evidence is leading towards standardisation of polypectomy technique. Key recent polypectomy developments include: 1. Use of cold snare polypectomy (CSP) for sessile polyps <10 mm; 2. Use of hot snare polypectomy (HSP) following submucosal injection for sessile polyps sized 10-19 mm; 3. Piecemeal cold snare polypectomy (PCSP), with or without prior submucosal injection, for select sessile polyps sized 10-19 mm, where the potential risk for an adverse event is increased (e.g. polyps in the caecum or ascending colon, or patients with increased risk of post-polypectomy bleeding), and where the risk of submucosal invasion is low; 4. Avoidance of hot biopsy forceps (HBF); 5. Limiting the use of cold biopsy forceps (CBF) to the smallest of diminutive polyps, where CSP is not feasible; 6. Mechanical haemostasis prior to polypectomy for large pedunculated polyps with head ≥20 mm or stalk ≥10 mm.

Cough with common cold
Saturday, September 9, 2017
pharmacological treatment for acute cough associated with the common cold (CACC) have changed little since the publication of the 2006 CHEST Cough Guidelines, according to a systematic review of randomized controlled trials (RCTs) that sought evidence of clinically relevant treatment effects for therapies in reducing the duration and severity of acute CACC. While the evidence supporting the management of CACC’s is overall of low quality, the expert panel did issue the following recommendations and suggestions:
• For adult and pediatric patients with cough due to the common cold, there is a suggestion against the use of over-the-counter (OTC) cough and cold medicines unless they have been shown to make cough less severe or resolve sooner (upgraded consensus-based statement).
• In adult patients with cough due to the common cold, there is a suggestion against the use of nonsteroidal anti-inflammatory agents until they have been shown to make cough less severe or resolve sooner (upgraded consensus-based statement).
• In pediatrics patients (aged 1-18 years) with cough due to the common cold, honey may offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo, but it is not better than dextromethorphan (upgraded consensus-based statement). Note: Infants less than 1 year of age should not be administered honey and children less than 2 years of age should not be administered dextromethorphan for cough symptoms.
• In pediatrics patients with cough due to the common cold, codeine-containing medications should not be used because of the potential for serious side effects including respiratory distress (upgraded consensus-based statement).
• The authors found no evidence to support or refute the use of OTC antitussives, expectorants, mucolytics, antihistamines, or combination products.

H2 blockers not PPI dementia
Sunday, September 10, 2017

A large prospective study of middle-aged and older women found no convincing evidence that using proton pump inhibitors increased their risk of dementia, investigators reported.
However, using H2 receptor antagonists for at least 9 years was associated with a slight decrease in scores of learning and working memory (mean decrease, –0.2; 95% confidence interval, –0.3 to –0.08; P less than .001), Paul Lochhead, MBChB, PhD, and his associates wrote in the October issue of Gastroenterology (doi: 10.1053/j.gastro.2017.06.061). “Since our primary hypothesis related to PPI [proton pump inhibitor] use, our findings for [H2 receptor antagonists] should be interpreted with caution,” they said.

In a recent German study of a medical claims database, use of PPIs was associated with a 44% increase in the likelihood of incident dementia (JAMA Neurol. 2016;73:410-6). “The existence of a causal mechanism linking PPI use to dementia is suggested by observations from cellular and animal models of Alzheimer’s disease, where PPI exposure appears to influence amyloid-beta metabolism,” Dr. Lochhead and his associates wrote. “However, other preclinical data on PPIs and Alzheimer’s disease are conflicting.” Noting that cognitive function predicts dementia later in life, they analyzed prospective data on medications and other potential risk factors from 13,864 participants in the Nurses’ Health Study IIwho had completed Cogstate, a computerized, self-administered neuropsychological battery.

Study participants averaged 61 years old when they underwent cognitive testing, ranging in age from 50 to 70 years. Users of PPIs tended to be older, had more comorbidities, were less physically active, had higher body mass indexes, had less education, and ate a lower-quality diet than women who did not use PPIs. After adjusting for such confounders, using PPIs for 9-14 years was associated with a modest decrease in scores for psychomotor speed and attention (mean score difference, compared with never users, –0.06; 95% CI, –0.11 to 0.00; P = .03). “For comparison, in multivariable models, a 1-year increase in age was associated with mean score decreases of 0.03 for psychomotor speed and attention, 0.02 for learning and working memory, and 0.03 for overall cognition,” the researchers wrote.

Next, they examined links between use of H2receptor antagonists and cognitive scores among 10,778 study participants who had used PPIs for 2 years or less. Use of H2 receptor antagonists for 9-14 years predicted poorer scores on learning, working memory, and overall cognition, even after controlling for potential confounders (P less than or equal to .002). “The magnitudes of mean score differences were larger than those observed in the analysis of PPI use, particularly for learning and working memory,” the researchers noted. Additionally, PPI use did not predict lower cognitive scores among individuals who had never used H2receptor antagonists.

On the other hand, using PPIs for 9-14 years was associated with the equivalent of about 2 years of age-related cognitive decline, and controlling for exposure to H2 receptor antagonists weakened even this modest effect, the investigators said. Users and nonusers of PPIs tend to differ on many measures, and analyses of claims data, such as the German study above, are less able to account for these potential confounders, they noted. “Nonjudicious PPI prescribing is especially frequent among the elderly and those with cognitive impairment,” they added. “Therefore, elderly individuals who have frequent contact with health providers are at increased risk of both PPI prescription and dementia diagnosis. This bias may not be completely mitigated by adjustment for comorbidities or polypharmacy.”

The findings regarding H2 receptor antagonists reflect those of three smaller cohort studies, and these medications are known to cause central nervous system effects in the elderly, including delirium, the researchers said. Ranitidine and cimetidine have anticholinergic effects that also could “pose a risk for adverse cognitive effects with long-term use.”

Dr. Lochhead reported having no conflicts. Two coinvestigators disclosed ties to Bayer Healthcare, Pfizer, Aralez Pharmaceuticals, AbbVie, Samsung Bioepis, and Takeda.

PBC pruritis options
Sunday, September 10, 2017
There are four treatments commonly used for treating pruritus in PBC patients: bile acid–binding resins, rifampicin, opioid antagonists, and sertraline. In the cases of bile acid–binding resins, rifampicin, and opioid antagonists, significant side effects and a lack of proof of long-term efficacy prevent the treatments from standing out. Sertraline seems to have no significant side effects, but research is lacking, and further investigation is required.

Several experimental treatments for refractory pruritus also exist: These include phototherapy, plasmapheresis, albumin dialysis, nasobiliary drainage, ileal bile acid transporter–inhibitors, methotrexate and colchicine, and fibrates. In extreme cases, liver transplant can also be utilized to reduce pruritus symptoms.

Tryptophan and IBD
Tuesday, September 12, 2017

analysis of serum samples from more than 500 patients with IBD, we observed a negative correlation between serum level of tryptophan and disease activity. Increased levels of tryptophan metabolites — especially of quinolinic acid — indicated a high activity of tryptophan degradation in patients with active IBD. Tryptophan deficiency could contribute to development of IBD. Studies are needed to determine whether modification of intestinal tryptophan pathways affects the severity of IBD.

IL 22 is high in flare up
Gut microbiome is abnormal, leading to abnormal tryptophan

COPD and endothelial dysfunction
Thursday, September 14, 2017

For every unit of endothelial dysfunction — defined as the ratio of maximum amplitude time over total pulse wave time as measured by photoplethysmography (MAT/TT) — forced expiratory volume in 1 second (FEV1) was reduced 1.86 liters, reported Luis Castillo-Aguilar, MD, of the Instituto Nacional de Enfermedades Respiratorias in Mexico City, and colleagues.

that ex-smokers with COPD had elevated plasma levels of endothelial microparticles (EMPs) compared with nonsmokers, and that a significant proportion of these EMPs were derived from pulmonary capillaries that had undergone apoptosis. Those study authors reported that apoptotic EMP levels did improve in COPD patients who stopped smoking, but they never returned to those considered normal for nonsmokers without COPD.
The relationship between endothelial dysfunction and COPD was likened to what happens when a person suffers an injury such as a burn or an infection, said Mina Gaga, MD, of Athens Chest Hospital, and ERS president. “Even if you have a toothache, it affects the whole body. It make you less tolerant to pain, for example. There is cross-talk between the systems. COPD is a systemic disease so reactions to lung inflammation affects other systems. It’s not jus

App for SUD
Thursday, September 14, 2017

ReSET for substance use. Works for alcohol. Not fit opioid

Friday, September 15, 2017

High myristic acid linked to flare up of UC

It is in coconut, butter and palm oil

Ipilumab enterocolitis
Saturday, September 16, 2017


Can cause colitis
Use steroid 1 mg /kg. Within 5 days
Infliximab 5 mg / kg if no response. Repeat in 2 weeks
If ulcers seen on colonoscopy the usually steroid refractory

Monoclonal Ab treatments for cancer – does it cause immune mediated colitis

Flicker fusion rate vision
Sunday, September 17, 2017
This happens because animals see the world around them like a continuous video. But in reality, they piece together images sent from the eyes to the brain in distinct flashes a set number of times per second. Humans average 60 flashes per second, turtles 15, and flies 250.
Time is relative
The speed at which those images are processed by the brain is called the “flicker fusion rate”. In general, the smaller the species, the faster its critical flicker fusion rate – and flies, in particular, put us to shame.

killer fly”. It’s a tiny predatory species found in Europe that catches other flies out of the air with super-fast reactions. In her “fly lab” at Cambridge University, Dr Paloma Gonzales-Bellido demonstrates the killer flies’ hunting behaviour by releasing fruit fly prey into a special filming box with a female killer fly.
Paloma records the behaviour at 1,000 frames per second using slow motion video cameras with a recording buffer.

Poop bacteria weight loss
Monday, September 18, 2017

with a high Prevotella to Bacteroides ratio, study participants on the high fiber (or NND) diet lost on average 3.15 kg (or 6.94 pounds) more body fat than those on the average Danish diet. By contrast, the two diets did not result in any significant difference among those with low Prevotella to Bacteroides ratios. In other words, different bacteria, different responses to the diet.

Bacterial vaginosis
Monday, September 18, 2017

Secnidazole (Solosec) for Bacterial Vaginosis

Tuesday, September 19, 2017
Among patients treated for 52 weeks with long-acting beta-agonists and medium-to-high doses of inhaled glucocorticoids, those receiving tezepelumab had lower rates of clinically significant asthma exacerbations compared to those taking placebo, a recent study found. The randomized, double-blind, placebo-controlled trial compared subcutaneous tezepelumab at 3 dose levels with placebo over a 52-week treatment period. Researchers found:
• The use of tezepelumab at a dose of 70 mg every 4 weeks (low dose; n=145 patients), 210 mg every 4 weeks (medium dose; n=145 patients), or 280 mg every 2 weeks (high dose; n=146 patients), resulted in annualized asthma exacerbation rates at week 52 of 0.26, 0.19, and 0.22, respectively, compared with 0.67 in the placebo group.
• This resulted in exacerbation rates in the respective tezepelumab groups lower by 61%, 71%, and 66% compared to the placebo group.
• Similar results were observed in patients regardless of blood eosinophil counts at enrollment.

Friday, September 22, 2017

The Food and Drug Administration has approved Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol), a triple-therapy inhaler for the treatment of chronic obstructive pulmonary disease (COPD) in adult patients, according to a press release from GlaxoSmithKline and Innoviva.

Trelegy Ellipta combines an inhaled corticosteroid, a long-acting muscarinic antagonist, and a long-acting beta2-adrenergic agonist into an inhaler meant for once-daily use in people with COPD. Chronic bronchitis and/or emphysema patients are also indicated for treatment. The FDA-approved dosage is 100 mcg of fluticasone furoate, 62.5 mcg of umeclidinium, and 25 mcg of vilanterol.

The most common adverse events associated with Trelegy Ellipta include headache, back pain, dysgeusia, diarrhea, cough, oropharyngeal pain, and gastroenteritis, and the inhaler is contraindicated for people with “severe hypersensitivity to milk proteins.” Trelegy Ellipta is not indicated for people with asthma or acute bronchospasm.

Quinolone and GI perforations
Friday, September 22, 2017

We found that use of fluoroquinolones was associated with a non-negligible increased risk of gastrointestinal perforation, and physicians should be aware of this possible association.

RF causes
Saturday, September 23, 2017
“Hypertension and diabetes are major risk factors for kidney disease, but there has been a surge of cases among people without hypertension or diabetes, and this phenomenon is very common in areas with high pollution. We think this might explain some of the burden of kidney disease that has no known cause.”
Air pollution, especially fine particulate matter <2.5 µm in aerodynamic diameter (PM2.5), is a well-established risk factor for heart disease, respiratory disease, and death. But Al-Aly said few previous studies have examined the potential impact of PM2.5 on kidney function in humans.

Air pollution leads to renal failure

Saturday, September 23, 2017
• Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs and spicy or fatty foods
• Grade II and grade III hemorrhoids are initially treated with nonsurgical procedures
• Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy
• Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation

Asthma treatment
Saturday, September 23, 2017

Among patients treated for 52 weeks with long-acting beta-agonists and medium-to-high doses of inhaled glucocorticoids, those receiving tezepelumab had lower rates of clinically significant asthma exacerbations compared to those taking placebo, a recent study found. The randomized, double-blind, placebo-controlled trial compared subcutaneous tezepelumab at 3 dose levels with placebo over a 52-week treatment period. R

Pediatric NASH
Saturday, September 23, 2017
Restricting fructose intake among obese children may reduce the risk of nonalcoholic fatty liver and help manage obesity, suggests a recent clinical study. Details are as follows:
• 41 children had their standard diet modified to replace sugar with starch, resulting in a dietary regimen that only contained 4% of its kilocalories from fructose.
• On day 10 of the experiment, hepatic fat had dropped from a median of 7.2% to 3.8%.
• Visceral fat decreased from 123 cm3 to 110 cm3.
• De novo lipogenesis also declined, with the area under the curve changing from 68% to 26%.
• Insulin kinetics also improved (P <.001).

Afib markers
Sunday, September 24, 2017
• ABC Risk Scores in AF[5]
• HAS-BLED might have been used in the selection of patients who have a contraindication to treatment or who have no indication
o The ABC scoring system is likely more sophisticated
• It can be tailored based on the clinical trial findings that should be done; this is the future direction
 Recommendations can be made based on scores
• A prospective randomized trial is suggested

See photo

Microbiome in weight reduction
Tuesday, September 26, 2017

Overweight individuals whose stool samples were abundant in Prevotella species lost about 2.3 kg more body fat on a 6-month high-fiber diet than individuals with a low ratio of Prevotella to Bacteroides, according to a randomized trial of 62 Danish adults.

The findings help explain why a high-fiber diet does not always produce meaningful weight loss, said Mads F. Hjorth, PhD, of the University of Copenhagen, and his associates. An “abundance of Prevotella” in the gut microbiome might underlie the “recent breakthrough in personalized nutrition,” they wrote in the International Journal of Obesity.

Wednesday, September 27, 2017
There are all sorts of strange and scientific weight loss tricks out there. A new technique developed by researchers at Columbia University and the University of North Carolina might sound pretty crazy but, according to a new study, it actually works. The method uses a microneedle skin patch to deliver a fat-shrinking drug to specific regions that are a bit thicker than desired.
“Our group has previously developed several microneedles patched for different applications, including insulin patch, glucagon, and PD1 patch,” Zhen Gu, patch designer and study co-lead, told Digital Trends. “One day my wife just asked me how about an anti-obesity patch. Meanwhile … our collaborator Doctor Li Qiang contacted me for such a patch also, so we just started.”
Human fat is divided into two types: White fat and brown fat. White fat helps store excess energy in large droplets, while brown fat uses smaller droplets and mitochondria — the powerhouse of the cell — to burn fat and generate heat. The thing is, humans don’t have a whole lot of brown fat once we reach adulthood. Researchers have been attempting to find a method to turn a person’s white fat into brown fat to treat obesity and diabetes, but a clean and effective solution has remained elusive.
“There are several clinically available drugs that promote browning, but all must be given as pills or injections,” Qiang said, the study’s co-lead. “This exposes the whole body to the drugs, which can lead to side effects such as stomach upset, weight gain, and bone fractures. Our skin patch appears to alleviate these complications by delivering most drugs directly to fat tissue.”

Wednesday, September 27, 2017
Drug-induced hepatic injury is likely to be more severe in African Americans than in non-Hispanic whites, according to an analysis of 144 black and 841 white patients. Researchers found:
• Blacks were most likely to develop liver damage from trimethoprim/sulfamethoxazole, when compared to whites (7.6% vs 3.6%).
• Methyldopa and phenytoin were also more likely to cause hepatic injury among blacks (4% vs 1%, and 5% vs <1%, respectively).
• Peak mean bilirubin readings, International Normalized Ratio (INR), and drug-induced liver injury severity scores indicated that hepatic damage was more severe in blacks than whites.
• Investigators also found that severe skin reactions were far more common among blacks (2.1% vs 0.36%).
• Black patients were also more likely to be admitted to the hospital as a result of drug-induced liver damage and experience more liver transplantation and liver-related deaths at 6 months.

Mri elastography
Wednesday, September 27, 2017
• Magnetic resonance imaging proton density fat fraction (PDFF) was compared to steatosis estimates based on histologic analysis by expert pathologists.
• When MRI readings found a reduction in fat fraction of 5.15%, it identified patients with reduced steatosis grade, yielding a sensitivity of 58% and specificity of 98%.
• A PDFF increase of 5.6% detected patients with increased steatosis grade with 57% sensitivity and 90% specificity.

New reflux medication
Friday, September 29, 2017

Vonoprazan fumarate (Takecab) is a first-in-class potassium-competitive acid blocker that has been available in the market in Japan since February 2015. Vonoprazan is administered orally at 20 mg once daily for the treatment of gastroduodenal ulcer, at 20 and 10 mg once daily for the treatment and secondary prevention of reflux esophagitis, respectively, at 10 mg once daily for the secondary prevention of low-dose aspirin- or non-steroidal anti-inflammatory drug-induced peptic ulcer, and at 20 mg twice daily in combination with clarithromycin and amoxicillin for the eradication of Helicobacter pylori. It inhibits H(+),K(+)-ATPase activities in a reversible and potassium-competitive manner with a potency of inhibition approximately 350 times higher than the proton pump inhibitor, lansoprazole. Vonoprazan is absorbed rapidly and reaches maximum plasma concentration at 1.5-2.0 h after oral administration. Food has minimal effect on its intestinal absorption. Oral bioavailability in humans remains unknown. The plasma protein binding of vonoprazan is 80% in healthy subjects.

Thursday, October 5, 2017

Newer antibiotics
Saturday, October 7, 2017
available is delafloxacin (Baxdela), a new fluoroquinolone that won FDA approval in June for acute bacterial skin and skin structure infections (ABSSSI), according to Sue Cammarata, MD, of Melinta Therapeutics in Lincolnshire, Illinois.
Notably, she pointed out, clinical trials of the drug showed potency against both susceptible and resistant bacterial species that was comparable to what was seen with vancomycin/aztreonam. But there was no evidence of some of the side effects of earlier medications in the class, such as tendon rupture or peripheral nerve damage.
Next closest to the clinic is meropenem-vaboractam (Vabomere), which has FDA approval and should be available by the end of October, according to Michael Dudley, PharmD, of The Medicines Company in San Diego.
The novel part of the combination is vaboractam, which Dudley said is the first of a new class of beta-lactamase inhibitors — drugs that block a common resistance mechanism to beta-lactam antibiotics and thereby restore their potency, often without an antibacterial mechanism of their own.
The combination has FDA approval for adults with complicated urinary tract infections (cUTIs) and acute pyelonephritis, Dudley said.
Further away is another beta-lactamase inhibitor, relebactam, which is being tested in combination with the beta-lactam imipenem, according to Amanda Paschke, MD, of Merck & Co. in Kenilworth, New Jersey.
The drug, designed to overcome beta-lactam resistance in Gram-negative pathogens, has shown promise in early-stage trials, including non-inferiority to comparator drugs in the phase II program, and is now in phase III studies, Paschke said.
Omadacycline is the first of a new class — the aminomethylcyclines — that are related to the tetracycylines, according to Paul McGovern, MD, of Paratek Pharmaceuticals in King of Prussia, Pennsylvania.
The company plans to seek approval for the drug early next year after it met all of the FDA and European endpoints in its phase III studies, Dudley said. Omadacycline has two formulations, oral and intravenous, and the company will be seeking indications for community acquired pneumonia and acute bacterial skin and skin structure infections (ABSSSI).
The Phase III trials have shown a “very high clinical efficacy” for the drug compared with standard treatments, he said.
Also new is fosfomycin for injection, according to Evelyn Ellis-Grosse, PhD, of San Diego’s Zavante Therapeutics. An oral fosfomycin, sold as Monurol, is approved for uncomplicated urinary tract infections, but the injectable form is aimed at cUTIs, including acute pyelonephritis.
It’s described as a first-in-class injectable epoxide antibiotic that functions by inhibiting cell-wall synthesis. In phase III studies, Ellis-Grosse said, the drug met the primary endpoint of statistical non-inferiority to piperacillin/tazobactam in patients with cUTIs.
Iclaprim, a diaminopyrimidine dihydrofolate reductase inhibitor, was designed to be more potent than trimethoprim, according to David Huang, MD, PhD, of Motif BioSciences in New York. The company is planning to seek FDA approval next year for ABSSSI, he said, after a phase III trial showed the drug was non-inferior to vancomycin at the early time point and test-of-cure endpoints.
The drug was initially submitted for approval in 2009 by the then-owner of the molecule, Arpida, but was rejected because of concerns over both its safety and efficacy.
Plazomicin, a next-generation aminoglycoside, outperformed its comparators in two phase III trials studying patients with, respectively, cUTIs and carbapenem-resistant Enterobacteriaceae infections, according to Ian Friedland, MD, of Achaogen in South San Francisco.
The drug met the planned non-inferiority margin for efficacy against meropenem in cUTIs and colistin in the CRE infections, but also showed statistical superiority, Friedland reported. The drug’s safety profile was comparable to that of meropenem, but superior to that of colistin, mainly owing to a lower rate of renal events, he said.
The company is hoping to launch the drug in mid-2018.
The pleuromutilin antibiotics were discovered more than half a century ago but have been mostly restricted to animal use since then. Although topical pleuromutilins have been approved for human use, lefamutilin is the first systemic pleuromutilin to be developed for humans, according to Steven Gelone, PharmD, of Nabriva Therapeutics in King of Prussia, Pennsylvania.
It’s currently being evaluated in two phase III trials in patients with community-acquired pneumonia and has shown non-inferiority against moxifloxacin (plus or minus linezolid) in the first of those, Gelone said. Interestingly, he reported, the drug has also shown activity against many sexually transmitted infections, including some that are now resistant to most medications.
Finally, the investigational siderophore cephalosporin cefiderocol has been shown to have efficacy against a range of Gram-negative pathogens and is stable in the face of all know beta-lactamases, according to Roger Echols, MD, of ID3C in Easton, Connecticut, making it useful against many carbapenem-resistant pathogens.
In a phase III trial in patients with cUTIs, with or without pyelonephritis, the drug was non-inferior to high-dose imipenem/cilastatin, Echols said, on a composite primary endpoint of clinical cure and microbiological eradication. But the statistical analys

Tuesday, October 10, 2017

Increased Level of Interleukin 6 Associates With Increased 90-day and 1-year Mortality in Patients With End-stage Liver Disease

Gold criteria COPD
Wednesday, October 11, 2017

before, the guidelines recommend evaluation for COPD in individuals with a history of risk factors or with dyspnea, chronic cough, or sputum production, using a postbronchodilator FEV1/FVC < 0.70 cutoff for diagnosis. In addition to family history, risk factors from childhood include low birthweight and childhood respiratory infections. Other risk factors include exposure to tobacco smoke, home cooking or heating fuels smoke, and occupational dusts, vapors, fumes, gases, and other chemicals.

recent comprehensive review provides some answers.[1] The investigators analyzed the results of 18 trials that compared fixed combinations of a long-acting beta-agonist/long-acting muscarinic antagonist (LABA/LAMA) with LAMA monotherapy. The LABAs included indacaterol, vilanterol, formoterol, salmeterol, or olodaterol; the LAMAs included glycopyrronium, umeclidinium, tiotropium, or aclidinium. Fluticasone was the inhaled corticosteroid (ICS) when a corticosteroid was a component.
The FEV1 as measured after 12-52 weeks was significantly greater with the LABA/LAMA combination than with LAMA monotherapy. Similarly, the LABA/LAMA combination yielded greater improvements in lung function than a LABA/ICS combination. In general, the improvements seen with fixed LABA/LAMA combinations were of meaningful magnitude, with the exception being those combinations that included aclidinium.

In fact, mepolizumab reduced exacerbations by about 20% overall in patients with high-risk eosinophilic COPD who were receiving optimal standard-of-care treatment.
However, in patients with blood counts of at least 300 eosinophils/mm³ — which are levels seen in those with severe asthma — exacerbations were decreased by at least 38%. This reduction is comparable to that seen in patients with asthma treated with the humanized anti-interleukin (IL)-5 monoclonal antibody.

Non invasive ventilator
Wednesday, October 11, 2017
Initial IPAP/EPAP settings are as follows:
• Start at 10 cm water/5 cm water
• Pressures less than 8 cm water/4 cm water not advised as this may be inadequate
• Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP and/or EPAP)
Subsequent adjustments based on arterial blood gas values are as follows:
o Increase IPAP by 2 cm water if persistent hypercapnia
o Increase IPAP and EPAP by 2 cm water if persistent hypoxemia
o Maximal IPAP limited to 20-25 cm water (avoids gastric distension, improves patient comfort)
o Maximal EPAP limited to 10-15 cm water
o FIO 2 at 1.0 and adjust to lowest level with an acceptable pulse oximetry value
o Back up respiratory rate 12-16 breaths/minute
Pressure control (PC) and average volume assured pressure support (AVAPS) ventilation

Predictors of success, with a response to a trial of NIV (1-2 h), are as follows:
• Decrease in PaCO 2 greater than 8 mm Hg
• Improvement in pH greater than 0.06
• Correction of respiratory acidosis
Predictors of failure are as follows:
• Severity of illness – Acidosis (pH <7.25), hypercapnia (>80 and pH <7.25), Acute Physiology and Chronic Health Evaluation II (APACHE II) score higher than 20 • Level of consciousness – Neurologic score (>4 = stuporous, arousal only after vigorous stimulation; inconsistently follows commands), encephalopathy score (>3 = major confusion, daytime sleepiness or agitation), Glasgow Coma Scale score lower than 8
• Failure of improvement with 12-24 hours of noninvasive ventilation

Some noninvasive ventilation is provided using proportional-assist ventilation (PAV), which provides flow and volume assistance with each breath. Clinical trials have not demonstrated a significant difference between PAV

Ocaliva deaths
Friday, October 13, 2017

the 13 months after obeticholic acid (Ocaliva) was approved in May 2016, 19 patient deaths were reported to the FDA, the agency said Thursday, at least some of which appeared to stem from doses higher than recommended on the drug’s label.

Triple T2D Rx
Sunday, October 15, 2017

The addition of dapagliflozin/saxagliptin (Qtern, AstraZeneca) to metformin (DAPA/SAXA-MET) resulted in a 1.4% decrease in glycated hemoglobin A1c (HbA1c) from baseline to week 26, which was 0.3% more than the 1.1% drop seen when sitagliptin (Januvia, Merck) was added onto metformin (SITA-MET; P less than .008).

Pancreatitis enhanced care
Tuesday, October 17, 2017
Patients recruited for the trial were admitted directly from an emergency department and received either enhanced care consisting of patient-directed oral intake, early ambulation, and nonopioid analgesia or received normal care consisting of opioid analgesia, physician-directed diet, and nursing parameters, Elizabeth Dong, MD, of the Kaiser Permanente Los Angeles Medical Center and her associates said.

Among the 46 patients included in the study, 61% had an etiology of gallstones, 15% had an etiology of alcohol, 13% had hyperglyceridemia, and 11% had a different etiology. Median age was 53.1 years, Dr. Dong and her associates noted.

Time to successful oral refeeding, the primary study endpoint, was significantly reduced in the enhanced treatment group, with a median time of 13.8 hours, compared with the normal treatment group, in which median time to oral refeeding was 124.8 hours. In addition, patients in the enhanced care group had a mean pancreatitis activity score of 43.5 after 48-72 hours, while patients in the control group had a mean score of 72.1.

Length of stay and frequency of 30-day readmission did not differ significantly between study groups.

Colonoscopy Benadryl
Tuesday, October 17, 2017

Results from a randomized, double-blind study of more than 100 patients indicated that, compared with placebo, add-on diphenhydramine significantly improved mean sedation scores as assessed separately by physicians (mean 6.2 versus 5.3 on a scale of 1-7; P=0.0002) and nurses (5.6 versus 5.1; P=0.04), reported Salman Nusrat, MD, of Oklahoma Health Sciences Center in Oklahoma City.

Electronic nose Barrett’s
Tuesday, October 17, 2017

A noninvasive “electronic nose” device that analyzes exhaled volatile organic compounds showed promise as a screening tool for Barrett’s esophagus, a researcher reported here.

Sudden death
Tuesday, October 17, 2017

Although we consider sudden cardiac death as death within 24 hours of last being seen healthy or within an hour of symptom onset and assume that these are cardiac, what the researchers found was that about 40% of the deaths were actually noncardiac; about 5%were neurologic. It allows us to challenge the idea that all of these sudden deaths are of cardiac origin.

we are talking about sudden unexplained death in epilepsy (SUDEP) that has gone underappreciated. Many deaths are due to drug use (eg, the opioid epidemic). Just because you die within 24 hours from being previously presumed healthy does not mean it is the heart.

We get tunnel vision and we prematurely and erroneously conclude that it must be the heart at fault, or it must be the heart because of coronary artery disease. We continue to invoke these reflexive reactions rather than asking, “Do we really understand what is killing people, whether they are 65 or 15?”

Tuesday, October 17, 2017

NSAIDs, other substances being investigated as risk factors for exertional rhabdomyolysis include alcohol, creatine, caffeine, and some anesthetics. Viral and bacterial infections may also increase the risk. And triggers for rhabdomyolysis could vary with genetic susceptibility.[4]

The Netherlands, have estimated that mutations in the skeletal muscle ryanodine receptor gene (RYR1) could account for up to 30% of rhabdomyolysis in otherwise healthy individuals.[4]

Tuesday, October 17, 2017

Dietary fructans exacerbate symptoms in some, but not all, adults with irritable bowel syndrome (IBS). We sought to determine whether fructans worsen symptoms in children with IBS and whether clinical and psychosocial factors, and/or gas production, can identify those who are fructan sensitive.

Mealtime insulin
Tuesday, October 17, 2017
The FDA has approved Fiasp (insulin aspart injection) 100 units/mL, a fast-acting mealtime insulin indicated to improve glycemic control in adults with type 1 and type 2 diabetes, available from Novo Nordisk, Plainsboro NJ.
Indications: Fiasp is a rapid-acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus.
Dosage/administration: Can be dosed at the beginning of a meal or within 20 minutes after starting a meal. Individualize and adjust dosage based on route of administration, individual’s metabolic needs, blood glucose monitoring results, and glycemic control goal.
Adverse reactions: Adverse reactions include hypoglycemia, allergic reactions, hypersensitivity, injection site reactions, lipodystrophy, and weight gain.

Supragastric bloating
Wednesday, October 18, 2017

Behavioral therapy and baclofen have shown promising results in patients with predominant belching. The role of therapy for patients with SGB-associated reflux symptoms or dysphagia is under current investigation.

Excessive SGB was defined as > 13 per 24 hours. We identified 100 patients with excessive SGB. Ninety-five percent of these patients suffered from typical reflux symptoms, 86% reported excessive belching, and 65% reported dysphagia. Forty-one percent of patients with excessive SGB had pathological acid reflux. Compared to the patients with normal acid exposure these patients trended towards a higher number of SGB episodes. Forty-four percent of patients had esophageal hypomotility. Patients with hypomotility had a significantly higher frequency of SGB compared to those with norm

Posterior Circ stroke
Thursday, October 19, 2017

Eye movement better than CT or MRI

He and his colleagues have developed a way to detect posterior fossa strokes using eye movement abnormalities. They call it HINTS, which stands for “head impulse, nystagmus, and test of skew. “It turns out that the eye movements of inner ear disease look slightly different than the eye movements of brain disease; the subtle differences are enough to distinguish between the two.” When the technique is mastered, “our best estimate is that the sensitivity for posterior circulation stroke is around 99%,” Dr. Newman-Toker said. He is working to get the message out and train people

Probiotics for Gastrointestinal Conditions
Thursday, October 19, 2017

Amyloid blood test
Sunday, October 22, 2017

It measures the ratio of amyloid-beta 42 to amyloid-beta 40; the numbers refer to how many amino acids are in the proteins. In healthy individuals, the ratio is “remarkably consistent, but when beta-42 starts to stick to plaques in the brain, it doesn’t get out into the blood, and the ratio drops; that’s what we are detecting.” It’s highly accurate in both “Alzheimer’s patients and people who are completely normal who have amyloid plaques in their brains,” said Randall Bateman, MD, a professor of neurology at Washington University, St. Louis.

Monday, October 23, 2017

In patients diagnosed with confirmed hyperammonemia at baseline, the new treatment, ornithine phenylacetate (OCR-002), lowered ammonia levels faster and led to faster clinical improvement compared with placebo, with a 21-hour median reduction in time to improvement (P=0.034), reported Robert Rahimi, MD, of the Baylor University Medical Center in Dallas, and colleagues in a poster presentation at at the Liver Meeting, the annual conference of the American Association for the Study of Liver Diseases.

Gut and breast cancer
Monday, October 23, 2017

New Study Shows Link Between Gut Bacteria And Breast Cancer

Tuesday, October 24, 2017
The more common form in the United States and the one associated with concurrent IBD is type 2, also known as idiopathic duct-centric chronic pancreatitis, which focuses locally on the pancreas. “Typically it is younger patients who get this in their 30s or 40s, and it affects men and women equally,” said DiMaio, who recently compiled an overview of AIP. “Type 2 patients usually present with symptoms of acute pancreatitis.”
Associated IBD, in fact, is one of the diagnostic criteria for type 2 AIP, in contrast to type 1, the more classic form, which is a wide-ranging systemic immunoglobulin G 4 (IgG4)-related disease. “Type 1 is male-predominant and strikes older men in their 60s and 70s,” DiMaio said. “As a hallmark, 90% of patients with type 1 AIP will have elevated serum IgG4 levels, whereas in type 2, blood tests are normal.”
Type 1 may feature the autoimmune involvement of other organs, including the bile ducts, salivary glands, kidneys, and lymph nodes; one of DiMaio’s recently diagnosed type 1 AIP patients also had vitiligo and Hashimoto’s thyroiditis, for example.
Both types respond well to short-term steroid therapy, but relapses may require longer treatment with immunomodulators.
Type 1 symptoms — obstruction, jaundice, weight loss — mimic those of pancreatic cancer, so careful diagnosis is paramount: “We have to be thoughtful on the differential. Pancreatic cancer is much more common than AIP, so have a high suspicion for cancer.”
So far, data on whether AIP increases the risk of pancreatic or other cancers are conflicting, and researchers point to the need for well-designed multicenter trials to clarify whether AIP patients are in fact more susceptible.
Studies of IBD-related AIP are few. The largest series to date was published this year by French researchers led by Diane Lorenzo, MD, of the Hopital Cochin in Paris. The team analyzed phenotypes and outcomes in a multicenter retrospective cohort of French and Belgian IBD patients who also had AIP during the period 2012-2015.
About two-thirds of IBD-AIP patients in the study were found to have ulcerative colitis, often with proctitis, while one-third had Crohn’s disease, often with inflammatory features. Patients with IBD and AIP tend to have higher rates of colectomy than those with IBD alone.
Of the cohort’s 91 individuals who had both IBD and AIP (47 women), 58 had ulcerative colitis and 33 had Cohn’s disease. A total of 89 patients had type 2 AIP, while just two had type 1 AIP. The mean age at diagnosis of IBD was 32 and for AIP, 35, but in 19 patients (21%), surprisingly, AIP diagnosis preceded that of IBD.
Over a mean follow-up period of 5.7 years, 31 patients (34%) relapsed, 11 (12%) became diabetic, and 17 (19%) developed exocrine pancreatic insufficiency.

Genes causing NAFLD
Tuesday, October 24, 2017

On initial analysis, 21 genetic loci met the criteria for genome-wide significant association; specifically, investigators successfully replicated three key variants that have been previously seen associated with NAFLD – PNPLA3, ERLIN1, and TRIB1.

Wednesday, October 25, 2017

Opdivo induces colitis

Tick borne
Wednesday, October 25, 2017
Anaplasmosis was once known as human granulocytic ehrlichiosis (HGE).

More recently, the ailment has been officially known as human granulocytic anaplasmosis (HGA).

According to the CDC, anaplasmosis is primarily spread to humans by bites from the black-legged tick and the western black-legged tick.

These are the same ticks that also spread Lyme disease.

The disease usually appears one to two weeks after a tick bite.

The symptoms include fever, headache, chills, and muscle aches.

Those symptoms are also similar to Lyme disease, although experts say Lyme disease can have more serious long-term effects.

With anaplasmosis, however, there is no telltale rash that appears, so it can be more difficult to diagnosis.

Anaplasmosis is usually treated with doxycycline…

IBD and fungi plus bacteria
Thursday, October 26, 2017
Fungi and bacteria in the gastrointestinal tract collaboratively form biofilms that may exacerbate inflammation in patients with inflammatory bowel disease (IBD), a review article concluded.
MD-IQ QUIZ: Evaluating constipation disorders
In particular, the investigators found patients with Crohn’s disease (CD) had higher levels of the fungus Candida tropicalis, and of two bacteria, Escherichia coli and Serratia marcescens, compared with healthy family members.

Furthermore, these three organisms “worked together to form robust biofilms capable of exacerbating intestinal inflammation,” wrote authors Christopher L. Hager, MD, and Mahmoud A. Ghannoum, PhD, of the center for medical mycology at Case Western Reserve University, Cleveland, and University Hospitals Cleveland Medical Center.

This “interkingdom interaction” suggests a potential role for antifungals combined with probiotics as a treatment strategy for patients with IBD, they said in their review article discussing both their own studies to date and those by other research groups.

“These studies clearly demonstrate that mycobiome/bacteriome interactions play an important role in the perpetuation of GI inflammation,” they wrote (Dig Liver Dis. 2017 Nov;49[11]:1171-6). “Not only have we shown that fungi are important for overall GI tract health, we have also shown that overgrowth of the fungus due to imbalance has deleterious effects on the gastric mucosa.”

Dr. Ghannoum and his colleagues first highlighted the importance of the mycobiome in a 2010 study that used deep sequencing to characterize the human oral fungal community (PLOS Pathogens. 2010 Jan 8. doi: 10.1371/journal.ppat.1000713). They found that humans were colonized with Candida, as was expected, but also with species including Aspergillus, Cryptococcus, and Fusarium, which was unexpected, Dr. Hager and Dr. Ghannoum wrote in their review.

In their more recent work, Dr. Ghannoum, Dr. Hager, and their coinvestigators compared CD patients with their healthy relatives and found increased levels of E. coli, S. marcescens, and the fungus C. tropicalis in the gastrointestinal tract (mBio. 2016 Sep 20. doi: 10.1128/mBio.01250-16). In vitro, those three organisms cooperate to form biofilms that could activate the host immune response, they said.

“These findings suggest a possible role of these pathogenic organisms in the initiation and perpetuation of chronic intestinal inflammation, such as that observed in patients with inflammatory bowel disease,” they wrote. “Not only has this opened up the possibility of new therapeutic approaches in patients with IBD (i.e., antifungals/antibiotics), it has also paved the way for groundbreaking research on probiotic development aimed at disrupting GI biofilm formation, thus ending a vicious cycle of chronic intestinal inflammation.”

Developing new probiotic therapies that leverage mycobiome-level observations could help overcome some limitations of current treatment options for IBD, such as biologic therapies and antibiotics, the authors wrote.

Biologics can block immune pathways implicated in mucosal inflammation and lead to potentially deleterious secondary infections, they explained. Likewise, antibiotics can be effective in controlling inflammatory symptoms but raise the concern of potentially increasing antibiotic resistance.

Although new probiotic research could provide a new avenue of treatment, development of clinical studies could be limited in part, they said, because probiotics are considered to be food supplements rather than drugs regulated by the Food and Drug Administration.

“Conducting such trials is challenging due to the lack of funding, leaving companies with very little impetus to perform long, expensive, placebo-controlled studies,” the authors wrote.

Opdivo. nivolumab
Thursday, October 26, 2017

Causes colitis

EoE patients 9 x more likely to have celiac
Friday, October 27, 2017

HBV Marker
Friday, October 27, 2017
HBcrAg exhibited good correlation with intrahepatic (ih) cccDNA, ih total hepatitis B virus (HBV) DNA, serum HBV DNA and to a lesser extent HBV surface antigen (HBsAg). In situations where serum HBV DNA levels become undetectable or HBsAg loss is achieved, HBcrAg can still be detectable. This marker is helpful in differentiation of HBeAg-negative chronic hepatitis from HBeAg-negative chronic infection, predicting spontaneous or treatment-induced HBeAg seroconversion, sustained response to nucleos(t)ide analogue (NA), risk of HBV reactivation in occult HBV infection under immunosuppressive therapies, and risk of hepatocellular carcinoma (HCC) development as well as post-operative HCC recurrence.
CONCLUSIONS: HBcrAg is a potential surrogate marker of cccDNA. It may soon become a useful marker for disease monitoring, predicting treatment response and disease outcome of chronic hepatitis B.

Saturday, October 28, 2017

Obesity week
Sunday, October 29, 2017

Sleeve leaks
E vac
Suturing 60% effective
Immediate post op – Gj Bleed do not use cautery.
Stent for VSG leak. Partially covered leaks
Glues plugs do not work well for endoscopic closure
Injection works by tamponade around vessel
Avoid thermal at anastomitic ulcer due to thin jejunum if acute post op. Chronic can use
Dilation. CRE IS better
Dilate after 2-4 weeks of surgery
Best results if dilated in3 months after surgery
Salivary flow prevents healing leaks. Stent it
Delayed leak : do intra gastric pig tail to manage the abscess or pig tail with septeptomy using hook

Anastomotic ulcers are from

Revisional endoluminal therapy for recidivism
20% gain above nadir weight loss ( peaks 2 years )
Under reported
BMI more than 50 20% failures rate
Reasons : GJ stoma diameter is risk factor
Pouch more than 6 cm long or diameter more than 5 cm
Stoma more than 2 cm

Look for gastro gastric fistula

Inject anastomosis with sodium morrhuate to decrease luminal side
Stabilize weight regain
Use it in patients who have significant weight gain
Use repeatedly


Late dumping syndrome :

Purse string better than interrupted technique

Single or double balloon or capsule balloon. Use 3 ( 2 weeks apart each. Use flouriscopy, dummy capsule )
Single ballloon. Use 600 cc. To remove puncture balloon and pull out
Complication : nausea pain reflux migration or obstruction death reported
Can cause pancreatitis
Migration into SB
If ballloon ruptures causes blue / green urine
Microbiofilm on balloon – fungi. Be careful removing balloon
No difference in success of single or double balloon
7 deaths. 4 from outside USA


Greater curvature might be better than anterior but more complications

POSE , endomina or overstitch
POSE not approved in USA
Primary obesity surgery endoluminal

Endomina 14 % weight loss

Overstitch includes fungus unlike VSG
18-65 age.
No cancer family
No cirrhosis or smokers
Causes nausea and pain
Start PPI a week before
Manage constipation
If more than 10% weight loss at 6 months successful. Enduring at 2 years
Use VSG for DM
300 cal causes satiation. Pre esg was 1000

VSG 30% ESG 18 and lap band 14%


Place PEG : aspirate food after 20 min of eating

Changes eating behavior by forcing them to chew longer

Magnetic anastomoses for enteral diversion

Two magnets in SB and then in TI. Creates fistula.
Endoscopic enteral diversion

If anastomoses ulcer use light APC before suturing stoma after bypass

Duodenal mucosal resurfacing. Works well for NASH

ESG need 35 cases to do it under an hour

Fundamentals of endoscopy curriculum

Associaton of bariatric endoscopy

GI mentor two

Competency and credentialing are different things

Gut bacteria in IBS
Friday, January 12, 2018
8:05 PM

PPI and gastric cancer
Tuesday, October 31, 2017
Use of a proton-pump inhibitor (PPI) after Helicobacter pylori eradication more than doubles the risk for gastric cancer, according to a population-based study from Hong Kong.
The “clear dose-response and time-response” trend in PPI use and gastric cancer risk observed suggests the need for “caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori,” write Wai Keung Leung, MBChB, MD, from Queen Mary Hospital, Hong Kong, and colleagues.

Wednesday, November 1, 2017
Varubi is a substance P/neurokinin 1 receptor antagonist indicated in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including highly emetogenic chemotherapy.
Dosage and administration:
• Tablets: 180 mg as a single dose.
• Injectable emulsion: 166.5 mg administered as an intravenous infusion over 30 minutes.
Efficacy and safety: Approval is based on results from 3 phase 3 studies showing superiority with Varubi when used with highly- and moderately- emetogenic chemotherapy regimens.

Dissolve fat in arteries. Diabetes drug
Thursday, November 2, 2017

But what if there was a drug that could reverse that dangerous buildup of fatty material and simply ‘melt’ it away from the walls of our arteries?
This type of drug – which honestly sounds a little too good to be true – could be more of a reality than we imaged after new trials at the University of Aberdeen found that diabetes drug Trodusquemine, could do exactly that.

Tryptophan deficiency leads to. IBD
Friday, November 3, 2017

development of IBD. Studies are needed to determine whether modification of intestinal tryptophan pathways affects [its] severity,” they wrote.

Several small case series have reported low levels of tryptophan in IBD and other autoimmune disorders, the investigators noted. Removing tryptophan from the diet has been found to increase susceptibility to colitis in mice, and supplementing with tryptophan or some of its metabolites has the opposite effect. For this study, the researchers used high-performance liquid chromatography to quantify tryptophan levels in serum samples from 535 consecutiv

Protective gut bacteria
Friday, November 3, 2017
Akkermansia muciniphila, a species associated with the gut’s mucus lining that may protect against obesity and diabetes. When germ-free mice with no gut bacteria received fecal transplants from responders, they did better on PD-1 blockers than did mice given nonresponder feces. And poorly responding mice could be turned into responders by feeding them A. muciniphila.

The gut microbiome also matters in melanoma patients receiving PD-1 blockers, a team led by Jennifer Wargo of MD Anderson Cancer Center in Houston, Texas, reports in the other paper: Responders had a more diverse microbiome and more of specific bacteria. Her group also found that giving mice fecal transplants from patients who did or did not respond to the drugs led to similar outcomes in the animals.

Travelers diarrhea.
Friday, November 3, 2017

The most widely studied probiotic in the analysis was Lactobacillus reuteri, used in six of the studies with a total of 405 randomized patients. The next most commonly studied agent was Lactobacillusrhamnosus GG, the focus of four studies and tested in a total of 270 randomized patients. Both microbes showed statistically significant and clinically meaningful levels of pain reduction when compared with placebo in subgroup analyses, said Dr. Morris, who performed the meta-analysis as a CochraneReview Groups systematic review.

Viral or bacterial infection
Monday, November 6, 2017

The test works by placing a spot of blood on a card. Within 15 minutes, lines appear on a display panel, indicating whether a virus or bacterial infection is present.

The card tracks the levels of two proteins – C-reactive protein, a marker of bacterial infection, and myxovirus resistance protein A, which appears when there is a viral infection.

Anti atherosclerotic?
Tuesday, November 7, 2017

Increases in blood lipids have been a nagging problem for rheumatology drugs targeting interleukin-6, including the market leader tocilizumab (Actemra). Now, developers of a new anti-IL-6 drug are making a bold claim: that the lipid changes it induces may actually inhibit atherosclerosis development.

Thursday, November 9, 2017
• Investigators reviewed 43 randomized trials that included >166,000 patients.
• On average NOACs were no more likely to cause major bleeding, clinically relevant nonmajor bleeding, upper GI bleeding, or lower GI bleeding than conventional drugs.
• However, dabigatran posed a greater risk of major GI bleeding when compared to conventional agents (2.0% vs 1.4%).
• Rivaroxaban likewise increased the risk of major GI bleeding (1.7% vs 1.3%).
• Apixaban and edoxaban did not pose an increased risk, when compared to conventional anticoagulants.

NOAC doac
Thursday, November 9, 2017

DILI biomarkers
Thursday, November 9, 2017
The motivation behind this research is that the standard biomarkers for DILI have several shortcomings,” Dr. Church said. “They’re not entirely liver specific, they’re not mechanistically informative, and they’re not sufficiently predictive of outcome.”

The researchers found that elevated levels of these six candidate biomarkers were predictive for adverse outcome in DILI: total keratin18 (K18); caspase-cleaved K18 (ccK18); alpha-fetoprotein (AFP); osteopontin (OPN); fatty acid–binding protein 1 (FABP1); and macrophage colony-stimulating factor receptor (MCSFR) determined by immunoassay. “We believe that using some of these candidate biomarkers in combination with the standard tests may be the best way to identify individuals at risk for an adverse outcome,” Dr. Church said.

While their analysis found that the traditional international normalized ratio had the overall best predictive value, measured as area under the curve (AUC) of 0.922, the candidate biomarker OPN was second best with an AUC of 0.871, “and actually performed better than total bilirubin,” Dr. Church said.

The study evaluated mechanistic candidate biomarkers by obtaining biopsies in a cohort of 27 patients within 2 weeks of diagnosis, focusing on three physiological reactions: inflammation, necrosis, and apoptosis.

With regard to inflammation, Dr. Church said, “What we found was that MCSFR actually was significantly elevated in patients who had a high score for inflammation; however, there was no significant difference in OPN, although there was a slight elevation.”

They evaluated necrosis using a semiquantitative confluent coagulative necrosis score, and found no difference in the typical biomarkers of cell necrosis, such as alanine transminase, aspartate aminotransferase, and K18. “So we also looked at the regenerative biomarkers, OPN and AFP, and indeed, we observed that both were significantly elevated with high confluent coagulative necrosis scores,” she said.

To evaluate apoptosis, the researchers used the semiquantitative apoptosis score. “We found there was a small but significant elevation in ccK18 in individuals with a high apoptosis score,” she said. They then evaluated the ratio of ccK18 to K18. “The closer the score is to 1, the more apoptosis you have; and the closer the score is to 0, the more necrosis you have,” Dr. Church said.

They also developed a predictive model that combined the traditional biomarkers INR, total bilirubin, and aspartate aminotransferase with the candidate biomarkers OPN and K18, which had an AUC of 0.97. “Some analysis of candidate biomarkers in combination with tests such as MELD score [Model for End-Stage Liver Disease] and ‘Hy’s Law’ saw that incorporating candidate biomarkers was useful,” Dr. Church said.

Simethicone for bowel prep
Thursday, November 9, 2017

The primary outcome was ADR; secondary outcomes were quality of bowel preparation, measured by the Boston bowel preparation scale (BBPS) and bubble scores. Results 583 patients were included. More adenomas were detected in the PEG plus simethicone group than in the PEG alone group (ADR 21.0 % vs. 14.3 %, P = 0.04; advanced ADR 9.0 % vs. 7.0 %, P = 0.38). The mean number of adenomas detected was 2.20 ± 1.36 vs. 1.63 ± 0.89 (P = 0.02). Patients in the PEG plus simethicone group showed better bowel cleansing efficacy: BBPS ≥ 6 in 88.3 % vs. 75.2 % (P<0.001) and bubble scores of 1.00 ± 1.26 vs. 3.98 ± 2.50 (P<0.001). Abdominal bloating was reported less frequently in the PEG plus simethicone group (7.8 % vs. 19.7 %, P<0.001) than in the PEG alone group. Conclusion Combined use of PEG and simethicone is associated with a significantly increased ADR in a Chinese population.Clinical trials registration number:

Thursday, November 9, 2017

Fibroblast growth factor 21 (FGF21), a nonmitogenic hormone, improved fibrosis, liver injury, and steatosis in patients with nonalcoholic steatohepatitis (NASH), according to a study presented at the American Association for the Study of Liver Disease’s annual meeting.

Pro-C3 levels dropped

Thursday, November 9, 2017
• The Hemoccult II SENSA, a HS-gFOBT, was compared to the InSure FIT and OC-FIT-CHEK.
• InSure FIT generated the highest sensitivity rating, 26.3%.
• OC-FIT-CHEK had a sensitivity of 15.1%
• Hemoccult II SENSA had a sensitivity of 7.4%.
• The sensitivity of InSure FIT was significantly better than OC-FIT-CHEK.
• Specificity for all 3 tests was relatively high (96.8% and 98.6%).

Hepatorenal criteria
Friday, November 10, 2017
The International Ascites Club5 has provided diagnostic criteria for hepatorenal syndrome:
• Cirrhosis and ascites
• Serum creatinine greater than 1.5 mg/dL
• Failure of serum creatinine to fall to less than 1.5 mg/dL after at least 48 hours of diuretic withdrawal and volume expansion with albumin (recommended dose 1 g/kg body weight per day up to a maximum of 100 g per day)
• Absence of shock
• No current or recent treatment with nephrotoxic drugs
• No signs of parenchymal kidney disease such as proteinuria (protein excretion > 500 mg/day), microhematuria (> 50 red blood cells per high-power field), or abnormalities on renal ultrasonography.

Friday, November 10, 2017

  1. What is the classic pathologic finding in HCV kidney disease?
    • Focal segmental glomerulosclerosis
    • Crescentic glomerulonephritis
    • Membranoproliferative glomerulonephritis
    • Membranous glomerulonephritis
    What laboratory finding is often seen in membranoproliferative glomerulonephritis?
    • Positive cytoplasmic antineutrophil cytoplasmic antibody
    • serum complement Low levels
    • Antiphospholipase A2 receptor antibodies
    Cytoplasmic antineutrophil cytoplasmic antibody is seen in granulomatosis with polyangiitis, while antiphospholipid A2 receptor antibodies are seen in idiopathic membranous nephritis.
    Low serum complement levels are frequently found in membranoproliferative glomerulonephritis. It is believed that immune complex deposition leads to glomerular damage through activation of the complement pathway and the subsequent influx of inflammatory cells, release of cytokines and proteases, and damage to capillary walls. When repair ensues, new mesangial matrix and basement membrane are deposited, leading to mesangial expansion and duplicated basement membrane.14
    In cryoglobulinemic membranoproliferative glomerulonephritis, the complement C4 level is often much lower than C3, but in noncryoglobulinemic forms C3 is lower. A mnemonic to remember nephritic syndromes with low complement levels is “hy-PO-CO-MP-L-EM-ents”; PO for postinfectious, CO for cryoglobulins, MP for membranoproliferative glomerulonephritis, L for lupus, and EM for embolic.

Post op IBD
Friday, November 10, 2017

Alvimopan, an oral peripherally acting mu-opioid receptor antagonist, decreased postoperative ileus after major abdominal surgery among patients with inflammatory bowel disease (IBD), researchers reported here.

HBV vaccine
Friday, November 10, 2017

Heplisav B vaccine approved

Anal cancer
Saturday, November 11, 2017
Risk factors for anal cancer include any of the following, with combinations of two or more factors posing particular risk:
• Active HPV infection
• Smoking
• Men having sex with men
• Anoreceptive sex
• Immunosuppression, with a correlation with low T-cell counts
• HIV infection
• Organ transplantation

Patients with anal cancer or its precursor lesion, anal intraepithelial neoplasia, may be asymptomatic or may present with a wide range of symptoms, including the following:
• Anal or pelvic pain and anal bleeding (approximately one half of patients)
• Sensation of rectal mass (approximately 30%)
• Local wetness and irritation
• Prolapse of tissue
• Incontinence of flatus or liquid or solid stool
• Obstipation

Follow-up in patients with a history of anal cancer should include the following:
• DRE and inguinal palpation every 3-6 months for 5 years
• Anoscopy every 6-12 months for 3 years
• Chest/abdominal/ pelvic CT annually for 3 years

Alcohol cancer
Sunday, November 12, 2017

Several leading cancers — including those of the breast, colon, esophagus, and head and neck — are linked with alcohol use.

Gut bacteria NEJM
Monday, November 13, 2017
Compared to lean mice, obese mice have a 50 percent reduction in organisms called Bacteroidetes and a proportional increase in Firmicutes, and lean mice get fat when given fecal transplants from obese mice. A similar shift has been observed in people, and the distorted ratio of organisms was shown to reverse in people who lose weight following bariatric surgery.
There is also evidence that microbes residing in the gut can affect distant sites through their influence on a person’s immune responses. This indirect action has been suggested as a possible mechanism behind rheumatoid arthritis. In mice, certain bacteria in the gut have been shown to foster production of antibodies that attack the joints, resulting in the joint destruction typical of rheumatoid arthritis.
Similarly, studies have suggested a role of the gut microbiota in the risk of developing neuropsychiatric illnesses like schizophrenia, obsessive-compulsive disorder, attention deficit hyperactivity disorder, autism and even chronic fatigue syndrome. Researchers have suggested that in genetically susceptible people, altered microbes in the gut may disrupt the blood-brain barrier, leading to the production of antibodies that adversely affect normal brain development.

BP guidelines 2017
Monday, November 13, 2017

n patients with diabetes and either a urine albumin-to-creatinine ratio ≥300 mg/g creatinine or 30 to 299 mg/g creatinine, the recommended first-line treatment for hypertension is an ACE inhibitor or ARB at the maximum tolerated dose for BP treatment. In the event that 1 drug class is not tolerated, the other should be substituted. Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored in patients treated with an ACE inhibitor, ARB, or diuretic.

Goal 120 or less. Avoid diastolic less than 60. Check while sitting

Management of DOAC
Monday, November 13, 2017

Wheat – fructan not gluten
Tuesday, November 14, 2017
Fructan is a type of carbohydrate found in wheat and also in other foods such as onions, garlic and some other vegetables. Prior research has found a possible link between fructan and symptoms of irritable bowel syndrome. Because of that, the researchers wondered if it might be behind some other less-problematic digestive problems. To find out, they enlisted the assistance of 59 people who had self-diagnosed themselves with gluten intolerance—each was given muesli bars to eat over the course of several weeks and to write down any symptoms they experienced. Some of the bars had gluten, some had fructan and some had neither.
Afterward, the researchers studied the records kept by the volunteers and found that they experienced the familiar bloating only when eating the bars with fructan—they were fine when eating the controls and the bars with gluten. This, the researchers contend, suggests that it is fructan, not gluten that is causing widespread bowel problems. This is an important distinction, they also note, because some recent research has found that people who put themselves on a gluten-free diet may be at an increased risk of developing type 2 diabetes.
More information: Gry I. Skodje et al. Fructan, Rather Than Gluten, Induces Symptoms in Patients With Self-reported Non-celiac Gluten Sensitivity, Gastroenterology (2017). DOI: 10.1053/j.gastro.2017.10.040

Travelers diarrhea
Tuesday, November 14, 2017

Aemcolo – a broad spectrum, semi-synthetic, orally administered, minimally absorbed antibiotic – is intended to treat patients with travelers’ diarrhea. The tablet is manufactured with the Company’s Multi Matrix MMX technology, designed to deliver active pharmaceuticals into the lumen in a delayed fashion that applies the ingredients to the full length of the colon.

NAFLD and cancer
Thursday, November 16, 2017
Nonalcoholic fatty liver disease (NAFLD) was tied to an increased risk of hepatocellular carcinoma (HCC), colorectal cancer in men, and breast cancer in women, South Korean researchers found.
Adjusted results from an observational meta-analysis of a cohort of 25,947 patients showed that after a median follow-up of 7.5 years, the cancer incidence rate was 782.9 per 100,000 person-years in 8,721 patients (33.6%) with NAFLD compared with 592.8 per 100,000 person-years in those without NAFLD (hazard ratio 1.32, P<0.001), according to Gi-Ae Kim of the University of Ulsan College of Medicine in Seoul, and colleagues.

HCV resistance
Thursday, November 16, 2017

A30K using voselvi 78% response rate IN GT 3
Mavyret requires 16 weeks in that situation

FIB-4 more than 3.25 is advanced liver diseases

Pancreatic cyst evaluation
Thursday, November 16, 2017

The LSS probe, which piggybacks onto the EUS-FNA procedure and goes into the mouth and down into the small intestine to rest next to the pancreas, detects the structural changes that occur in cancerous or precancerous cells by bouncing light off tissues and analyzing the reflected spectrum. The researchers intend to eventually be able to undertake in real time an assessment of cysts while the LSS procedure is being performed. The assessment can be completed in a matter of seconds to minutes. In the study, the assessment was performed post procedure by the team, which assessed the LSS results.

experimental light-scattering spectroscopy (LSS) evaluated the malignant potential of 27 cystic lesions from 25 patients in a double-blind comparison with either postoperative histopathology or survival outcomes and achieved 95% accuracy (95% confidence interval, 78% – 99%).

IBD surveillance
Thursday, November 16, 2017

The SCENIC nomenclature uses a modification of the Paris classification system31 and primarily classifies lesions as visible or invisible and as endoscopically resectable or not. Visible lesions can be further characterized as polypoid (sessile or pedunculated), which protrude by 2.5 mm or more into the lumen, and nonpolypoid (flat or depressed), which are <2.5 mm into the lumen. In addition, the presence or absence of a distinct border is a critical feature to describe to assess the feasibility of complete endoscopic resection. The term “endoscopically resectable” is defined as a lesion with identifiable distinct margins, appears to be completely removed on visual inspection after endoscopic resection, completely removed on histologic examination, and is dysplasia-free on confirmatory biopsy specimens from mucosa immediately adjacent to the resection margin. The nomenclature has since shown clinical validity. A recent retrospective study of 39 lesions (31 patients) with high-grade dysplasia detected by targeted biopsy sampling successfully classified all lesions using

Endoscopic features of dysplasia. A,Superficially elevated morphology accentuated with chromoendoscopy. B,Nonpolypoid dysplastic lesion with vascular and surface pattern of neoplasia. C, Focal friability. D, Uneven erythema. E, Villous mucosa. F, In contrast, pseudopolyps have an inflammatory

Celiac testing
Thursday, November 16, 2017
point-of-care test (POCT) that uses IgA/IgG-deamidated gliadin peptide may help clinicians monitor mucosal healing in patients with celiac disease, suggests a prospective study that included 217 patients.
• Investigators used IgA endomysial antibodies (EMA), IgA-tissue transglutaminase (TTG), the POCT, and a dietary adherence questionnaire to evaluate histological remission in patients on a gluten free diet.
• The IgA/IgG-deamidated gliadin peptide-based test was the most sensitive of all procedures performed, with a rating of 67.1%.
• Sensitivities for TTG, EMA, and the adherence questionnaire score were 44.7%, 37.7%, and 24.7%, respectively.
• Combining the POCT with the adherence score increased sensitivity to 70.6%

Gut diversity
Friday, November 17, 2017

The study used two indexes to determine the alpha diversity of microbiota: the Chao index to estimate richness and the Shannon diversity index to determine the abundance of species in different settings. “We observed dynamic temporal evolution of alpha diversity and taxa abundance over the 1-year follow-up period,” Dr. Uhlemann said. “The diagnosis, the Child-Pugh class, and changes in perioperative antibiotics were important predictors of posttransplant alpha diversity.”

This affects liver transplant success

Friday, November 17, 2017

Improve Alzheimer’s memory
Friday, November 17, 2017

The first group was given instructions on strategies to help boost memory, the second received instructions on strategies to improve reasoning skills, and the third group received individual speed-of-processing training, which was developed by the researchers.

Speed of processing helps most

Focus attention on center and periphery and identify both

PPI leads to cirrhosis in HCV
Saturday, November 18, 2017

Proton pump inhibitors are associated with accelerated development of cirrhosis, hepatic decompensation and hepatocellular carcinoma in noncirrhotic patients with chronic hepatitis C infection: results from ERCHIVES

Osteoporosis guidelines 2017
Saturday, November 18, 2017

• ACP recommends that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis.
• ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years.
• ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinically recognized osteoporosis.
• ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women.
• ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women.

MI blood tests
Saturday, November 18, 2017

H-FABP was more sensitive to detect OMD and could identify patients better than troponin

Monday, November 20, 2017
Cholesterol Notes

  1. Types of LDL
    a. Large, fluffy LDL
    b. Small, dense LDL  associated with higher risk of coronary artery disease vs large fluffy type
  2. Ways to measure LDL
    a. LDL-C number (traditional way of measuring LDL)
    i. Measures amount of cholesterol within LDL particles
    b. LDL-P number
    i. Tests for number of LDL particles in the blood
    ii. Can also measure small LDL-P number
  3. Triglyceride to HDL ratio
    a. Ideally, less than 2
    b. Even better, less than 1.33
  4. Ways to increase LDL receptors
    a. Statins
    b. PCSK9 inhibitors – new
    i. Examples: evolocumab (Repatha); alirocumab (Praluent)
    ii. Mode of delivery: subcutaneous injection
    iii. Mechanism of action: inhibit PCSK9
  5. PCSK9 inactivates LDL receptors which leads to increased levels of LDL in the bloodstream
    iiii. Pricey (can cost approximately $14,000/year)
    c. Small interfering RNA molecules (siRNA molecules) – new
    i. Example: Inclisiran
    ii. Mode of delivery: subcutaneous injection
    iii. Mechanism of action: causes mRNA for PCSK9 to be degraded  less expression of PCSK9
  6. Bile acid sequestrants: decrease LDL
    a. Examples: colestipol, cholestyramine, colesvelam
    b. Mechanism of action: bind to bile acids, preventing reabsorption from GI tract and causing them to be excreted  circulating cholesterol used to replace lost bile
  7. Niacin/nicotinic acid: decrease LDL, decrease TG, increase HDL
  8. Statins: decrease LDL, decrease TG (slightly), increase HDL (slightly)
    a. Mechanism of action: mimics HMG-CoA, competing for binding to HMG-CoA reductase
    i. FYI: HMG-CoA reductase normally binds to HMG-CoA, an important step in the production of cholesterol
    ii. Interruption in this pathway leads to lower cholesterol production  lower levels of cholesterol in blood  increased expression of LDL receptors  further decrease in circulating cholesterol
    b. Concerns
    i. Associated with development of DM
  9. Exception: pitavastatin (Levalo)
    ii. Rhabdomyolysis
  10. Labs
    a. CKMM
    b. SGOT
    c. BUN/creatinine ratio (will be less than 10)
    d. Myoglobin
    e. urine dipstick (tests positive b/c cannot differentiate myoglobin from hemoglobin)
  • microscopic evaluation shows otherwise
    iii. Drug interaction between statins and Diflucan
    iiii. Autoimmune necrotizing myopathy
  1. Usually affects proximal muscles
  2. Can lead to death
  3. Confirmed via biopsy

Extra sources:

Asthma eosinophilia
Tuesday, November 21, 2017

monoclonal antibody benralizumab has been approved by the FDA for use as add-on maintenance therapy for eosinophilic asthma patients aged 12 years and older, AstraZeneca announced Nov. 14.

HBV vaccine
Wednesday, November 22, 2017
The new vaccine’s approval came after review of safety and efficacy data from three phase 3 trials comparing Heplisav-B with Engerix-B, another HBV vaccine currently available, that is given in a three-dose regimen.

In one study of 2,032 patients between the ages of 18 and 55 years, seroprotection rate in the Heplisav-B group (1,511) was 95%, compared with 81.5% in the Engerix-B group (521).

Heplisav-B patients were given a two-dose regimen of the drug at 0 and 1 months, followed by a placebo at 6 months, while investigators administered Engerix-B at all three intervals in the comparator subjects.

CAVEAT NEEDS AMI ( myocardial infarction) evaluation

Wednesday, November 22, 2017
Their findings, which appear in the December issue of the journal Metabolism, indicated that cinnamaldehyde improves metabolic health by acting directly on fat cells, or adipocytes, inducing them to start burning energy through a process called thermogenesis.
Wu and her colleagues tested human adipocytes from volunteers representing a range of ages, ethnicities and body mass indices. When the cells were treated with cinnamaldehyde, the researchers noticed increased expression of several genes and enzymes that enhance lipid metabolism. They also observed an increase in Ucp1 and Fgf21, which are important metabolic regulatory proteins involved in thermogenesis.

Cerebral edema in ALF
Friday, November 24, 2017
Many treatments are available for cerebral edema and intracranial hypertension. The first step is to elevate the head of the bed about 30 degrees. In addition, hyponatremia should be corrected, as it can worsen cerebral edema.41 If patients are intubated, maintaining a hypercapneic state is advisable to decrease the intracranial pressure.
Of the two pharmacologic options, mannitol is more often used.42 It is given as a bolus dose of 0.5 to 1 g/kg intravenously if the serum osmolality is less than 320 mOsm/L.1 Given the risk of fluid overload with mannitol, caution must be exercised in patients with renal dysfunction. The other pharmacologic option is 3% hypertonic saline.
Therapeutic hypothermia is a newer treatment for cerebral edema. Lowering the body temperature to 32 to 33°C (89.6 to 91.4°F) using cooling blankets decreases intracranial pressure and cerebral blood flow and improves the cerebral perfusion pressure.43 With this treatment, patients should be closely monitored for side effects of infection, coagulopathy, and cardiac arrythmias.1
l-ornithine l-aspartate was successfully used to prevent brain edema in rats, but in humans, no benefit was seen compared with placebo.44,45The underlying basis for this experimental treatment is that supplemental ornithine and aspartate should increase glutamate synthesis, which should increase the activity of enzyme glutamine synthetase in skeletal muscles. With the increase in enzyme activity, conversion of ammonia to glutamine should increase, thereby decreasing ammonia circulation and thus decreasing cerebral edema.
Patients with cerebral edema have a high incidence of seizures, but prophylactic antiseizure medications such as phenytoin have not been proven to be beneficial.46

Pancreatitis causes
Friday, November 24, 2017

The spectrum of nonalcoholic, nonbiliary pancreatitis includes autoimmune pancreatitis, groove pancreatitis, hereditary pancreatitis, tropical pancreatitis, tuberculous pancreatitis, and metabolic pancreatitis. Advances in genetics and molecular pathology have shed new light on the etiopathogenesis and course of these syndromes. Accurate diagnosis aided by imaging findings allows optimal management.

Friday, November 24, 2017
Herpes simplex virus should be suspected in patients presenting with anicteric hepatitis with fever. Polymerase chain reaction testing for herpes simplex virus should be done,30 and if positive, patients should be given intravenous acyclovir.31 Despite treatment, herpes simplex virus disease is associated with a very poor prognosis without liver transplant.
Autoimmune hepatitis
The autoantibodies usually seen in autoimmune hepatitis are antinuclear antibody, antismooth muscle antibody, and anti-liver-kidney microsomal antibody, and patients need to be tested for them.
The diagnosis of autoimmune hepatitis can be challenging, as these autoimmune markers can be negative in 5% of patients. Liver biopsy becomes essential to establish the diagnosis in that setting.32
Guidelines advise starting prednisone 40 to 60 mg/day and placing the patient on the liver transplant list.1
Wilson disease
Although it is an uncommon cause of liver failure, Wilson disease needs special attention because it has a poor prognosis. The mortality rate in acute liver failure from Wilson disease reaches 100% without liver transplant.
Wilson disease is caused by a genetic defect that allows copper to accumulate in the liver and other organs. However, diagnosing Wilson disease as the cause of acute liver failure can be challenging because elevated serum and urine copper levels are not specific to Wilson disease and can be seen in patients with acute liver failure from any cause. In addition, the ceruloplasmin level is usually normal or high because it is an acute-phase reactant. Accumulation of copper in the liver parenchyma is usually patchy; therefore, qualitative copper staining on random liver biopsy samples provides low diagnostic yield. Quantitative copper on liver biopsy is the gold standard test to establish the diagnosis, but the test is time-consuming. Kayser-Fleischer rings around the iris are considered pathognomic for Wilson disease when seen with acute liver failure, but they are seen in only about 50% of patients.33
A unique feature of acute Wilson disease is that most patients have very high bilirubin levels and low alkaline phosphatase levels. An alkaline phosphatase-to-bilirubin ratio less than 2 in patients with acute liver failure is highly suggestive of Wilson disease.34
Another clue to the diagnosis is that patients with Wilson disease tend to develop Coombs-negative hemolytic anemia, which leads to a disproportionate elevation in aminotransferase levels, with aspartate aminotransferase being higher than alanine aminotransferase.
Once Wilson disease is suspected, the patient should be listed for liver transplant because death is almost certain without it. For patients awaiting liver transplant, the American Association for the Study of Liver Diseases guidelines recommend certain measures to lower the serum copper level such as albumin dialysis, continuous hemofiltration, plasmapheresis, and plasma exchange,1 but the evidence supporting their use is limited.

Different criteria have been used to identify patients with poor prognosis who may eventually need to undergo liver transplant.

The King’s College criteriasystem is the most commonly used for prognosis (Table 4).37,66–69 Its main drawback is that it is applicable only in patients with encephalopathy, and when patients reach this stage, their condition often deteriorates rapidly, and they die while awaiting liver transplant.37,66,67
The Model for End-Stage Liver Disease (MELD) score is an alternative to the King’s College criteria. A high MELD score on admission signifies advanced disease, and patients with a high MELD score tend to have a worse prognosis than those with a low score.68
The Acute Physiology and Chronic Health Evaluation (APACHE) II score can also be used, as it is more sensitive than the King’s College criteria.6
The Clichy criteria66,69 can also be used.
Liver biopsy. In addition to helping establish the cause of acute liver failure, liver biopsy can also be used as a prognostic tool. Hepatocellular necrosis greater than 70% on the biopsy predicts death with a specificity of 90% and a sensitivity of 56%.70
Hypophosphatemia has been reported to indicate recovering liver function in patients with acute liver failure.71 As the liver regenerates, its energy requirement increases. To supply the energy, adenosine triphosphate production increases, and phosphorus shifts from the extracellular to the intracellular compartment to meet the need for extra phosphorus during this process. A serum phosphorus level of 2.9 mg/dL or higher appears to indicate a poor prognosis in patients with acute liver failure, as it signifies that adequate hepatocyte regeneration is not occurring.

Sunday, November 26, 2017

The norUDCA dose of 1,500 mg resulted in significant reduction of ALT [alanine aminotransferase] within 12 weeks,” said Michael Trauner, MD, head of the division of gastroenterology and hepatology at the Medical University of Vienna, a coinventor of the drug. “The results are supported by improvement in liver stiffness and steatosis in the subsets analyzed.”

Mtx hepatotoxicity
Monday, November 27, 2017
MTX Doubles Hepatotoxicity Risk in Psoriasis Patients
But methotrexate does not increase risk of liver disease in patients with rheumatoid arthritis

Depression -stop it before it happens
Monday, November 27, 2017

A recent study found that transdermal estradiol plus progesterone can reduce the incidence of depression in menopausal women.

Light to control heart rates
Tuesday, November 28, 2017
Optogenetics is a reversible way to dampen the cardiac sympathetic nervous system, as researchers showed they could inhibit neurons of the left stellate ganglion (LSG) and thereby increase electrophysiological stability and protect against myocardial ischemia-induced ventricular arrhythmias in dogs.
Dogs subject to optogenetic neuromodulation of the heart had LSG function suppressed every time investigators turned neurons “off” with a green-to-yellow light-emitting diode (LED) implanted in the chest. LSG function, measured as maximal systolic blood pressure change in response to 10-15 V electrical stimulation, fell from 60.9% at baseline to 37.6% with transient LED illumination to 20% after 30 minutes of LED illumination.

NASH Update 2017
Wednesday, November 29, 2017
She noted several studies that evaluated the prevalence of NAFLD, including a study that found that “about one-third of patients walking through the door of the clinic had nonalcoholic steatohepatitis [NASH],” suggesting physicians should consider screening at-risk patients (abstract 58). A Korean study found about 18% of asymptomatic lean individuals (body mass index less than 23 kg/m2) had NAFLD and identified sarcopenia as a significant risk factor for NAFLD in these lean patients (abstract 59). “Sarcopenia is something that we really need to pay a lot more attention to,” Dr. Watt said.

Other studies better outlined the increasing association between NAFLD and hepatocellular carcinoma, Dr. Watt noted (abstracts 2119 and 2102). Another study confirmed that men with NAFLD/NASH have almost twice the incidence of hepatocellular carcinoma (HCC) as women — 0.43%-0.5% vs. 0.22%-0.28%, with both groups significantly higher than the general population (abstract 2116). “And looking further, we can actually quote an HCC incidence in NASH of 0.009%,” she added.

Again emphasizing the multisystem impact of NAFLD, Dr. Watt cited a study that calculated the cardiovascular risks incumbent with liver disease. Researchers reported that men and women at the time of NAFLD diagnosis had significantly higher rates of either angina/ischemic heart disease or heart failure (abstract 55). Women, specifically, had a higher risk for cardiovascular events earlier than men and overall are at equal risk to men, unlike in the general population where women are at lower risk. “We need to start looking at screening and prevention of other diseases in our patients with NASH,” Dr. Watt said. “In addition, we need to be more aware of the elevated risk in these patients and not just approach them in the same way as the general population.”

Physicians may be tempted to discontinue statin therapy in patients with chronic liver disease, but Dr. Watt cited a poster that showed that this results in worse outcomes (abstract 2106). The researchers found that continued statin use was associated with a lower risk of death with compensated and decompensated liver function. “These data help to educate certain patients of their risk of decompensation over time,” Dr. Watt said.

An international study determined that the severity of advanced compensated liver disease is a key determinant in outcomes, finding that those with bridging fibrosis are at greater risk of vascular events, but those with cirrhosis and Child-Turcotte-Pugh A5 and A6 disease have much higher risks of hepatic decompensation and HCC out to 14 years (abstract 60). “The reason to look at these is to be able to tell your patients that they probably have a 30% increased risk of decompensation by 4 years,” Dr. Watt said.

Dr. Watt pointed out three studies that shed more light on important biomarkers of NAFLD. One study reported that three biomarkers – alpha-2-macroglobulin, hyaluronic acid, and tissue inhibitor of metalloproteinase-1 – have a high sensitivity for differentiating low-stage and stage F3-F4 disease (abstract 95). Another study found that a measure using Pro-C3 and other clinical markers were predictive of F3 or F4 fibrosis in NAFLD (abstract 93). And, other researchers found that a HepQuant-STAT measure of greater than 0.50 microM in patients who ingested deuterated cholic acid (d4-CA) solution may be a minimally invasive alternative to biopsy for diagnosing NASH (abstract 96).

Management studies focusing on varying targets were also presented. A trial of fibroblast growth factor–21 for treatment of NAFLD found that patients in the 10- and 20-mg dose arms showed improvement in MRI hepatic fat fraction, ALT, AST, and liver stiffness at 16 weeks vs. placebo. A few patients had some mild elevation to their liver enzymes on treatment (abstract 182). “So I think we need to remain cautious and watch these patients closely, but overall it seems to be reasonably safe data,” she said. Another drug trial of the acetyl-CoA carboxylase inhibitor GS-0976 also showed promise for overall improvement in MRI steatosis measures (abstract LB-9).

Three preclinical studies of dual-agent therapies in animals have demonstrated improvement in inflammatory and fibrosis scores, Dr. Watt noted (abstracts 2,000, 2,002and 2,052). “There’s no one drug that’s going to be likely the magic cure,” Dr. Watt said. “There will likely be a lot more focus and data coming out on dual-action agents.” Another animal study addressed the burning question if decaffeinated coffee has the same protective effect against NASH as caffeinated coffee (abstract 2093). Said Dr. Watt: “If you are interested in the potential benefits of coffee but really can’t handle the caffeine, this study suggests, you may still be OK.”

Finally, Dr. Watt noted an early study of three-dimensional printing has shown potential for replicating NASH tissue for bench studies (abstract 1963). “3-D printing is certainly a wave of the future,” she said, pointing out that researchers have created a 3-D model that has some metabolic equivalency to NASH, with the inflammatory cytokine release, hepatic stellate cell activation, “and all of the features that we see in NASH. This may be of potential use down the road to avoid relying on animal models in preclinical studies.”

Wednesday, November 29, 2017

Optimal CHF
Wednesday, November 29, 2017

We really should combine the two, and if you have both worsening renal function and hemoconcentration, you probably have reached euvolemia.”
At time of discharge
If renal function improves poor outcome in CHF patients

Collagenous Colitis
Thursday, November 30, 2017
Budesonide appears to be effective in treating collagenous colitis, suggests a recent Cochrane review. A small study also found that bismuth subsalicylate (Pepto-Bismol), when compared to placebo, resolves the diarrhea brought on by the colitis. Among the other findings:
• A placebo-controlled trial concluded that Boswellia serrata extract resolved diarrhea in 44% of patients, compared to 27% in the placebo group. but this small trial was deemed of very low quality.
• A separate study found diarrhea cleared up in 80% of patients on budesonide, compared to 44% of those taking mesalamine; there were no differences between the drugs’ side effect profiles.

Dermatological side effects of cannabis
Thursday, November 30, 2017

There are several approved medical indications for cannabis use and very preliminary studies have suggested cannabis and its derivatives might have use in acne, dermatitis, pruritus, wound healing, and skin cancer. Conversely, the side effects of cannabis use are relatively well documented, and dermatologists should be aware of these presentations. Side effects of cannabis use include cannabis allergy manifesting as urticaria and pruritus, cannabis arteritis presenting with necrosis and ulcers, a

Investigational rx for pneumococcal meningitis
Thursday, November 30, 2017

complement inhibitors, matrix-metalloproteinase inhibitors, and nonbacteriolytic antibiotics.

Friday, December 1, 2017

The acute or chronic manifestations encompass a broad range of peripheral and central neurological problems, with peripheral neuropathy being the most frequent. Complications include multifocal motor neuropathies, Melkersson-Rosenthal syndrome, optic neuritis, sensorineural hearing loss, and cerebral vasculitis.
“Straight neuromuscular complication as a direct consequence of IBD inflammation affects fewer than half of 1% of patients,” Korzenik said. “The category we worry about most is an IBD-related hypercoagulable state where there’s a question of an increased risk of clotting and stroke induced by the inflammatory response. Fortunately this is quite uncommon.”
In an interview in Gastroenterology & Hepatology, Jose Ferro, MD, PhD, of Lisbon University in Portugal, noted that IBD patients have an approximately threefold higher risk of developing venous cerebral thrombosis compared with the general population.
The risk is also increased for arterial thromboembolism, explained Stidham: “And that relative risk further increases from five-fold to upwards of nine-fold when you look at patients with active inflammation. The risk differential may be partly due to corticosteroid use, especially prednisone, which is associated with hypercoagulability.”
IBD has been linked to demyelinating diseases such as multiple sclerosis. “There’s been some suggestion that these diseases are potentially more threatening in Crohn’s disease, but the numbers are so small that it’s difficult to determine,” he said.
Other central nervous system manifestations include epidural and subdural spinal empyema, vision problems, seizures, and encephalopathy. Some patients may be susceptible to headaches, chronic fatigue, and Parkinson-like syndrome.

One central neuropathy associated with anti-TNF is optic neuritis. “If a patient on anti-TNF describes paresthesia in the periphery or any visual changes, it’s important for the provider to drill down to the details and have a pretty low threshold
for having that investigated,” Stidham said

.In postmarketing reports, both optic neuritis and demyelinating polyneuropathy have been reported with infliximab (Remicade) and adalimumab (Humira).

According to Zois and colleagues, underlying disturbances in the mind-gut axis — which mediate the reciprocal influence of the neuronal system of the brain and enteric disease via neuroendocrine pathways — may also be at play. Abnormalities could potentially involve the hypothalamic-pituitary-adrenal axis, corticotropin and adrenal corticoid secretion, and the effects of the autonomic nervous system on immune function.

Cancer testing
Friday, December 1, 2017
The FDA has approved a new test that can detect a host of mutations in any solid tumor, and the Centers for Medicare and Medicaid Services (CMS) simultaneously proposed to let Medicare pay for it, the agencies announced.
The FoundationOne CDx (F1CDx) from Foundation Medicine is the first next-generation sequencing (NGS)-based in vitro diagnostic (IVD) test that can detect genetic mutations in 324 genes and two genomic signatures in any solid tumor type.

Friday, December 1, 2017
The researchers noted specific independent predictors of radiograph-confirmed pneumonia among this cohort, including temperature 37.8°C or higher (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.46 – 4.81), pulse rate 100/minute or higher (RR, 1.90; 95% CI, 1.12 – 3.24), crackles on auscultation (RR, 1.82; 95% CI, 1.12 – 2.97), and oxygen saturation below 95% (RR, 1.73; 95% CI, 0.98 – 3.06).
Overall, 86.1% (99/115) of patients with pneumonia exhibited at least one of these clinical signs. In contrast, other factors, including presenting symptoms, age, sex, smoking history, and past medical history, provided no predictive information for a pneumonia diagnosis.

Repatha and MI
Friday, December 1, 2017

The trial, which included more than 27,000 participants with atherosclerotic CVD already receiving statins, showed that patients who received injections of evolocumab at doses of 140 mg every other week or 420 mg monthly had a 15% reduced risk for the composite of MI, stroke, CV death, coronary revascularization, and unstable angina hospitalization at 22 months compared with those receiving matching placebo (P < .001).

Migraine prevention
Sunday, December 3, 2017

Fremanezumab, a humanized monoclonal antibody targeting calcitonin gene–related peptide (CGRP), is being investigated as a preventive treatment for migraine.

Biotin interference
Saturday, December 2, 2017

The FDA has received a report that one patient taking high levels of biotin died following falsely low troponin test results when a troponin test known to have biotin interference was used.

• Consider that the daily recommended allowance for biotin is 0.03 mg and these biotin levels do not typically cause significant interference. However, supplements containing high biotin levels including those marketed for hair, skin, and nail benefits, may contain up to 20 mg of biotin, and physicians may recommend up to 300 mg per day for conditions such as multiple sclerosis. Biotin levels higher than the recommended daily allowance may cause significant interference with affected lab tests.
• Be aware that specimens collected from patients taking high levels of biotin may contain more than 100 ng/mL biotin. Concentrations of biotin up to 1200 ng/mL may be present in specimens collected from patients taking up to 300 mg per day.

Be aware that many lab tests, including but not limited to cardiovascular diagnostic tests and hormone tests, that use biotin technology are potentially affected, and incorrect test results may be generated if there is biotin in the patient’s specim

Systemic sclerosis scleroderma
Monday, December 4, 2017

Factors Predict Severe GI Problems in SSc
Dysmotility in systemic sclerosis linked with myopathy, sicca symptoms, nonwhite race, and male sex
Up to 90% of patients with SSc experience some degree of GI tract involvement. For most, this consists of mild gastroesophageal reflux, but some patients — an estimated 8% — develop severe dysmotility resulting in malabsorption and pseudo-obstruction and requiring enteral or parenteral feeding. The mortality rate approaches 85%.

Esophageal cancer
Tuesday, December 5, 2017

The presence of one oral bacterium in particular, called Tannerella forsythia, was tied to a 21 percent increase in the odds of developing esophageal tumors, said a team led by Jiyoung Ahn. She is associate director for population science at NYU Langone Health in New York City.

T1D between 30 to 60
Tuesday, December 5, 2017
However, the clinical characteristics of those diagnosed between ages 31 and 60 were significantly different from those diagnosed with type 2 at this age (all comparisons P<0.001):
• BMI: 27.4 (95% CI 26.7-28.0; type 1) versus 32.4 (32.2-32.5; type 2)
• Insulin at study entry: 100% (100-100%) versus 16% (15-17%)
• Insulin 1 year after diagnosis: 89% (86-91%) versus 6% (5-6%)
• Diabetic ketoacidosis: 11% (9-14%) versus 0.3% (0.1-0.4%)

analysis reported that 42% (95% CI 39-45) of people with type 1 diabetes were diagnosed between the ages of 31 and 60, despite representing only 4% (n=537) of new diabetes cases diagnosed after the age of 30 in the cohort.

he highlighted that the study failed to address LADA — latent autoimmune diabetes of adults — writing, “whether LADA is a distinct entity, a less aggressive form of type 1 diabetes on an autoimmune continuum, or an artificial construct that results from a mixture of patients with type 1 and type 2 diabetes remains a point of contention.”

RFA and esophageal stricture
Tuesday, December 5, 2017

Left atrial RFA is an effective and relatively safe treatment for atrial fibrillation. Major complications secondary to left atrial RFA have been reported in 2% to 6% of cases, but esophageal injury has been rarely reported.1, 3 Severe esophageal strictures owing to thermal injury may develop, causing significant morbidity and mortality.1,

Non invasive sugar monitoring
Wednesday, December 6, 2017


consequence, TensorTip CoG may provide reliable glucose information on a daily basis. It is a true alternative to current semi-invasive needle sensors used for treatment monitoring in patients with diabetes.”

Lung cancer
Saturday, December 2, 2017

Consider testing for epidermal growth factor

Fecal incontinence Mx
Thursday, December 7, 2017
Fecal incontinence affects 7%-15% of individuals and has potentially “devastating” implications for quality of life, the experts note. They recommend starting treatment by meticulously documenting bowel habits, triggers of incontinence, and treatment history. For fecal incontinence with diarrhea, they suggest eliminating caffeine and poorly absorbed dietary sugars, such as sorbitol and fructose, and adding loperamide, starting with one 2-mg tablet taken 30 minutes before breakfast and titrating up to a maximum of 16 mg per day. Other conservative therapeutic options for diarrhea include fiber supplementation, scheduled toileting, a bowel retraining program, anticholinergic agents, clonidine, and cholestyramine or colesevelam to correct bile salt malabsorption. Patients whose fecal incontinence involves constipation should start with laxatives and anorectal testing for evacuation disorders. Rectal cleansing with a small enema or tap water can help prevent stool leakage, the experts write.

If these conservative measures fail to improve fecal incontinence, they recommend anorectal manometry to test for anal weakness, reduced or increased rectal sensation, and impaired rectal balloon expulsion, all of which can improve with biofeedback therapy to retrain the pelvic floor. If biofeedback fails, consider perianal bulking agents, such as intra-anal injection of dextranomer, the experts suggest. Sacral nerve stimulation might be indicated if moderate or severe fecal incontinence does not respond to at least 3 months of conservative treatment. However, the experts do not recommend percutaneous tibial nerve stimulation, which failed to outperform sham stimulation in a 12-week, double-blind, multicenter trial (Lancet. 2015;386:1640-8). Surgery is indicated for fecal incontinence associated with major anatomic defects, such as rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity. Additionally, sphincteroplasty is an option for postpartum women with fecal incontinence, patients with recent sphincter injuries, and patients with sphincter damage and fecal incontinence fecal incontinence that fails to improve with conservative and biofeedback therapy, perianal bulking injection, and sacral nerve stimulation, according to the clinical practice update.

Barrier devices should be offered if fecal incontinence fails conservative treatments and surgery, or if surgery is not an option. Most anal plugs are “poorly tolerated,” with two exceptions – a Food and Drug Administration–approved device from Renew Medical and a vaginal insert and pressure-regulated pump from Pelvalon. Colostomy might be indicated if patients with severe fecal incontinence fail conservative treatment and or are not candidates for barrier devices, minimally invasive surgeries, and sphincteroplasty.

If severe fecal incontinence that is refractory to or contraindicated for all these interventions, the experts suggest considering artificial anal sphincter repair by dynamic graciloplasty. Surgery also is indicated to repair major anatomic defects such as rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity, they noted. A magnetic anal sphincter device is a possibility for patients with medically refractory severe fecal incontinence who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. However, the study that led to FDA approval of a magnetic anal sphincter device included only 35 patients, and 7 (20%) had the device removed because of infection, erosion, or inefficacy. Another patient required a stoma in order to be able to defecate, and a total of 40% had moderate or severe complications when pain and bleeding were also considered, the experts noted.

Biofeedback is the preferred treatment for defecatory disorders – that is, chronic constipation or constipation-predominant irritable bowel syndrome with impaired rectal evacuation, according to the clinical practice update. The experts recommend against sacral nerve stimulation, anteretrograde colonic enemas, and stapled transanal rectal resection for patients with defecatory disorders. Surgical treatment typically is reserved for the small minority of patients with considerable pelvic organ or rectal prolapse, they note.

Diabetes and fracture
Thursday, December 7, 2017

relative risk of hip fracture is as much as seven times higher for those with type 1 diabetes and about 1.5 times higher for type 2 diabetes patients compared with the non-diabetes population.

Causes – unknown. SGLT2 drugs causes osteoporosis
Insulin with higher risk of falls
Osteopenia occurs only in t1D
Hyperglycemia compromises bone quality

Transferrin liver mortality in cirrhosis
Thursday, December 7, 2017

During a median follow-up of 2.41 years, 193 deaths occurred and 254 patients underwent liver transplantation. In patients with transferrin<180 mg/dL, 3-month, 1-year and 5-year transplant-free survival estimates were significantly lower (91.7%, 79.0% and 30.5%) when compared with the group of patients with transferrin ≥ 180 mg/dL (98.9%, 95.5% and 68.0%, P<.001). Transferrin predicted transplant-free survival independently of MELD-Na and C-reactive protein (CRP) in multivariable regression analysis including all patients. When patients with alcoholic or non-alcoholic fatty liver disease were excluded, transferrin was in addition an albumin-independent predictor of transplant-free survival.

HH In cirrhosis
Thursday, December 7, 2017

The analysis of the data showed that despite the progress of modern hepatology, the presence of HH is associated with poor prognosis and high mortality. Most patients suffering from it are candidates for orthotopic liver transplantation. I

Ghrelin Antagonist
Thursday, December 7, 2017

LEAP2 could help fight obesity. People who lose weight often gain it back because their appetite revs up, possibly due to a corresponding rise in ghrelin levels. Using LEAP2 or a similar molecule, perhaps “we can prevent that almost inevitable hunger that follows weight loss,” he says.

Diarem score
Friday, December 8, 2017

Surgery success in bariatic surgeyfor curing diabetes
Use score from

T2d medicine
Monday, December 11, 2017

Lorcaserin targets important brain hormones called pro-opiomelanocortin (POMC) peptides, which are responsible for regulating appetite.”
It also helps treat T2D by changing the way it processs glucose metabolism

BELVIQ (lorcaserin hydrochloride) is a serotonin 2C receptor agonist for oral administration used for chronic weight management

Peri operative risk
Monday, December 11, 2017
• Perioperative complications (pneumonia, unplanned intubation, ventilator dependence, cardiac arrest or myocardial infarction, stroke or coma >24 hours, acute or progressive renal failure, bleeding, sepsis, surgical site infections, wound dehiscence, venous thromboembolism, and urinary tract infections) within 30 days occurred in 2457 patieThe 11-item mFI consisted of: history of diabetes; impaired functional status; history of chronic obstructive pulmonary disease or pneumonia; history of congestive heart failure; history of myocardial infarction within 6 months; history of percutaneous coronary intervention; cardiac surgery or angina; receipt of antihypertensive medications; peripheral vascular disease or rest pain; impaired sensorium; and history of transient ischemic attack or cerebrovascular accident with persistent residual deficit.
• nts (1.7%), including 971 (0.7%) serious perioperative complications (excluding urinary tract infections and superficial surgical site infections).
• Multivariable analysis adjusting for age, sex, race or ethnicity, type of anesthesia, tobacco use, kidney failure, corticosteroid use, and CPT clustering showed that increasing mFI score was associated with a stepwise increase in the incidence of complications by 30 days

Although overall and serious rates of complication were low (1.7% and 0.7%, respectively), “the relative risk of complications was increased, with patients with 2 to 3 frailty traits (intermediate mFI score) having more than 2 times the odds of serious complications, after adjusting for poor prognostic factors,” the authors write. Specifically, after adjustment for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology(CPT) codes, the odds ratios (ORs) for any and serious complications, respectively, in patients with intermediate mFI scores were 1.70 (95% confidence interval [CI], 1.54-1.88; P <.001) and 2.00 (95% CI, 1.72-2.34; P <.001).
As mFI score increased, so did the risk for any and serious complications. For patients with high mFI scores, the respective ORs for any and serious complications rose to 3.35 (95% CI, 2.52-4.46; P<.001) and 3.95 (95% CI, 2.65-5.87; P <.001).

Friday, December 15, 2017

Dr. McMahon’s analysis also revealed that two other clinical conditions that are generally believed to raise VTE risk – obesity and impaired overall renal function identified with stagnant measures – did not correspond with a significantly elevated VTE rate in this study.
But AKI IS associated with doubled VTE

Sunday, December 17, 2017

Patients who received three 100-mcg intra-articular injections of sprifermin every 6 months (group 1) showed a gain in TFJ cartilage thickness of 0.03 mm as seen on MRI, while those who received three 100-mcg injections of sprifermin every 12 months (group 2) had a gain of 0.02 mm, Dr. Hochberg said during a late-breaking abstract session at the annual meeting of the American College of Rheumatology.

CAR T-cell treatment for cancer
Monday, December 18, 2017

treatment, called CAR T-cell therapy, treats cancer in a completely new way by removing a patient’s cells, re-engineering them, and then re-inserting them into the body to go after cancer cells.

In August the FDA approved Novartis’ Kymriah, a treatment that uses the body’s immune system to attack pediatric acute lymphoblastic leukemia. Novartis said the approach costs $475,000 per person.

In October, another kind of CAR-T treatment, Yescarta, was approved for adults to treat the blood cancer known as aggressive B-cell non-Hodgkin lymphoma.

Post gastric bypass hypoglycemia
Monday, December 18, 2017

• The differential diagnosis for endogenous causes of hyperinsulinemic hypoglycemia after gastric bypass surgery includes insulinoma, late dumping syndrome, and post-gastric bypass hypoglycemia (PGBH).
• The Whipple triad consists of measured low blood glucose, symptoms of low blood glucose, and reversal of symptoms when low blood glucose is corrected. If the triad is not present, then hypoglycemia is not causing the patient’s symptoms.
• PGBH should initially be treated with a high-protein, high-fiber, low-carbohydrate diet and then, if hypoglycemia persists, by medication (initially acarbose, then a calcium channel blocker and octreotide or diazoxide or both).
• PGBH ranges from mild, in which neuroglycopenia resolves with dietary changes with or without acarbose, to severe, in which neuroglycopenia persists despite dietary changes and multiple drugs.
• Gastric bypass reversal and pancreatic surgery are a last resort for patients with debilitating neuroglycopenia when dietary modification and drug therapy fail.

TB test – IGRA
Wednesday, December 20, 2017
There are currently two IFN-γ release assays available for the diagnosis of tuberculosis:
• QuantiFERON-TB Gold (licensed in US, Europe and Japan); and
• T-SPOT.TB, a form of ELISPOT (licensed in Europe, US, Japan and China).[2]
The former test quantitates the amount of IFN-γproduced in response to the ESAT-6 and CFP-10 antigens from Mycobacterium tuberculosis, which are distinguishable from those present in BCG and most other non-tuberculous mycobacteria. The latter test determines the total number of individual effector T cellsexpressing IFN-γ.

memory and vegetables
Thursday, December 21, 2017

Compared with the one-fifth of participants who consumed the least amount of leafy green vegetables (0.1 average servings/day), the one-fifth who consumed the most (1.3 average servings/day) slowed their cognitive decline by an average of 0.05 standardized units per year (P=0.0001) after adjustments, they wrote in Neurology.

Thursday, December 21, 2017

Chantix causes CV disease between. 6 to 32 % higher rate

Septic shock
Thursday, December 21, 2017
In a clinical trial of 321 patients with shock and critically low blood pressure, significantly more patients responded to treatment with the angiotensin II injection compared with those treated with placebo. “Giapreza effectively increased blood pressure when added to conventional treatments used to raise blood pressure,” the FDA said.
The agency cautions that the drug can cause deep venous thrombosis and arterial thrombosis, and prophylactic treatment for blood clots “should be used.”

Low calorie sweetener
Sunday, December 24, 2017

Using human subcutaneous fat tissue taken from individuals who consumed low-calorie sweeteners, Sabyasachi Sen, MD, of George Washington University, Washington, and his colleagues showed that these cells had at least a twofold overexpression of glucose transporters. Also overexpressed were sweet taste receptors and adipogenic genes.

T1D autoimmune
Tuesday, December 26, 2017
Until now, scientists had found four molecules that are attacked by the immune system in Type 1 diabetes.
The identity of a fifth molecule — known only as ‘Glima’ for the past 20 years — has been a mystery.
Dr Christie’s team have successfully identified this fifth molecule as Tetraspanin-7, which could make tests for predicting Type 1 diabetes more accurate.

Dietary Fat
Tuesday, December 26, 2017

Epidemiological evidence to date found no significant difference in CHD mortality and total fat or saturated fat intake and thus does not support the present dietary fat guidelines. The evidence per se lacks generalisability for population-wide guidelines.

Cannabis in dermatology
Wednesday, December 27, 2017

There are several approved medical indications for cannabis use and very preliminary studies have suggested cannabis and its derivatives might have use in acne, dermatitis, pruritus, wound healing, and skin cancer. Conversely, the side effects of cannabis use are relatively well documented, and dermatologists should be aware of these presentations. Side effects of cannabis use include cannabis allergy manifesting as urticaria and pruritus, cannabis arteritis presenting with necrosis and ulcers, and oral cancers from cannabis smoke.

Almond plus dark chocolate
Wednesday, December 27, 2017

1) no treatment foods (average American diet), 2) 42.5 g/d of almonds, 3) 18 g/d of cocoa powder and 43 g/d of dark chocolate, or 4) all 3 foods. Each diet period lasted 4 weeks, followed by a 2-week compliance break. Researchers found:
• Compared with the average American diet, total cholesterol, non-high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol (LDL-C) after the almond diet were lower by 4%, 5%, and 7%, respectively.
• The chocolate + almond diet decreased apolipoprotein B by 5% compared with the average American diet.
• For LDL subclasses, the almond diet showed a greater reduction in large buoyant LDL particles, whereas the chocolate + almonds diet had a greater decrease in small dense LDL particles.

LDL particle size. Ldl-p
Thursday, December 28, 2017

LDL size correlated nega- tively with plasma triglycerides (TGs) (R2 = 0.52) and positively with HDL cholesterol (R2 = 0.14). However, an inverse correlation between the TG–to–HDL cholesterol molar ratio and LDL size was even stronger (R2 = 0.59). The ratio was 1.33 in 90% of the patients with small LDL particles (95% CI 79.3–100) and 16.5% of those with larger LDL particles. A cutoff point of 1.33 for the TG–to–HDL cholesterol ratio distinguishes between patients having small LDL values better than TG cutoff of 1.70 and 1.45 mmol/l.

Friday, December 29, 2017

Celiac test
Friday, December 29, 2017

An HLA-DQ–gluten tetramer-based assays that detects gluten-reactive T cells identifies patients with and without celiac disease with a high level of accuracy, regardless of whether the individuals are on a GFD. This test would allow individuals with suspected celiac disease to avoid gluten challenge and duodenal biopsy, but requires validation in a larger study.

Diabetic foot ulcer
Monday, January 1, 2018

Sanuwave put the Dermapace system was put through a pair of double-blind studies to prove its effectiveness, using a total of 336 patients as test subjects. Patients were given the typical treatment for their foot ulcers, which included wound dressings and upkeep, along with either a fake shock wave therapy with a non-working system or the Dermapace treatment. Patients who received the real shock wave therapy demonstrated a significantly higher wound closer rate vs their peers who received the fake treatment (44% vs 30%).

Off label IBD drug
Tuesday, January 2, 2018
Eventually, he stumbled upon research suggesting that an antidepressant called bupropion had an effect on Crohn’s disease, another type of IBD where the immune system attacks the lining of the gut. Studies on mice had shown that instead of blocking the action of inflammatory proteins, bupropion appeared to lower the production of those proteins in the first place.
Briggs decided to give it a try.

Fiber. Why
Wednesday, January 3, 2018
Recent journal article , how does fiber help

Finally we have an answer , albeit mice study

I will describe it in bullet points
Colon and SB is lined by mucos
Multiple bacteria reside on the mucosal lining
These bacteria create SCFA ( short chain fatty acids) which is absorbed. The SCFA helps reduce auto immunity, helps control blood sugar
These bacteria live off fiber. Without fiber they die and then more harmful bacteria grow which leads to – End result of weight gain, autoimmune diseases and diabetes

Eat more fiber – especially vegetables

This new research shows that the short chain fatty acids increase the number of chemical markers on our genes. These markers, called crotonylations, were only discovered recently and are a new addition to the chemical annotations in the genome that are collectively called epigenetic markers. The team showed that short chain fatty acids increase the number of crotonylations by shutting down a protein called HDAC2. Scientists think that changes in crotonylation can alter gene activity by turning genes on or off.

C diff and sugar
Thursday, January 4, 2018

To probe the mystery, a team of scientists led out of Baylor College of Medicine in Texas examined two particularly successful lineages of C. difficile, RT027 and RT078, examining what kind of carbon-rich molecules they ate. Both types, they noticed, seemed very good at using low concentrations of the sugar trehalose as a sole carbon source.

Exercise increases gut microbiome
Thursday, January 4, 2018

6 weeks of exercise changes gut flora to a new flora which helps fight inflammation and obesity and diabetes
Effects lasts only for 6 weeks if you give up exercise. Best results in volunteers who are lean

Xeralto drug interaction
Friday, January 5, 2018

Amiodarone had a relative risk (RR) for bleeding of 1.37 (P = .01) and was associated with significantly more bleeding events, with the study authors concluding that the risk “probably exceeds any benefit that such a combination could deliver.” Fluconazole had an RR of 2.35 (P< .01).

Also phenytoin causes higher chance of bleeding

Anti TNF in pregnancy
Wednesday, March 7, 2018
7:23 PM

British study which studied women on remicaide or adalinumab were found to have no adverse outcome on mother or baby.

March 2018

Tuesday, July 24, 2018
6:51 PM

Melanoma, autoimmune diseases, cervical cancer, lymphoma
Invasive aspergillosis, Hep B, TB
Steroid dependent after 2 courses of treatment
My humira services for injection
Lupus like and MS like problems, 1 in 1000 incidence
Psoriasis, eczema, local site reaction and pain

Malaria new drug
Tuesday, July 24, 2018
7:30 PM

The FDA approved tafenoquine (Krintafel) for the “radical cure” of Plasmodium vivax malaria in patients, ages ≥16 years, who are receiving antimalarial therapy for acute infection, manufacturer GlaxoSmithKline (GSK) announced.

Vaginal bacteriosis
Tuesday, July 24, 2018
7:35 PM

Vaginal microbiome. With increasing estrogen in body, lactobacillus in vagina goes up.
With drop in estrogen, there is dysbiosis and disease

Novel cause of rectal bleeding
Tuesday, July 24, 2018
7:43 PM

Rectal trumpet inserted in rectum for diarrhea can make an artery open up and bleed

Friday, January 5, 2018

the Mayo team reported that – compared to women who hadn’t had a hysterectomy – women who had the procedure experienced an average 14 percent higher risk of abnormal blood fat levels; a 13 percent higher risk for high blood pressure; an 18 percent higher risk for obesity and a 33 percent greater risk for heart disease.

Hypertension emergency
Saturday, January 6, 2018

Other IV antihypertensive regimens are available for specific hypertensive emergencies. For example, nitroprusside, nitroglycerin, or fenoldopam may be used in myocardial infarction; however, for aortic dissection, esmolol should be added. In patients with pre-eclampsia or eclampsia, magnesium and hydralazine are superior choices. The medications used depend on the specific circumstances.

For acute intracerebral hemorrhage, the preferred medications are labetalol, nicardipine, and esmolol; avoid nitroprusside and hydralazine. The treatment is based on clinical/radiographic evidence of increased intracranial pressure.

In aortic dissection, the preferred medications are labetalol, nicardipine, nitroprusside (with beta-blocker), esmolol, and morphine sulfate. However, avoid beta-blockers if aortic valvular regurgitation or suspected cardiac tamponade is present.

3D surgery
Wednesday, January 10, 2018

The device at Lenox Hill is called the Orbeye, made by Somed — a joint venture of Olympus and Sony — and marketed by Olympus. Dr. Langer has received consulting fees from the company.

Low platelet in cirrhosis
Friday, January 12, 2018
Thrombopoietin-Receptor Agonists for Liver Disease Thrombocytopenia
Thrombocytopenia associated with chronic liver disease is due, in part, to defective production of thrombopoietin. Whether novel thrombopoietin-receptor agonists are safe and effective in this setting was addressed by two groups of investigators.

Frelinger and colleagues evaluated the use of avatrombopag in 30 thrombocytopenic patients with liver disease undergoing invasive procedures (abstract 290). The drug was given to 20 patients in doses of 60 mg daily if the platelet count was <40,000/µL, and 40 mg if between 40,000 and 50,000/µL; 10 patients receive a placebo.

Platelet counts increased significantly with avatrombopag versus placebo (5300 to 36,300/µL vs. 1000 to 1700/µL; P<0.0001). Platelet counts increased, without an increase in circulating activated platelets or in vitro platelet reactivity, suggesting that thrombotic events might not be a problem with this agent.

Afdhal and colleagues evaluated the use of lusutrombopag, an orally available small molecule TPO receptor agonist, in a placebo-controlled trial of 180 patients with chronic liver disease undergoing invasive procedures (abstract 291). The drug was given in a dose of 3 mg/day for up to 7 days before and up to 28 days after the procedure, depending on the platelet count. More patients in the lusutrombopag group than the placebo group had an increase in platelet count to >50,000/µL (64.8% vs. 13.1%; P<0.0001) and did not require platelet transfusion or rescue therapy (72.5% vs. 20.2%; P<0.0001), regardless of baseline platelet count, age, body weight, or Child-Pugh score. Three lusutrombopag-treated patients died, but none of the deaths were assessed as related to the drug.

These two new orally administered thrombopoietin-receptor agonists appear to have efficacy in the management of liver-disease associated thrombocytopenia, and are undergoing continued evaluation

Hep b eradication
Friday, January 12, 2018
• Inarigivir: Inarigivir soproxil, or SB 9200, being developed by Spring Bank Pharmaceuticals, is an oral immune modulator that activates RIG-I (retinoic acid inducible gene I). It appears to both interfere with viral transcription and packaging (encapsidation) and stimulate interferon production. In the phase II ACHIEVE trial, patients who received 25 mg once-daily inarigivir monotherapy for 12 weeks followed by 12 weeks of tenofovir DF had a larger decrease in HBV viral load than those who received a placebo followed by tenofovir, with steeper declines seen in hepatitis B “e” antigen (HBeAg)-negative compared with HBeAg-positive patients. Six of the 16 treated participants had a sustained reduction in HBsAg levels of more than -0.5 log; some also saw declines in HBV RNA and HBeAg levels. Inarigivir was generally safe and well tolerated with no serious adverse events reported. Higher doses are currently being evaluated
• JNJ-56136379: JNJ-379, being developed by Janssen, binds to the HBV core protein, interfering with capsid disassembly when HBV enters cells and assembly of new capsids when the virus multiplies, resulting in production of non-functional viral particles. In a phase I study of 24 treatment-naive mostly HBeAg-negative chronic hepatitis B patients, 75 mg of JNJ-379 taken for 28 days reduced HBV DNA by 2.89 log. Three people who used the 75 mg dose — but none of those who used a 25 mg dose — reached an undetectable viral load. HBV RNA levels also declined, but there was no notable change in HBsAg levels. JNJ-379 was also generally safe and well tolerated. A 150 mg cohort is now enrolling
• REP 2139: REP 2139, being developed by Replicor, is a nucleic acid polymer that interferes with assembly and release of subviral particles from HBV-infected hepatocytes. In a phase II study of previously untreated HBeAg-negative chronic hepatitis B patients, eight out of 10 treated with weekly IV infusions of REP 2139 in combination with tenofovir DF and pegylated interferon for 48 weeks achieved HBsAg clearance (<1 IU/mL), increases in anti-HBs antibodies, and liver enzyme flares followed by normalization. This functional control persisted for up to 24 weeks after completing treatment, suggesting a potential cure. A related agent, REP 2165, did not perform as well.
• ARB-1467: ARB-1467, being developed by Arbutus Biopharma, consists of synthetic small interfering RNAs directed against HBV messenger RNAs. In a phase II clinical trial, 36 mostly HBeAg-negative chronic hepatitis B patients on tenofovir DF or entecavir received IV infusions of ARB-1467 or placebo at doses of 0.2 or 0.4 mg/kg once a month or biweekly for 12 weeks. Everyone treated with ARB-1467 saw a reduction in HBsAg, with the higher dose given biweekly producing the greatest decline. Seven of the 11 evaluable patients in the biweekly cohort (64%) were classified as responders and switched to monthly dosing for up to a year. The largest HBsAg decrease was 2.7 log, and five people in this group reached levels below 50 IU/mL; none, however, achieved HBsAg clearance. The researchers concluded that monthly dosing does not appear sufficient to maintain or improve initial HBsAg reductions achieved with biweekly administration and suggesting that combination therapy may be more effective. A forthcoming trial will evaluate ARB-1467 plus tenofovir and pegylated interferon.
While it remains to be seen whether it is possible to completely eradicate cccDNA from infected liver cells, research to date suggests that a functional cure, or sustained undetectable HBV DNA and HBsAg loss after stopping treatment, may be achievable. This would be expected to substantially reduce the likelihood of liver disease progression and the development of hepatocellular carcinoma, although t

Flu influenza A Rx
Saturday, January 13, 2018
• Antiviral treatment should be started as soon as possible after illness onset and should not be delayed even for a few hours to wait for the results of testing.
• The most accurate influenza tests are molecular assays.
• Neuraminidase inhibitors can benefit other individuals with influenza. Three prescription neuraminidase inhibitor antiviral medications are recommended for use the US during the 2017-2018 season: iseltamivir (Tamiflu), zanamivir (Relenza), and peramivir (Rapivab).

New Diabetes drug
Sunday, January 14, 2018
Lorcaserin is prescribed to help patients lose weight and works by regulating how hungry we feel. However, researchers have discovered that as well as doing this, the drug can also reduce glucose levels in the body and increase the body’s cells sensitivity to insulin.
When the body fails to produce enough insulin or the body’s cells fail to react to insulin this leads to Type 2 diabetes meaning that glucose remains in the blood rather than being used as fuel for energy.
Professor Lora Heisler, who is leading the Aberdeen team, explains: “Current medications for type 2 diabetes improve symptoms of this disease by acting in the body.
We have discovered that this obesity drug, lorcaserin, acts in the brain to improve type 2 diabetes.”
“Lorcaserin targets important brain hormones called pro-opiomelanocortin (POMC) peptides, which are responsible for regulating appetite.”

Sunday, January 14, 2018

CF and colon cancer
Sunday, January 14, 2018
Adults with cystic fibrosis (CF) should undergo screening colonoscopy for colorectal cancer every 5 years beginning at age 40 years, unless they have had a solid organ transplant – in which case, screening should begin at age 30 years. For both groups, screening intervals should be shortened to 3 years if any adenomatous polyps are recovered.
The new screening recommendation is 1 of 10 set forth by the Cystic Fibrosis Foundation, in conjunction with the American Gastroenterological Association. The document reflects the significantly increased risk of colorectal cancer among adults with the chronic lung disorder, Denis Hadjiliadis, MD,and his colleagues wrote in the February issue of Gastroenterology. CF patients face up to a 10-fold risk of colorectal cancer, compared with the general population; the risk approaches a 30-fold increase among CF patients who have undergone a lung transplant.

Wednesday, January 24, 2018
The medical textbooks don’t discuss isolated severe tricuspid regurgitation (ISTR) or its etiology. ISTR is a disorder of progressive right ventricular dilation and dysfunction whose etiology involves either longstanding atrial fibrillation or valvular disruption due to interference from a crossing lead of a permanent pacemaker or implantable cardioverter defibrillator.
“This is something different. These patients have a normal left heart and left heart valves and normal pressures, with no pulmonary hypertension. So it doesn’t fit into any of the textbook categories of tricuspid regurgitation,” the cardiologist said.
On physical examination, the patient will have elevated jugular venous pressure with large V waves.
“This is a clue that something is going on. The patient will have neck veins jumping up to her ear lobes. The ear lobes are going to wiggle with every heart beat – boom, boom, boom. If you see that, you start to figure out what’s going on. You need nothing else,” Dr. Nishimura said.
The patient will likely also have a pulsatile enlarged liver and, even though this is valve disease, a murmur that’s either soft or inaudible.
Echocardiography will show a dilated right ventricle and right atrium, a dilated inferior vena cava, and a normal left ventricle with no pulmonary hypertension. The classic sign of ISTR on continuous wave Doppler echocardiography is a dagger-shaped tricuspid regurgitation peak velocity signal of less than 2.5 meters/sec, which indicates the absence of pulmonary hypertension. This dagger shape occurs because the right atrial pressure equalizes the right ventricular pressure.
It’s also important to point the echo probe at the hepatic veins to spot another echocardiographic hallmark of ISTR: systolic reversal.

Thursday, January 25, 2018
296,439 individuals (30.1% with NAFLD) and nearly 16,000 cases of incident diabetes over a median of 5 years were included in the final analysis. Patients with NAFLD had a greater risk of incident diabetes than those without NAFLD (random-effects hazard ratio [HR] 2.22, 95% CI 1.84–2.60; I2 = 79.2%). Patients with more “severe” NAFLD were also more likely to develop incident diabetes; this risk increased across the ultrasonographic scores of steatosis (n = 3 studies), but it appeared to be even greater among NAFLD patients with advanced high NAFLD fibrosis score (n = 1 study; random-effects HR 4.74, 95% CI 3.54–5.94). Sensitivity analyses did not alter these findings. Funnel plot and Egger test did not reveal significant publication bias. Study limitations included high heterogeneity, varying degrees of confounder adjustment across individual studies, and lack of studies using liver biopsy.
CONCLUSIONS NAFLD is significantly associated with a twofold increased risk of incident diabetes. However, the observational design of the eligible studies does not allow for proving causality.

Stroke lysis
Thursday, January 25, 2018

Tenecteplase (TNKase) is a more powerful thrombolytic for large vessel acute ischemic stroke than alteplase (Activase) but just as safe, the EXTEND-IA TNK trial showed.

Lymphoma and IBD
Friday, January 26, 2018

the risk of lymphoma was higher among those exposed to either therapy or both therapies in combination. Thiopurine monotherapy had an adjusted hazard ratio (aHR) of 2.60 (95% CI 1.96-3.44, P<0.001), while anti-TNF monotherapy had an aHR of 2.41 (95% CI 1.60-3.64, P<0.001). Combination therapy had the highest aHR – 6.11 (95% CI 3.46-10.8, P<0.001).

C diff in hospital
Sunday, January 28, 2018
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (Pless than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

CMx for coloncancer
Sunday, January 28, 2018

Dr. Tsai noted that the CTC assay’s sensitivity of nearly 77% for precancer compares favorably with that of a variety of other screening tests, such as the stool guaiac test for fecal occult blood (2%-10%), FIT alone (23.8%), and a stool DNA test combined with FIT (42%), and, in fact, falls within the range reported for colonoscopy (76%-94%).
Circulating tumor cells

Crohns poor response
Wednesday, January 31, 2018
• Among 858 IBD patients, including 562 with Crohn’s disease, anti-CBir1 seropositivity and low socioeconomic status were independently associated with greater use of health resources.
• However, a diagnosis of Crohn’s disease seemed to lower inpatient healthcare resource utilization in patients who required at least 1 visit to the ED or hospitalization.

Smokers paradox
Thursday, February 1, 2018

Dr. Khan and his associates also found that a higher proportion of female CD patients were smokers, compared with female UC patients (57% vs. 47.3%; P less than .001), and that mortality among UC and CD patients with no smoking history was higher than that of their counterparts who had a smoking history (2.5% vs. 1.2% and 1.2% vs. 0.7%, respectively; P less than .001 for both associations).
Dr. Khan and his associates also found that a higher proportion of female CD patients were smokers, compared with female UC patients (57% vs. 47.3%; P less than .001), and that mortality among UC and CD patients with no smoking history was higher than that of their counterparts who had a smoking history (2.5% vs. 1.2% and 1.2% vs. 0.7%, respectively; P less than .001 for both associations).

In fact, a recent analysis of a nationwide cohort of patients who underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction found that smokers had significantly lower risk‐adjusted in‐hospital mortality, compared with nonsmokers (J Am Heart Assoc. 2016 Apr 22;5:e003370. doi:

Friday, February 2, 2018

Acid plus bile 56 % acid 30 and bile is 14%

Marshmallow bagel swallow

DCI 550 and above
70% or more successful swallows
Amplitude pressure more than35
Match pressures and symptoms

GERD HRQL on all patients

Ppi alternative
Friday, February 2, 2018

Vonoprazan acid inhibitor

Coffee and cancer
Friday, February 2, 2018
Coffee contains traces of acrylamide, a chemical formed during the roasting process that CERT believes is cancerous. The American Cancer Society has conducted several case studies on acrylamide since 2002, but found no definitive proof of a correlation with cancer.
If no settlement is reached during the Feb. 8 mediation session, a judge will make a decision later this year.

Friday, February 2, 2018

SMSA is a simple, readily applicable, clinical score that identifies a subgroup of patients who are at increased risk of failed EMR, adverse events, and adenoma recurrence at surveillance colonoscopy. This information may be useful for improving informed consent, planning endoscopy lists, and developing quality control measures for practitioners of EMR, with potential implications for EMR benchmarking and training
SMSA is a simple, readily applicable, clinical score that identifies a subgroup of patients who are at increased risk of failed EMR, adverse events, and adenoma recurrence at surveillance colonoscopy. This information may be useful for improving informed consent, planning endoscopy lists, and developing quality control measures for practitioners of EMR, with potential implications for EMR benchmarking and training

Hyperplastiic polyp
Friday, February 2, 2018

Patients with small and diminutive proximal HPs tend to harbor higher rates of synchronous AN compared with those without any serrated lesions detected on screening colonoscopy. Surveillance outcomes for metachronous advanced neoplasia for patients with small proximal HPs deserves further study. The synchronous AN rate in patients with proximal diminutive HP is similar to that of proximal diminutive SSP, and could have implications in a resect and discard strategy.

Saturday, February 3, 2018

Still other pharmacologic agents with novel mechanisms of action are currently under investigation. Tenapanor, an inhibitor of a particular sodium/potassium exchanger in the gut lumen, mitigates intestinal sodium absorption, which increases fluid volume and transit. A recent phase 2 study demonstrated significantly increased stool frequency relative to placebo in patients with IBS-C.23 Elobixibat, an ileal bile acid transport inhibitor, promotes colonic retention of bile acids and, in placebo-controlled studies, has led to accelerated colonic transit and an increased number of spontaneous bowel movements in patients with CIC.24

Saturday, February 3, 2018

An abnormal qualitative assessment on digital rectal examination should trigger a more formal characterization of the patient’s defecatory mechanics via anorectal manometry (ARM) and balloon expulsion testing (BET). Likewise, a lack of response to initial pharmacotherapy should prompt suspicion for outlet dysfunction, which can be queried with functional testing even if a rectal examination is qualitatively unrevealing.

Cardiac risk factor. CHIP
Sunday, February 4, 2018

They have learned that a bizarre accumulation of mutated stem cells in bone marrow increases a person’s risk of dying within a decade, usually from a heart attack or stroke, by 40 or 50 percent. They named the condition with medical jargon: clonal hematopoiesis of indeterminate potential.

CHIP has emerged as a risk for heart attack and stroke that is as powerful as high LDL or high blood pressure but it acts independently of them. And CHIP is not uncommon.
The condition becomes more likely with age. Up to 20 percent of people in their 60s have it, and perhaps 50 percent of those in their 80s.

Cabozantinib for hepatoma hcc
Thursday, February 8, 2018

SSRI withdrawal
Thursday, February 8, 2018

Serotonin syndrome (SS) is diagnosed by the clinical triad of dysautonomia (fever, mydriasis, diaphoresis, tachycardia), neuromuscular signs (ataxia, hyperreflexia, tremor, myoclonus), and altered mental status (seizures, delirium). Two validated criteria groups are accepted, the Hunter criteria and the Sternbach criteria. These criteria require a menu-like approach of clinical manifestations of the above signs with known addition or increase of a serotonergic medication and the absence of other possible causes, such as neuroleptics.

• Desvenlafaxine (Pristiq, Khedezla)
• Duloxetine (Cymbalta) ― also approved to treat anxiety and certain types of chronic pain
• Levomilnacipran (Fetzima)
• Venlafaxine (Effexor XR) ― also approved to treat anxiety and panic disorder

• Nausea
• Dry mouth
• Dizziness
• Headache
• Excessive sweating
Other possible side effects may include:
• Tiredness
• Constipation
• Insomnia
• Changes in sexual function, such as reduced sexual desire, difficulty reaching orgasm or the inability to maintain an erection (erectile dysfunction)
• Loss of appetite

Saturday, February 10, 2018

Takotsubo cardiomyopathy
More common in women, physical or emotional stress can trigger it , ( more physical ), associated with seizure , near drowning but does not cause SUDEP

• Learning of the death of a loved one
• Bad financial news
• Legal problems
• Natural disasters
• Motor vehicle collisions
• Exacerbation of a chronic medical illness
• Newly diagnosed, significant medical condition
• Surgery
• Intensive care unit (ICU) stay
• Use of or withdrawal from illicit drugs

• Markers

• Ratio of NTproBNP to troponin I
• Ratio of NTproBNP to creatine kinase MB (CKMB) mass
• Ratio of NTproBNP to EF

In addition to evaluating wall-motion abnormalities and LVEF, cardiac MRI has been found to differentiate Takotsubo cardiomyopathy, which is characterized by the absence of delayed gadolinium hyperenhancement, from MI and myocarditis, in which the opposite occurs.

They have normal cath

Elastography MRE
Wednesday, February 14, 2018

Dr. Caussy of the University of California, San Diego, and her colleagues had noted that MRE and TE had discordant findings in obese patients. To ascertain under what conditions TE and MRE produce the same readings, Dr. Caussy and her associates conducted a cross-sectional study of two cohorts with nonalcoholic fatty liver disease (NAFLD) who underwent contemporaneous MRE, TE, and liver biopsy. TE utilized both M and XL probes during imaging. The training cohort involved 119 adult patients undergoing NAFLD testing from October 2011 through January 2017. The validation cohort, consisting of 75 adults with NAFLD undergoing liver imaging from March 2010 through May 2013, was formed to validate the findings of the training cohort.

Friday, February 16, 2018

The Brain Trauma Indicator measures levels of two proteins — ubiquitin C-terminal hydrolase and glial fibrillary acidic protein — that are released from the brain into blood and measured within 12 hours of head injury.

Pharmacy discounts
Sunday, February 18, 2018
For physicians in US
How GoodRx works

Pharmacy buy a drug for X dollars
They mark it up for example to 5X. This is known as usual and customary rate (U and C)

U and C is what consumers pay By law this price has to be maintained

There is a division of pharmacy called PBM ( Pharnacy benefit management ). They can negotiate a contract with insurances and others to sell drugs for a lower price. This could be for example 70 % less. So price would be 0.7 of 5X

This is where Good Rx enters. Individuals cannot negotiate price. But good Rx can negotiate with PBM and give discount coupons.
These coupons are given to consumers and at times less expensive than even the co pay of insurance negotiated price

Surgical glue metro
Thursday, February 22, 2018
It’s actually not glue – but it is protein from elastin fibers in human
Not metro but MeTro
MeTro is shorthand for methacryloyl-substituted tropoelastin — a protein derived from the elastic fibers that make up human tissue,” the authors explained.

IBD IBS overlap
Friday, February 23, 2018

If there is history of severe IBD later symptoms of IBS MORE likely
Check FCP
More common in smokers

GERD Lyon criteria
Friday, February 23, 2018

Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and

Pancreatitis and P cancer
Saturday, February 24, 2018

Pancreatitis increases Rick of pancreatic cancer 20 x in first two years and the 2x after 2 years in general population

Weight loss
Saturday, February 24, 2018
testing its oral semaglutide were released this week, showing that 3 mg, 7 mg, and 14 mg of the pill were superior to placebo for weight loss. (Reuters)
When taken three times a day, the blood pressure drug methyldopa was successful at preventing type 1 diabetes onset in about 60% of those at risk. A l

T1D prevention methyldopa
Saturday, February 24, 2018

testing its oral semaglutide were released this week, showing that 3 mg, 7 mg, and 14 mg of the pill were superior to placebo for weight loss. (Reuters)
When taken three times a day, the blood pressure drug methyldopa was successful at preventing type 1 diabetes onset in about 60% of those at risk. A l

GFD Concerns
Thursday, March 1, 2018

Arsenic and heavy metal
Folate b12 and D def
Cost is twice as much
Prefer natural GFD OVER substitutes

Thursday, March 1, 2018

Two types EA and NEA ( eosinophilia asthma and non eosinophilic asthma )

NEA 4 phenotypes – 2 with neutrophilia and 2 with absence of airway inflammation
They respond to Macrolides, statins, glitazones, and phosphodiesterase-4 inhibitors have shown improvements in specific outcomes in small studies.

EA – 8 phenotypes. Best response to steroids
targeting interleukin-5 (mepolizumab and reslizumab) and its receptor (benralizumab) highlight the potential benefits from phenotyping asthma and understanding the underlying molecular pathways.

Source The American Journal of Respiratory and Critical Care Medicine started the new year with a review article[2] summarizing what we know about the different clinical, cellular, and molecular types of asthma.

Friday, March 9, 2018

A Norwegian study has found that fructan is somewhat more likely than gluten to induce the symptoms of non-celiac related gluten sensitivity (NCGS), a term first used in 1978.

UC new approval
Friday, March 9, 2018

Pfizer’s two phase III clinical trials included both induction and maintenance phases, with 8 weeks of induction using a 10-mg twice daily dose and 44 additional weeks of maintenance with 5 mg or 10 mg twice daily doses. The two studies included 1,139 patients.

Xeljanz Tofacitinab

RF with uncontrolled HTN
Friday, March 9, 2018

A group of 96 adults who had resistant hypertension without moderate or severe renal insufficiency were enrolled with baseline office systolic blood pressure averaging 176 mm Hg and 24-hour ambulatory pressure of 156 mm Hg.
Twelve months after renal denervation, their office and ambulatory blood pressures fell by 15 mm Hg and 7.5 mm Hg, respectively (P<0.001 for both), according to Joost Daemen, MD, PhD, of Erasmus Medical Center in Rotterdam, the Netherlands.

Acute MI in paraplegics
Friday, March 9, 2018

Unique population


Stent in diabetes
Friday, March 9, 2018
An abluminal-coated sirolimus-eluting stent with a biodegradable polymer showed promise for PCI in patients with diabetes, one researcher reported.
One year after implantation of the Abluminus DES+, diabetes patients were not at increased risk of major adverse cardiac events compared to peers without diabetes (3.31% versus 2.33%, P=0.198). This held up for the individual components of that composite endpoint:

Sunday, March 11, 2018

The guideline addresses the initial 2-week period of treating acute pancreatitis. It defines goal-directed fluid therapy as titration based on meaningful targets, such as heart rate, mean arterial pressure, central venous pressure, urine output, blood urea nitrogen concentration, and hematocrit.

Early food. And either normal saline or RL
No role for early ERCP
Same admission cholecystectomy

Sunday, March 11, 2018

Dr Christie’s team have successfully identified this fifth molecule as Tetraspanin-7, which could make tests for predicting Type 1 diabetes more accurate.

Statin and mortality
Tuesday, March 13, 2018
Back in 2002, the ALLHAT-LLT trial, an unblinded, randomized, 6-year trial of pravastatin versus usual care in patients with hypertension and dyslipidemia found no significant reduction in all-cause mortality or coronary heart disease events with the statin.
The recent post hoc analysis of the almost 3000 participants ≥65 years of age suggested that statins for primary prevention do not lower the risk for cardiovascular (CV) or all-cause mortality in older adults with CV risk factors. While not statistically significant, there was a trend towards increased all-cause mortality in patients ≥75 years taking statins. The trial has well-recognized limitations, and experts cautioned that the trial was not originally designed to study statins in older adults and that the analyses are underpowered.

Statin myalgia
Tuesday, March 13, 2018

Statin can lower vitamin D

Causes myalgia

Use vitamin D for myalgia

Factor x reversal
Wednesday, March 14, 2018

We have shown that andexanet is both effective and safe and once it is approved and becomes available is a drug that will be very helpful to physicians who are treating the acutely bleeding patient,” Connolly said.

NASH cancer
Wednesday, March 14, 2018

At the same time, even a conservative linear model for the changing prevalence of NASH forecast a rapid increase from 1.37 million cases in 2005 to 17.95 million in 2025. The exponential model suggested an increase from 2.41 million in 2005 to 42.34 million in 2025.

Wednesday, March 14, 2018

Esophagus clears in 8-10 seconds
Rapid swallowing stops peristalsis
It is Deglutitive inhibution

Secondary peristalsis – ues does not relax
After peristalsis there is 15 sec refractory aperistalsis
So swallows done every 30 sec

Phrenic ampulla – contractile deceleration point – bulging of lower esophagus with swallow
Lower 2/3 is called distal contractile integral but above phrenic ampulla

High pressure zone HPZ – in lower esophagus

Types of swallow- five rapid swallows, upright and solid ( toast and saline )

Cine – bagel or marshmallow

PIP IS pressure inversion point where from bottom to going up becomes positive to negative. That is diaphragm

Sphincter 3-5 cm
Intra abd sphincter should be more than 1.5 cm

Distal sphincter minus PIP is abd length of LES
If meg ?

Sphincter pressure is 10-45 during mid respiration

Sphincter pressure only is 6-35
Chicago classification. LES relaxation should be less than 20. Medtronic uses 15. Caked IRP 4 since it measures 4 lowest pressure from UES LES relaxation simultaneously

With swallow both UES and LES relaxes at same time

Grey line for pressure
Black line fir velocity

DP IS decelerating point. Use black line

Skeletal muscle narrow resolution
Smooth wide on resolution
Sphincter narrow again

DCI distal contraction integral – distance x time x pressure – 20. Normal is 450 – 8000

Old way was amplitude ( 30-220) and time 1-6 sec)

Chicago velocity should be less than 9 cm / sec

Distal latency normal more than 4.5 cm time from start of food to deceleration point

If less than 4.5. Premature contractions

Peristaltic break less than 5 cm. Weak pressure less than 20 milimeter pressure

Three types of IBPO intrabolus pressure pattern

Compartmentalizations , columnixation and eegj pressure

CV contractile vigor – normal, weak, failed hyperconteactile

Contractile pattern – intact, fragmented, ( more than 5) premature ( less than 4.5)

More than 8 of liquid or 7 for viscous must go through

Skeletal – done with wave, 30-220 pressure and time is ??

UES – 30-118 pressure
Amplitude more than 60 mm, and relaxation less than 8 ?
Do 3-5 measurements

Multiple rapid swallow, only look for DCI

And do ratio of DCI of multiple swallow to single swallow. multiple should be more

Chronic narcotic may cause type 3 achalasia (vigorous)

Eso abnormality – pressure or motility abnormality

Sluggish motility – consider heavy metal screening, paraneoplastic syndrome

Phrenic ampulla, just above sphincter where barium drops down and peristalsis eventually pushes out later when pressure exceeeds 30 mm in distal esophagus

Dysphagia can occur during ovulation catamenalia dysphagia
DES – velocity less than 8 cm / sec due to simultantous contraction with Distal latency less than 4.5 sec
And have 2 or emore liquid abnormality but if all abnormal then type 3 achalasia

Nutcracker esophagus : high amplitude, longer than 6 sec and normal peristalsis

Now called JACKHAMMER – if 20% of swallows with DCI more than 8000 and normal DL more than 4.5 sec

Scleroderma features occur in radiation fibrosis, MCTD, dermatomyositis, SLE, amyloidosis

SSC (scleroderma like esophagus)

ineffective esophageal motility : ocurs with chronic cough, asthma and heartburn. Important to diagnose before fundoplication and shows imedance abnormality. More than 50% persistalsis ineffective. Weak DCI has 100-450. Absent is les than100. Fragmented motility – peristaltic break is more than 5 or island hopping in DCI contraction

Impedance abnormality – is entry 50% lowering of UES pressure and then 3 exit pressures which go above baseline and lasts in distal probes. Always look for retained fluid in esophagus to draw mid pressure

4 sec IRP – integrated relaxation pressure

Peristaltic break at junction of skeletal and smooth. Normal less than 5 cm.

Achalasia when IRP upper limit of normal and 100% failed perstalsis or spasm. Simultaneous relaxation of the UES and LES does not occur

If IRP is upper limit of normal and sufficient perstalsis . EGJ outflow obstruction, mechanical obs or incompletely expressed achalasia

EGJ obstruction can be from fat around esophagus like omental fat (high IRP but normal peristalsis)

EGJ obstruction, – epiprenic diverticulum
Stiletto pattern with anatomic obstruction

Reflux – symptom index
Symptom associated assessment SAP score more than more than 95% and SI more than 50 and must have 3 events

Do not use ba swallow to diagnose GERD

AET more thsn6 % is abnormal
AET less than 4 is normal

Thursday, March 15, 2018

Fecal profiling of volatile organic compounds (VOCs) may provide a low cost, non-invasive tool to predict the responses of irritable bowel syndrome (IBS) patients to probiotics and diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), according to British researchers.
Modeling baseline fecal VOCs, and using key features of VOC profiles, correctly predicted response to a low-FODMAP diet in 100% of patients and in 89% of patients receiving a probiotic, reported Megan Rossi, PhD, RD of King’s College in London, and colleagues.

HIV antibody
Saturday, March 17, 2018
first-in-class agent for HIV infection targeting the CD4 protein, ibalizumab-uiyk (Trogarzo), won FDA approval Tuesday, the agency announced.

first-in-class agent for HIV infection targeting the CD4 protein, ibalizumab-uiyk (Trogarzo), won FDA approval Tuesday, the agency announced.

NASH drugs
Friday, March 23, 2018
There are many trials of agents ranging from phase 1 to phase 3, encompassing several mechanisms that may be important to the pathogenesis of NAFLD,” Chung said. “Some promising approaches include FXR [farnesoid X receptor] agonists, PPAR [peroxisome proliferator-activated receptor] agonists, ASK1 [apoptosis signal-regulating kinase 1] inhibitors, ACC1 [acetyl-CoA carboxylase 1] inhibitors, and CCR2/CCR5 inhibitors.”
Rohit Loomba, MD, director of the NAFLD Research Center at the University of California at San Diego, told MedPage Today that several drugs are currently in phase 3 trials, including obeticholic acid, selonsertib, elafibrinor, and cenicriviroc, and that there are more than 50 drugs in the pipeline. These include:
• Obeticholic acid (Ocaliva), a synthetic bile acid that acts as an FXR agonist, is approved for the treatment of primary biliary cholangitis; it has shown promise for primary sclerosing cholangitis, and is being studied as a treatment for NASH. Obeticholic acid can cause severe adverse events in people with decompensated liver disease, however, prompting the FDA to require a “Black Box” warning
• Selonsertib (GS-4997), an ASK1 inhibitor that interferes with a signaling pathway that promotes inflammation and fibrosis. Loomba presented Phase 2 data at the 2016 Liver Meeting showing that the drug was safe and effective for patients with NASH and moderate to advanced fibrosis
• Elafibranor (GFT505), a PPAR alpha and delta agonist that improves insulin sensitivity and lipid metabolism and reduces inflammation. The drug did not meet its primary endpoint of reversing NASH without worsening fibrosis in the GOLDEN trial, but did improve steatosis and fibrosis in a subset of patients with moderate or severe NASH
• Cenicriviroc, a dual CCR5 and CCR2 receptor inhibitor that was previously evaluated as a treatment for HIV and is now under study for NASH. Friedman presented results from the Phase 2 CENTAUR studyat the 2017 Liver Meeting, showing that although cenicriviroc did not reduce the severity of steatosis or liver inflammation more than placebo, it did lead to a significant reduction in fibrosis. Cenicriviroc is now being tested further in the Phase 3 AURORA trial
• GS-0976 is an ACC inhibitor that interferes with de novo lipogenesis, or conversion of carbohydrates into fatty acids in the liver. In another presentation at last year’s Liver Meeting, Loomba reported that the drug led to significant reductions in liver fat accumulation and fibrosis in NASH patients in a Phase 2 study
• BMS-986036 is a recombinant fibroblast growth factor 21 analog that improved steatosis, hepatocyte ballooning, and liver inflammation in preclinical studies. Arun Sanyal, MD, of Virginia Commonwealth University in Richmond, reported Phase 2 study results at the Liver Meeting, showing that the drug significantly decreased liver fat and led to improved biomarkers of fibrosis and inflammation in people with NASH

Hyperemesis gravidarum
Friday, March 23, 2018
• Treatment

• Mild symptoms: ginger, pyridoxine, pyridoxine-doxylamine, antihistamines, metoclopramide
• Moderate symptoms: pyridoxine-doxylamine, antihistamines, promethazine, metoclopramide
• Severe symptoms: ondansetron, corticosteroids (when other treatments have failed)
• Other methods that have shown promise according to McParlin include hypnotherapy and acupressure at pressure point Pericardium 6. Anecdotally, women have found relief eating smaller more frequent meals, and eating and drinking separately—both of which avoid over-stretching and irritating the stomach, making it more likely that the food and fluid will be tolerated.
• Plenty of rest

Functional dyspepsia
Friday, March 23, 2018

.75 mg of capsicain reproduces symptoms
Sensitivity 60% specificity 90%

PASS score for pancreatitis
Friday, March 23, 2018

High dose steroids
Sunday, March 25, 2018

More than 3000 mg in a year

That is 10 weeks of 40 mg a day

The 1,879 Crohn’s disease patients who entered the cohort as new users of anti-TNF therapy had a subsequent mortality incidence rate of 21.4 per 1,000 person-years, compared with a rate of 30.1 per 1,000 person-years in the 7,694 who entered the study period as prolonged steroid users. In a multivariate analysis accounting for 57 potential confounding factors, this translated to a highly significant 22% relative risk reduction in mortality in the patients who went with anti-TNF therapy (Am J Gastroenterol. 2018 Jan 16. doi:

High fiber diet and microbiome
Tuesday, March 27, 2018

Of the 141 strains of SCFA-producing gut bacteria identified by next-generation sequencing, only 15 strains belonging to Firmicutes, Actinobacteria and Proteobacteriaphyla were promoted by consuming a high fibre diet and the response was strain-specific.

Pseudomelanosis Duodeni
Wednesday, March 28, 2018
Answer: Pseudomelanosis Duodeni

Our patient was diagnosed with pseudomelanosis duodeni. This is a rare condition where dark pigmented granules are noted inside the macrophages at the tips of duodenal villi. The pigmentation, which consists largely of ferrous sulfide, is endoscopically visible in roughly one-third of cases,1 and gives the duodenum a dark speckled appearance. Pseudomelanosis duodeni is more common in elderly women, and is strongly associated with oral iron intake, hypertension, end-stage renal disease, certain medications, and diabetes.1

The etiology of pseudomelanosis duodeni is unclear. Oral iron supplementation and gastrointestinal bleeding have been proposed as possible sources of the deposited iron. However, although 76% of cases of pseudomelanosis duodeni in case series were on iron supplementation, the majority of individuals taking iron do not develop this condition, and the risk seems to be greatest in those with multiple comorbidities. Proposed causes for the iron deposition include impaired luminal iron transport owing to coupling with sulfur and intramucosal hemorrhage.

Wednesday, March 28, 2018

Other name


IBD from bariatric surgery
Tuesday, April 3, 2018

Dr. Ungaro and his colleagues found that any type of bariatric surgery increased the odds of developing IBD (adjusted odds ratio, 1.45; 95% confidence interval, 1.08-1.94). Interestingly, only past history of bariatric surgery was associated with an almost twofold increase in onset of IBD. The study also revealed that bariatric surgeries prior to 2008 were associated with an increase chance of developing IBD.

More common after reux surgery

Barretts scoring system
Tuesday, April 3, 2018

Those risk factors included sex, smoking, length of Barrett’s esophagus, and the presence of baseline low-grade dysplasia, said Sravanthi Parasa, MD, of Swedish Medical Center, Seattle, and her associates. For example, a male with a history of smoking found to have a 5-cm, nondysplastic Barrett’s esophagus on histology during his index endoscopy would fall into the model’s intermediate risk category, with a 0.7% annual risk of progression to high-grade dysplasia

Ascitis Q questionaire
Tuesday, April 3, 2018

Higher scores on the Ascites-Q (r = 0.477; P < .001), the FACIT-AI (r = 0.317; P = .007) and the ASI-7 (r = 0.34; P = .004) correlated with lower QoL VAS scores, but only the Ascites-Q showed convergent validity.

Friday, April 6, 2018

Causes renal failure
2 types 1 and 2
China has vaccine
Zoonotic. – eating pork, boar deer

OLT Failure marker
Sunday, April 8, 2018

Glycomic alterations of immunoglobulin G “represent inflammatory disturbances in the liver that [mean it] will fail after transplantation,” wrote Xavier Verhelst, MD, of Ghent (Belgium) University Hospital, and his associates. The new glycomarker “could be a tool to safely select high-risk organs for liver transplantation that otherwise would be discarded from the donor pool based on a conventional clinical assessment,” and also could help prevent engraftment failures. “To our knowledge, not a single biomarker has demonstrated the same accuracy today,” they wrote in the April issue of Gastroenterology.

Alzheimer’s bio markers
Tuesday, April 10, 2018
The paradigm recasts Alzheimer’s from a symptomatic syndrome validated by biomarkers to a strictly biological construct defined by the presence of amyloid beta (AB), tau, and neuronal damage.

AB is the key to this classification paradigm – any patient with it (A+) is on the Alzheimer’s continuum. But only those with both amyloid and tau in the brain (A+T+) receive the “Alzheimer’s disease” classification. A third biomarker, neurodegeneration, may be either present or absent for an Alzheimer’s disease profile (N+ or N-). Cognitive staging adds important details, but remains secondary to the biomarker classification.

Tuesday, April 10, 2018

In a 5-year study of patients with IBS in Sweden, we found three classes of GI symptom development. We found levels of GI-specific anxiety to associate with GI symptom severity and quality of life 1 year later. Clinicians should be aware of GI-specific anxiety in patients with IBS, to identify patients at risk for lack of long-term symptom improvement with standard medical treatment.

Nash rx
Friday, April 13, 2018
MGL-3196 was well-tolerated and most adverse events were mild (85%) or moderate (15%). The researchers did not consider the three observed severe adverse events related to treatment.

“MGL-3196 significantly reduced blood pressure and multiple atherogenic lipids which provides support for potential cardiobeneficial effects in NASH patients who most frequently die of cardiovascular disease,” Harrison concluded. “Histopathologic assessment by 36-week liver biopsy will allow for correlations with the baseline biopsy in addition to multiple 12-week and 36-week noninvasive imaging and biomarker assessments.” – by Talitha Bennett

CHF Management
Saturday, April 14, 2018
Cornerstone medications for reduced ejection fraction HF include beta blockers and either angiotensin converting-enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). In general, when initiating treatment for HF, ACEIs/ARBs may be better suited for patients with volume overload, whereas beta blockers might be preferred for patients without excess fluid. Beta blockers and ACEIs/ARBs may be initiated simultaneously if done cautiously.
For patients with persistent class II or III HF symptoms despite treatment with beta blockers and ACEIs/ARBs, clinicians should consider a switch to an ARNI. ARNIs increase serum levels of angiotensin, and patients should have a 36-hour washout period after terminating ACEI therapy before initiating an ARNI. No such washout period is necessary in transitioning from an ARB to an ARNI.
An ARNI may be considered for treatment in ACEI/ARB-naive patients, although there are no predicate data to support this practice.
The recommendations emphasize the need to titrate HF medications to the most effective dose. In general, higher doses of beta blockers and ACEIs/ARBs result in better hospitalization and mortality outcomes.
However, for patients with persistent HF symptoms and a resting heart rate of more than 70 beats per minute, adding ivabradine may improve the risk for HF hospitalization. Ivabradine should only be used among patients with sinus rhythm.
Pharmacotherapy for HF can be adjusted every 2 weeks to optimize treatment. Ideally, patients should achieve optimal medical therapy within 3 to 6 months of their HF diagnosis.
Treatment for HF with doses above those prescribed applied in clinical trials is not proven more effective than routine dosing and should be avoided.
Hydralazine/isosorbide dinitrate is underused among African American adults with HF but should be initiated among these patients after treatment with beta blockers and ACEI/ARB is established.
Renal function and serum potassium should be evaluated within 2 weeks of changes to a dose of an ACEI/ARB/ARNI. Afterward, these values should be assessed at least monthly for 3 months, and then at least every 3 months routinely.
Renal function should be assessed within 2 to 3 days of increasing the dose of loop diuretics.
ARNIs may lower blood pressure, and a more conservative titration schedule for ARNIs can reduce the risk for adverse effects related to ARNIs.
Reasons enumerated for a referral to a HF specialist include:
need for chronic intravenous inotropes;
persistent class III or IV HF symptoms;
persistent hypotension;
serum creatinine 1.8 mg/dL or more, or blood urea nitrogen 43 mg/dL or more;
incident arrhythmia;
2 or more emergency department visits or hospitalizations for HF in the last year; and
inability to tolerate guideline-based therapy.

Esketamine nasal spray brings fast relief of depressive symptoms
Monday, April 16, 2018

Emotion alexithymia
Tuesday, April 17, 2018
Heightened alexithymia may explain poor sleep quality, a pair of studies shows.

Alexithymia is a condition characterized by difficulty identifying and expressing one’s emotions. “The mechanism by which alexithymia confers risk of disrupted sleep remains unclear, [but] suggestions include increased nocturnal arousal as a result of poor verbalization of emotions and increased light sleep,” wrote Jennifer Murphy

Tuesday, April 17, 2018

Treatment with the investigative agent NGM282 failed to reduce alkaline phosphatase (ALP) in patients with primary sclerosing cholangitis (PSC), but did lead to changes in

Wednesday, April 18, 2018

Empagliflozin, an oral sodium-glucose cotransporter 2 (SGLT-2), reduced liver fat by 5% and improved ALT in patients with nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus, according to a study presented at the annual meeting of the Endocrine Society.

CVD 2018 diet recommendations
Saturday, April 21, 2018

Lifestyle modification focusing on weight loss (if indicated); the reduction of saturated fat, trans fat, and cholesterol intake; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. (Grade A recommendation)
Use aspirin therapy (75-162 mg/day) as secondary prevention in those with diabetes and a history of ASCVD. (Grade A recommendation)

Viscous fiber
Saturday, April 21, 2018

Soluble and insoluble fiber
Soluble fiber is better

Two types of soluble fiber – viscous and non viscous

Viscous is better.

Viscous soluble fibers such as pectins, β-glucans, psyllium, glucomannan and guar gum all thicken in water, forming a gel-like substance that “sits” in the gut (22).

This gel slows down the emptying of the stomach and increases the time it takes to digest and absorb nutrients. The end result is a prolonged feeling of fullness and a significantly reduced appetite (23, 24).

There is some evidence that the weight loss effects of fiber target the belly fat specifically, which is the harmful fat in the abdominal cavity that is strongly associated with metabolic disease (25).

A very large review study found that psyllium and guar gum (both soluble, viscous fibers) are ineffective as weight loss supplements (26).

One notable exception is glucomannan, a fiber extracted from the konjac root.

This is one of the most viscous dietary fibers known, and has been shown to cause modest weight loss when used as a supplement (27, 28, 29).

Saturday, April 21, 2018

We found that the absence of gastric acid promotes growth of Enterococcus bacteria in the intestines and translocation to the liver, where they exacerbate inflammation and worsen chronic liver disease.”

the rate of liver disease in people who chronically abuse alcohol was 8.3 percent higher for those who actively use PPIs compared to those who never used the acid-blocking medications.

alcohol consumption and mortality
Tuesday, April 24, 2018

A person’s risk of death shot up as they drank more. The researchers used a mathematical model to estimate that people who consumed between seven and 14 drinks per week had a lower life expectancy at age 40 of about six months; people who drank between 14 and 24 drinks per week had one to two years shaved off their lives; and people who imbibed more than 24 drinks a week had a lower life expectancy of four to five years.

The non drinkers in past had higher mortality because they were sicker sub population

HCV Vaccine response
Thursday, April 26, 2018
In patients with chronic hepatitis C (HCV) and HIV infection, blood protein markers showing evidence of systemic inflammation were associated with a poor immune response to hepatitis A/hepatitis B vaccination, according to a study of blood samples obtained in two small clinical trials.

Prevaccination plasma levels of inflammatory proteins IP10, IL-6, and sCD14 were elevated in both HCV- and HIV-infected patients, while sCD163 was also elevated in HCV-infected patients, according to the report in Vaccine.

Vitamin D low and T2D
Thursday, April 26, 2018

We found that participants with blood levels of 25-hydroxyvitamin D that were above 30 ng/mL had one third of the risk of diabetes, and those with levels above 50 ng/mL had one fifth of the risk of developing diabetes [compared with those whose levels were < 30 ng/mL],” said lead author Sue K Park, MD, Seoul National University College of Medicine, South Korea, in a press release by the University of California, San Diego (UCSD), where some of the team are based.

Acupuncture constipation
Monday, April 30, 2018

Monday, April 30, 2018

Can be helpful in necrotizing enterocolitis in infants
Helps in depression with patients IBS
Bufidobacterium longum helps celiac
It reduces morbidity not mortality with OLT
Helps with HE
Prevents antiobiotic associated diarrhea in children 11% reduction
Weight loss with dairy probiotics ? Maybe
May help peanut allergy with desensitized protocol

Chest pain in teens
Tuesday, May 1, 2018

Precordial catch syndrome or Texidors twinge

Thursday, May 3, 2018

The use of nebivolol as part of a multidrug regimen to treat hypertension was associated with a significantly lower cardiovascular event risk than was combination antihypertensive therapy featuring either metoprolol or atenolol in a large observational study, Brent M. Egan, MD, reported at the annual meeting of the American College of Cardiology.

depression gene testing
Monday, May 7, 2018

Right now, there is overwhelming evidence of efficacy for drugs that are in the SSRI [selective serotonin reuptake inhibitor] or SNRI [serotonin-norepinephrine reuptake inhibitor] class, and these are considered first-line drugs for major depression, and approximately 50% of patients will respond to that first treatment,” Murrough noted.

The GeneSight test combines personal genetic data with medication information to shorten the road to recovery. The information involves 12 genes and 56 medications. DNA samples are taken with cheek swabs, which are sent to a laboratory. Results are returned in 36 hours in the form of a color-coded chart listing drugs with significant gene-drug interactions (red), those with moderate gene-drug interactions (yellow), and those that are not associated with any known genetic problems (green) for the patient.
This test can help spare the physician and patient from “riding through weeks” of an antidepressant trial only to fail, said Greden, executive director of the University of Michigan’s Comprehensive Depression Center, Ann Arbor.

complicated UTI
Monday, May 7, 2018

The US Food and Drug Administration’s (FDA’s) Antimicrobial Drugs Advisory Committee yesterday recommended plazomicin (Achaogen Inc) for complicated urinary tract infections (cUTIs) but not for bloodstream infections (BSIs) in adults with limited or no treatment options.

Tuesday, May 8, 2018

Among the 190,694 patients with IBD included in our analysis, 8,561 serious infections and 674 opportunistic infections occurred. Compared to anti-TNF monotherapy, combination therapy was associated with increased risks of serious infection (hazard ratio [HR], 1.23; 95% CI, 1.05–1.45) and opportunistic infection (HR, 1.96; 95% CI, 1.32–2.91). Compared with thiopurine monotherapy, anti-TNF monotherapy was associated with increased risks of serious infection (HR, 1.71; 95% CI, 1.56–1.88), mycobacterial infection (HR, 1.98; 95% CI, 1.15–3.40), and bacterial infection (HR, 2.38; 95% CI, 1.23–4.58, respectively). Conversely, anti-TNF monotherapy was associated with decreased risk of opportunistic viral infection compared to thiopurine monotherapy (HR, 0.57, 95% CI, 0.38–0.

Diabolo study for diverticulitis
Tuesday, May 8, 2018

Ok not to treat uncomplicated diverticulitis

Tuesday, May 8, 2018
In clinical trials of more than 30,000 people, Shingrix was not associated with serious adverse events.[1,2] However, local and systemic reactions were common among those who got the vaccine. More than 75% of people who got Shingrix reported at least some pain at the injection site.[1,2] About 17% of patients who got Shingrix reported grade 3 reactions, which are severe enough to prevent normal activities. One in 10 reported grade 3 reactions due to pain or injection-site redness or swelling of at least 4 inches in diameter.[1,2] Also, about 1 in 10 people who got Shingrix reported systemic effects that limited activity, such as myalgia, fatigue, headache, shivering, fever, or gastrointestinal illness.[1,2]
CDC recommends counselling your patients about the possible reactions to the vaccine before administering Shingrix. Advise patients not to engage in strenuous activities for a few days after vaccination. If reactions do occur, you can suggest that patients take over-the-counter ibuprofen or acetaminophen to help relieve pain and inflammation. In clinical trials, a reaction to the first dose did not predict a reaction to the second dose.[1,2] Therefore, you should encourage patients to complete the two-dose series, even if they experience a reaction to the first dose. Most reactions to Shingrix are self-limited and resolve in 2-3 days. Report any clinically significant reactions online to the Vaccine Adverse Event Reporting System.

High triglycerides
Thursday, May 10, 2018

Volanasorsen new med

Ascites Mx. EASL
Friday, May 11, 2018
A moderate restriction of sodium intake (80–120 mmol/day, corresponding to 4.6–6.9 g of salt) is recommended in patients with moderate, uncomplicated ascites. This is generally equivalent to a no-added-salt diet with avoidance of pre-prepared meals. Adequate nutritional education of patients on how to manage dietary sodium is also recommended.
Diets with a very low sodium content (<40 mmol/day) should be avoided, as they favor diuretic-induced complications and can endanger a patient’s nutritional status. Patients with the first episode of grade 2 (moderate) ascites should receive an anti-mineralocorticoid drug alone, starting at 100 mg/day with stepwise increases every 72 hr (in 100 mg steps) to a maximum of 400 mg/day if there is no response to lower doses. In patients who do not respond to anti-mineralocorticoids, as defined by a body weight reduction of less than 2 kg/wk, or in patients who develop hyperkalemia, furosemide should be added at an increasing stepwise dose from 40 mg/day to a maximum of 160 mg/day (in 40 mg steps). Patients with long-standing or recurrent ascites should be treated with a combination of an anti-mineralocorticoid drug and furosemide, the dose of which should be increased sequentially according to the response. Torasemide can be given in patients exhibiting a weak response to furosemide. During diuretic therapy, a maximum weight loss of 0.5 kg/day in patients without edema and 1 kg/day in patients with edema is recommended. Once ascites has largely resolved, the dose of diuretics should be reduced to the lowest effective dose. In patients presenting with GI hemorrhage, renal impairment, hepatic encephalopathy, hyponatremia, or alterations in serum potassium concentration, these abnormalities should be corrected before starting diuretic therapy. In these patients, cautious initiation of diuretic therapy and frequent clinical and biochemical assessments should be performed. Diuretic therapy is generally not recommended in patients with persistent overt hepatic encephalopathy. Diuretics should be discontinued if severe hyponatremia (serum sodium concentration <125 mmol/L), acute kidney injury (AKI), worsening hepatic encephalopathy, or incapacitating muscle cramps develop. Furosemide should be stopped if severe hypokalemia occurs (<3 mmol/L). Anti-mineralocorticoids should be stopped if severe hyperkalemia occurs (>6 mmol/L).
Albumin infusion or baclofen administration (10 mg/day, with a weekly increase of 10 mg/day up to 30 mg/day) is recommended in patients with muscle cramps.
Large volume paracentesis (LVP) is the first-line therapy in patients with large ascites (grade 3 ascites), which should be completely removed in a single session. LVP should be followed with plasma volume expansion to prevent post-paracentesis circulatory dysfunction (PPCD).
In patients undergoing LVP greater than 5 L of ascites, plasma volume expansion should be performed by infusing albumin (8 g/L of ascites removed), as it is more effective than other plasma expanders, which are not recommended for this setting.
In patients undergoing LVP less than 5 L of ascites, the risk of developing PPCD is low. However, it is generally agreed that these patients should still be treated with albumin because of concerns about use of alternative plasma expanders.
Non-steroidal anti-inflammatory drugs should not be used in patients with ascites because of the high risk of developing further sodium retention, hyponatremia, and AKI.
Repeated LVP plus albumin (8 g/L of ascites removed) is recommended as first-line treatment for refractory ascites.
Diuretics should be discontinued in patients with refractory ascites who do not excrete >30 mmol/day of sodium under diuretic treatment.
Antibiotic prophylaxis is recommended in cirrhotic patients with acute GI bleeding because it reduces the incidence of infections and improves control of bleeding and survival. Treatment should be initiated on presentation of bleeding and continued for up to 7 days. Ceftriaxone (1 g/24 hr) is the first choice in patients with decompensated cirrhosis, those already on quinolone prophylaxis, and in hospital settings with high prevalence of quinolone-resistant bacterial infections. Oral quinolones (norfloxacin 400 mg bid) should be used in the remaining patients.

SSP gene testing stool
Sunday, May 13, 2018
These SSP-specific methylation patterns effectively distinguish SSP from adenomatous polyps, which could be important for both diagnosis and treatment. It also suggests that the BRAF-V600E mutation directly or indirectly results in the remodeling of the epigenome and that this may set a stage for tumor progression,” they wrote in the open-access journal PLOS One.

Approximately one-third of sporadic colorectal cancers, which account for about 95% of all colorectal malignancies, are thought to arise from premalignant serrated lesions, including SSPs, hyperplastic polyps, and traditional serrated adenomas, the authors noted.

Obscure bleeding. Misoprostol
Wednesday, May 16, 2018

Non opioid drug for withdrawal
Wednesday, May 16, 2018

The US Food and Drug Administration (FDA) has approved lofexidine hydrochloride (Lucemyra, US WorldMeds), a nonopioid, for the mitigation of symptoms in the setting of abrupt opioid withdrawal in adults.

Thursday, May 17, 2018

Perianal crohns
Thursday, May 17, 2018

Mesenchymal cell

Misoprostol for obscure bleed
Thursday, May 17, 2018

Thursday, May 17, 2018

New oral drug for high k
Friday, May 18, 2018

The US Food and Drug Administration (FDA) has approved sodium zirconium cyclosilicate (Lokelma, AstraZeneca) — a medication that rapidly restores normal potassium levels — for adults with hyperkalemia.

Pancreas cancer blood test ?
Sunday, May 20, 2018

Researchers then apply fluorescently labeled antibodies that specifically target two protein biomarkers for pancreatic cancer: glypican-1 and CD63.
Based on nanoparticle exosomes

Low platelet in liver failure
Monday, May 21, 2018

The US Food and Drug Administration (FDA) has approved avatrombopag (Doptelet, AkaRx Inc) to increase platelet counts in adults with thrombocytopenia and chronic liver disease who are to undergo a planned medical or dental procedure.
Avatrombopag, a second-generation oral thrombopoietin receptor agonist that stimulates platelet production, is the first drug to be approved by the FDA for this use. It was reviewed under the FDA’s priority review process.

E. coli toxin b17 and IBD
Tuesday, May 22, 2018
The John Innes Centre scientists, led by Professor Tony Maxwell, have been working with microcin B17 for several years in their search for new antibiotics. It is produced by E. coli (Escherichia coli) as a weapon against other bacteria in the gut.

Professor Maxwell says: ‘This is largely a chance finding. We have been studying this toxin for its antibacterial properties and we were contacted by Professor Richard Blumberg who leads the Boston group for quite different reasons—they thought there might be a connection between the toxin and IBD.”

Thursday, May 24, 2018
After adjustment for traditional cardiovascular disease (CVD) risk factors, IBD associated independently with increased risk of AMI (adjusted hazard ratio [aHR], 2.82) and HF (aHR, 2.03).
The relative risk of AMI was significantly increased in patients with CD (aHR vs controls, 2.89) or ulcerative colitis (UC) (aHR vs controls, 2.70).
The relative risk of HF was significantly increased among patients with UC (aHR, 2.06), but not CD.
The relative risk of both AMI and HF was increased among users of systemic corticosteroids.

Osteoporosis with steroids
Saturday, May 26, 2018

The FDA added another approval for denosumab (Prolia) this week to include treatment of glucocorticoid-induced osteoporosis — the therapy’s fifth indication.

New device for STEMI
Saturday, May 26, 2018

A device providing pressure-controlled intermittent coronary sinus occlusion (PICSO) therapy may be tied to reduced infarct size and better microvascular function when used in certain ST-segment elevation myocardial infarction (STEMI) patients, researchers reported

Seafood and sexuality
Saturday, May 26, 2018

Higher male and female seafood intake was associated with higher frequency of sexual intercourse and fecundity among a large prospective cohort of couples attempting pregnancy.

Drug for celiac on interleukin 15 block
Sunday, May 27, 2018

AMG 714 also improved gluten-triggered diarrhea and physician assessments, according to Dr. Leon. In fact, using the Bristol Stool Form Scale, patients who received both the 150-mg (P = .01) and 300-mg (P = .0002) doses had substantially lower rates of diarrhea, compared with placebo.

Hypertension from skin
Sunday, May 27, 2018

In a study published in the open access journal eLife, the researchers show that skin — our largest organ, typically covering two square metres in humans — helps regulate blood pressure and heart rate in response to changes in the amount of oxygen available in the environment.

Previous research has shown that when a tissue is starved of oxygen — as can happen in areas of high altitude, or in response to pollution, smoking or obesity, for example — blood flow to that tissue will increase.
In such situations, this increase in blood flow is controlled in part by the ‘HIF’ family of proteins.
To investigate what role the skin plays in the flow of blood through small vessels, a team of researchers from Cambridge and Sweden exposed mice to low-oxygen conditions.
These mice had been genetically modified so that they are unable to produce certain HIF proteins in the skin.
“Nine of ten cases of high blood pressure appear to occur spontaneously, with no known cause,” says Professor Randall Johnson from the Department of Physiology, Development and Neuroscience at the U

Starless galaxies
Monday, May 28, 2018
It’s thought that these star-less galaxies, also known as dark galaxies, might be a very early stage of galactic formation. According to some theoretical models they may have been more common in the early Universe, when galaxies might have had more difficulty forming stars.

However, because dark galaxies don’t contain stars, just matter and gas, they emit little visible light – making them very difficult to detect and study. Just a few candidates have ever been detected.

So the discovery of six new candidates could really help to unravel what dark galaxies are, and their place in the formation of galaxies.

It was through a combination of an old technique and new technology that enabled a team of researchers led by physicists at ETH Zurich to make the discovery.

The technique relies on the presence of quasars, which are some of the brightest objects in the Universe, powered by supermassive black holes in the centres of galaxies. The light doesn’t come from the black hole itself, but the incredible friction in the accretion disc around the black hole as it falls into it.

They give off intense ultraviolet light, which fluoresces nearby hydrogen atoms. This emission is known as the Lyman-alpha line.

If a dark galaxy, full of hydrogen, is near a galaxy with a quasar at the centre, it will act as a sort of cosmic flashlight, and this line will show up in its spectrum.

Propofol mechanism of action
Tuesday, May 29, 2018

We found that propofol restricts the movement of a key protein (syntaxin1A) required at the synapses of all neurons. This restriction leads to decreased communication between neurons in the brain,” he said.
Associate Professor van Swinderen said the finding contributed to understanding how general anesthetics worked, and could explain why people experienced grogginess and disorientation after coming out of surgery.
“We think that widespread disruption to synaptic connectivity — the brain’s communication pathways — is what makes surgery possible, although effective anesthetics such as propofol do put you to sleep first,” he said.
“The discovery has implications for people whose brain connectivity is vulnerable, for example in children whose brains are still developing or for people with Alzheimer’s or Parkinson’s disease.

Hair products and endocrine health
Tuesday, May 29, 2018

Hair care products commonly used by black women and children to straighten or relax hair contain endocrine-disrupting chemicals, according to a recent analysis published in Environmental Research.[1] Many of these chemicals were not labeled on the products and some are prohibited in the European Union.
This may help explain why black women have a higher incidence of premature puberty, uterine fibroids, infertility, and more aggressive forms of breast and uterine cancer. These chemicals are also associated with asthma, a chronic condition more prevalent in black women and children.

Statin benefit in elderly
Tuesday, May 29, 2018

Statins are commonly prescribed to patients 65 years and older, but are they effective for primary prevention of CVD? Study 5 randomized nearly 3,000 adults 65 years and older without known CVD to receive pravastatin (Pravachol; 40 mg per day) or placebo. No reduction in coronary events or all-cause mortality was found, and a nonsignificant trend toward higher mortality in patients older than 75 years was observed in those taking the statin (hazard ratio = 1.34; 95% confidence interval, 0.98 to 1.84).[14]

Tuesday, May 29, 2018

Thursday, May 31, 2018
The US Food and Drug Administration (FDA) has approved estradiol vaginal inserts (Imvexxy, TherapeuticsMD) for women with moderate to severe dyspareunia (vaginal pain during sex) resulting from menopause.
The vaginal inserts, which will be available as 4-μg and 10-μg softgel capsules in July, are the only product in their therapeutic class to offer those doses, and the 4-μg dose is now the lowest approved dose of vaginal estradiol on the market.

PE RX device
Wednesday, May 30, 2018
This makes the FlowTriever System the first and only thrombectomy device cleared by the FDA for the treatment of PE.

The 510(k) clearance was based on results from the FlowTriever Pulmonary Embolectomy (FLARE) study.

Obesity and anti TNF
Wednesday, May 30, 2018
Obesity, which is linked to systemic inflammation, is thought to increase the risk of Crohn’s disease, rheumatoid arthritis (RA), and psoriasis, and as many as 50% of patients with IMIDs are obese.
Last year, Singh and colleagues reported that obesity might contribute to the pathogenesis of IBD through dysbiosis, mucosal barrier dysfunction with bacterial translocation, and activation of adipocytes.

Friday, June 1, 2018

The authors noted that in the U.S., more than 50% of individuals ages 60 and over have diagnosed colonic diverticulosis. There is the belief that low-grade inflammation of the diverticula contributes to chronic gastrointestinal symptoms, and the term SUDD (symptomatic uncomplicated diverticular disease) is applied in the absence of overt inflammation.


Diet in IBD
Saturday, June 2, 2018

Immunonutrition has emerged as a new concept putting forward the importance of vitamins such as vitamins A, C, E, and D, folic acid, beta carotene and trace elements such as zinc, selenium, manganese and iron. However, when assessed in clinical trials, specific micronutrients exerted a limited benefit. Beyond nutrients, an anti-inflammatory dietary pattern as a complex intervention approach has become popular in recent years. Hence, exclusive enteral nutrition in paediatric Crohn’s disease is the only nutritional intervention currently recommended as a first-line therapy. Other nutritional interventions or specific diets including the Specific Carbohydrate Diet (SCD), the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyol (FODMAP) diet and, most recently, the Mediterranean diet have shown strong anti-inflammatory properties and show promise for improving disease symptoms. More work is required to evaluate the role of individual food compounds and complex nutritional interventions with the potential to decrease inflammation as a means of prevention and management of IBD.

In paediatric patients with Crohn’s disease (CD) enteral nutrition (EN) reaches remission rates similar to steroids. In adult patients, however, EN is inferior to corticosteroids.

Saturday, June 2, 2018

Mepolizumab is a humanized immunoglobulin G1 kappa monoclonal antibody specific for interleukin 5 (IL-5). Mepolizumab binds to IL-5 and therefore stops IL-5 from binding to its receptor on the surface of eosinophils. Inhibiting IL-5 binding to eosinophils reduces blood, tissue, and sputum eosinophil levels. It is indicated for add-on maintenance treatment of patients with severe asthma aged 12 years or older and with an eosinophilic phenotype.

both adults and children with severe allergic asthma should undergo a therapeutic trial of omalizumab.

Nose contact lens for obesity
Sunday, June 3, 2018

The device, which will be marketed under the name NozNoz (Beck Medical), is a wearable nasal insert that inhibits an individual’s sense of smell without affecting the ability to breath.

BEA3. HCV rx does it help
Sunday, June 3, 2018

A new scoring system predicted which patients with decompensated cirrhosis caused by hepatitis C virus (HCV) infection were most likely to experience meaningful benefits from direct-acting antiviral (DAA) therapy.

Dubbed BEA3, their scoring system assigns one point each for body mass index under 25 kg/m2, absence of encephalopathy, absence of ascites, ALT more than 1.5 times the upper limit of normal, and albumin above 3.5 g/dL. Patients who scored 4 or 5 were more than 50 times more likely to improve to Child-Pugh Turcotte (CPT) class A (compensated) cirrhosis with DAA therapy than were patients who scored 0 (hazard ratio, 52.3; 95% confidence interval, 15.2-179.7; P less than .001), wrote Omar El-Sherif, MB, BCh, of St. James’s Hospital, Dublin, together with his associates in the June issue of Gastroenterology.

Low FT3 predicts pancreatitis
Sunday, June 3, 2018

Nafld and Mediterranean diet
Tuesday, June 5, 2018

Mediterranean-style Diet Score (MDS) correlated with significantly decreased hepatic fat accumulation and a 26% lower odds of new onset fatty liver disease (P = .002). “To our knowledge, ours is the first prospective study to examine the relations of long-term habitual diet to fatty liver,” Jiantao Ma, MBBS, PhD, and his associates wrote in Gastroenterology. “Our findings indicate that improved diet quality may be particularly important for those with high genetic risk for NAFLD.”

Frailty score for colonscopy
Tuesday, June 5, 2018

The online Johns Hopkins Frailty Assessment Calculator allows a clinician or researcher to enter five standardized measurements. The output is a single score that is automatically generated, providing a classification of either frail (score 3-5), pre-frail (score 1 or 2) or robust (score 0). The Hopkins Frailty Assessment Calculator is one of the most commonly utilized and cited tools available for researchers and clinicians. Using this tool, frailty is defined using measures of five phenotypic criteria: unintentional weight loss, exhaustion, low energy expenditure, low grip strength, and/or slowed walking speed.

Dynamometer (grip strength measurement tool)
Stop Watch (to time walking speed movement)
Tape Measure (to lay out 4-meter walking course)
Stadiometer (or other height measurement tool)
Scale for weight measurement

Blood test fir lung cancer
Tuesday, June 5, 2018

Uptake of recommended low-dose CT for lung cancer screening has been dismal. Blood-based assays are an attractive alternative being explored by the Circulating Cell–Free Genome Atlas (CCGA) project. Interim results of a CCGA study of 561 individuals without cancer and 118 patients with lung cancers of all stages have found that a trio of assays searching for molecular signatures in plasma cell-free DNA achieved roughly 50% sensitivity for detection of early-stage (stage I-IIIA) lung cancers and 91% sensitivity for detection of late-stage (stage IIIB-IV) lung cancers.

Ppi plus aspirin for Barrett’s
Tuesday, June 5, 2018

Researchers followed a randomized group of 2,563 patients from Canadian and British hospitals for a median of nearly nine years. Of those parents, 313 developed cancer, worsened Barrett’s, or died.
The participants received either 20 or 40 milligrams of Nexium twice daily, taken with or without aspirin. Researchers then studied whether patients developed esophageal cancer, worsened Barrett’s Esophagus, or if they died.
Researchers determined that a high dose of acid suppressant was superior to a low dose, and that taking aspirin with the high dose proton pump inhibitors showed a 20% overall risk reduction.

Genetic testing for anti platelet in ACS
Wednesday, June 6, 2018

which included the genotyping of ABCB1, CYP2C192, and CYP2C1917 using an ST Q3 system that provides data within 70 min at each patient’s bedside. The patients were followed up for 12 ± 1 month for the primary composite endpoint of cardiovascular death and the first occurrence of nonfatal myocardial infarction, nonfatal stroke, and major bleeding defined according to Bleeding Academic Research Consortium type 3 to 5 criteria.

Itzel’s for UC
Thursday, June 7, 2018
Patients with active ulcerative colitis treated with the phosphodiesterase-4 inhibitor apremilast (Otezla) had clinically meaningful improvements on multiple efficacy measures in a 12-week phase II trial.
At week 12, 31.6% of patients randomized to receive apremilast at 30 mg twice daily achieved clinical remission on the Total Mayo Score, compared with 13.8% of those receiving placebo (P<0.05), according to Silvio Danese, MD, PhD, who heads the Inflammatory Bowel Disease Clinical and Research Center at Humanitas Hospital in Milan. The rate of clinical remission among those receiving 40 mg apremilast twice daily was 21.8%, he reported at Digestive Disease Week here.

PBC med gemfibrizole
Thursday, June 7, 2018
lipid-lowering drug also works in primary biliary cholangitis (PBC) to normalize biochemical liver measures, researchers found.
Among patients randomized to 24 months of bezafibrate therapy on top of ursodeoxycholic acid, 31% had a complete biochemical response — in the form of normal levels of total bilirubin, alkaline phosphatase, aminotransferases, and albumin, as well as a normal prothrombin index — in contrast to the zero patients who achieved this on ursodeoxycholic acid alone (P<0.001), according Christophe Corpechot, MD, of Saint-Antoine University Hospital in Paris, and colleagues.

Smectite for diarrhea
Thursday, June 7, 2018
When used as an adjuvant to rehydration therapy, smectite may reduce the duration of diarrhea in children with acute infectious diarrhea by 1 day and increase cure rate by the third day, but has no effect on hospitalization rates or need for intravenous therapy, according to a recent Cochrane review. Randomized and quasi-randomized trials compared smectite to a control group in children aged 1 month to 18 years with acute diarrhea. 18 trials with 2,616 children met inclusion criteria. Among the findings and conclusions:

Smectite may reduce the duration of diarrhea by approximately 1 day and may increase clinical resolution at day 3.
Smectite may reduce stool output; it is uncertain whether is reduces stool frequency.
There was no evidence of an effect on need for hospitalization.
The most frequently reported side effect was constipation.
No deaths or serious adverse effects were reported.

High BMI young male pt
Thursday, June 7, 2018

Are more likely to have colon polyps

Cancer increases risk of diabetes
Thursday, June 7, 2018

cancer can increase the risk of developing new cases of diabetes, especially after pancreatic, colorectal, and breast cancer,” the authors write.

A significantly elevated risk of new diabetes was also observed in those diagnosed with tumors of the kidney (HR, 2.06), liver (HR, 1.95), gallbladder (HR 1.79), lung (HR, 1.74), blood (HR, 1.61), breast (HR, 1.60), stomach (HR 1.35), and thyroid (HR, 1.33).

Cough syrup
Friday, June 8, 2018

An increasingly popular traditional medicine remedy, Nin Jiom pei pa koa seems to have all the right ingredients to help relieve cough

Available as a lozenge or as syrup, the product contains 16 different ingredients, with honey, Sichuan fritillary, Chinese licorice, apricot seed extract, and loquat present in the largest quantities (Table).

Honey, the largest-quantity ingredient, provides about 800 mg per 15-mL dose. Of all the ingredients, honey has the best evidence supporting its use for cough. A Cochrane review of clinical trials that evaluated honey for cough in children found that it was more effective than diphenhydramine or placebo but not as effective as dextromethorphan for reducing cough frequency.[3] Largely on the basis of these findings, a recent expert panel report also suggested honey as an option for cough in pediatric patients older than 1 year.[4]
Sichuan fritillary (Fritillaria verticillata), also known as chuan bei mu, has a long history of traditional use as an antitussive and expectorant agent. Multiple isolated constituents have been found to have antitussive and anti-inflammatory effects in animal models.[5] However, clinical research has not confirmed these effects in humans.
Chinese licorice (Glycyrrhiza uralensis), also known as gan coa, is also traditionally used as an antitussive and expectorant. Licorice constituents are thought to reduce inflammation of the laryngeal mucosa, thereby reducing cough. Clinical research shows that preoperative use of licorice lozenges or a licorice-containing gargle can significantly reduce postoperative sore throat and related cough compared with placebo.[6,7]
Apricot seed (Prunus armeniaca), also known as xing ren, is commonly used in traditional Chinese medicine as an antitussive. The seed contains amygdalin, which can be hydrolyzed in the gut to produce small amounts of cyanic acid. The cyanic acid constituent is thought to produce the antitussive effect. This constituent can produce cyanide toxicity, especially in children. Several cases have been documented of serious cyanide toxicity in children consuming apricot seeds.[8] Because of this safety hazard, parents should be advised against using this product for their children.
Loquat (Eriobotrya japonica), like many of the other ingredients in the product, has traditionally been used for cough and other respiratory conditions, such as bronchitis and asthma. Extracts of the loquat leaf have been found to have anti-inflammatory and analgesic effects, possibly owing to weak opioid agonist action, in animal models.[9,10] However, these effects have not been documented clinically.
The other ingredients in the product are present in relatively small quantities. Historically, most have been used for cough or as an expectorant in traditional Chinese medicine formulations. However, clinical evidence supporting these ingredients for such uses is lacking.

Honey 813 mg Reduces cough frequency, but not as effective dextromethorphan[3]
Sichuan fritillary (bulb) 179 mg Antitussive and anti-inflammatory effects in animal models[5]
Chinese licorice (root) 164 mg Clinical research shows that it can lower postoperative sore throat and cough[6,7]
Apricot seed extract 45 mg Concerns about cyanide toxicity[8]
Loquat (leaf) 41 mg Anti-inflammatory and analgesic effects in animal models[9,10]
Coltsfoot (flower bud) 25 mg Traditional use as an expectorant and antitussive[11]
Polygala (root) 25 mg Traditional use as an expectorant[11]
Pummelo (peel) 25 mg Traditional use as an expectorant and antitussive[11]
Platycodon (root) 15 mg Traditional use as an expectorant and for sore throat[11]
Menthol 7 mg Counterirritant effects[11,12]
Adenophora (root) 6 mg Traditional use as an expectorant for bronchitis and whooping cough[11]
Ginger (fresh rhizome) 6 mg Traditional use as an anti-inflammatory and antipyretic[11]
Poria (sclerotium) 6 mg Traditional use as an antitussive; some evidence of anti-inflammatory effects[12]
Tricosanthes (seed) 6 mg Traditional use as an expectorant and antitussive[11]
Apricot (seed) 4 mg Concerns about cyanide toxicity[8]
Schisandra (fruit) 1 mg Traditional use as an expectorant and for influenza[11]
From a traditional medicine perspective, Nin Jiom pei pa koa has all the right ingredients to help relieve cough—but from an evidence-based medicine perspective, very little scientific support exists for using this product. Two primary ingredients, honey and Chinese licorice, have some evidentiary support for relieving cough; evidence for most other ingredients is speculative at best.

Migraine Almovig CGRP
Saturday, June 9, 2018
The US Food and Drug Administration (FDA) has approved the humanized monoclonal antibody fremanezumab-vfrm (Ajovy, Teva Pharmaceuticals) for migraine prevention in adults, the manufacturer has announced.
The injectable calcitonin-gene-related peptide (CGRP) antagonist “is the first and only anti-CGRP treatment for the prevention of migraine with quarterly (675 mg) and monthly (225 mg) dosing options,” the company said in a press release.
As reported by Medscape Medical News, in May the FDA approved the self-injectable erenumab (Aimovig, Amgen and Novartis) as the first CGRP antagonist for this indication. It’s now offered as once-monthly 70- or 140-mg single-use prefilled autoinjectors.

The US Food and Drug Administration (FDA) today approved the fully human monoclonal antibody erenumab (Aimovig, Amgen and Novartis) for the prevention of migraine in adult patients.
The once-monthly self-injectable drug, which is a calcitonin-gene-related peptide (CGRP) antagonist, is the first in its class to receive FDA approval for this indication.

The 95 patients included in the analysis reported experiencing headache attacks on 1613 of 4195 days (38.5%) in electronic diary data; patients kept individual diaries for an average of 49 days each.
The average level of affective distress reported was low to moderate, with moderate levels of headache-related disability.
The model showed that the frequency of stressful events or the perceived intensity of the events effectively predicted headache with high accuracy (an area under the curve of 0.73 in a training sample and 0.65 in a leave-one-out validation sample).

Menstrual migraines that occur in the days following menstrual bleeding may be related to low ferritin caused by blood loss rather than to estrogen fluctuations.
“End menstrual migraine is a common complaint in women evaluated for menstrual related migraine, yet these migraines occur many days after the estrogen withdrawal that precipitates menstrual-related migraine,” the authors, led by Anne H. Calhoun, MD, from the University of North Carolina and Carolina Headache Institute–Research, Durham, report.
“[We] believe that end menstrual migraine is not hormonally mediated, but rather that it is causally related to menstrual blood loss, resulting in a brief relative anemia with consequent migraine,” the researchers add.

For patients with migraine, repetitive yawning may accompany or precede a migraine attack, new research shows.

VAT Score for dementia
Tuesday, June 12, 2018

Visual association test

Phase 3 for NASH
Wednesday, June 13, 2018

There’s elafibranor, obeticholic acid (OCA), selonsertib, and cenicriviroc. Each of these have there own phase 3.”

IBS-c drug
Thursday, June 14, 2018

Tenapanor is an inhibitor of sodium/hydrogen exchanger isoform 3, the predominant intestinal sodium transporter. Through this inhibition tenapanor reduces sodium uptake in the gut, causing increased intestinal fluid volume and shorter transit time and thereby softening stool consistency and increasing bowel movement frequency.

50 mg bid

Thursday, June 14, 2018

An elevated ratio of testosterone to estradiol in a racially diverse group of postmenopausal women was associated with an increased risk for myocardial infarction, stroke, and heart failure over a 12-year period, a new study shows.

Hormone prevents T2D
Tuesday, June 19, 2018
Two hormones called “notum” and “lipocalin-5” that speed up the body’s ability to burn fat.
Lipocalin-5 protected mice from developing diabetes—or cured the disease after they developed it.
Lipocalin-5 also enhanced muscle tissue’s ability to metabolize and absorb dietary nutrients, reducing the risk of obesity and diabetes.

Implantantable glucose monitoring
Thursday, June 21, 2018

The Eversense CGM is marketed by Senseonics, which funded the studies underpinning approval.

Emplagloflozin helps NASH in T2D
Friday, June 22, 2018

Diabetic journal

Janus kinase uses tofacitinib
Friday, June 22, 2018

Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway, which plays an important role in immunoregulation and normal cell growth. This class includes the drugs tofacitinib, approved for the treatment of rheumatoid arthritis, and ruxolitinib, approved for the treatment of myelofibrosis and polycythemia rubra vera. The most common adverse events (AEs) reported in patients taking tofacitinib are infections, whereas the most common AEs in patients taking ruxolitinib are anemia and thrombocytopenia. Both first and second generation Janus kinase inhibitors have become promising treatment modalities for dermatologic conditions such as psoriasis, atopic dermatitis, alopecia areata, vilitigo, dermatomyositis, and graft-versus-host disease. Future promising areas of investigation include treatment of cutaneous lupus, cutaneous T-cell lymphoma, melanoma, allergic contact dermatitis, and lichen planus.

Alcohol dementia
Friday, June 22, 2018

Alcohol alters gene expression in microglial cells and the immune system, impairing the ability of phagocytes to clear amyloid β (Aβ) plaque, in findings that may explain the link between alcohol consumption and the risk for Alzheimer’s disease (AD).

GERD MX DIFFICULT CASES with extra GI symptoms
Friday, June 29, 2018

Number 1 step
taking their PPIs correctly: 30-60 minutes before breakfast and 30-60 minutes before dinner. Over time, a lot of these patients change to taking their PPIs with meals or at bedtime, which does not work as well.
Number 2 is to consider alginic acid or alginate products, like Gaviscon®. They are very effective at augmenting the PPI effect. I find it particularly helpful with the postprandial symptoms or with patients who are experiencing nighttime symptoms. I tell patients that this is an alginate made from seaweed, and it works like putting a cap on a bottle; it effectively coats the hiatal hernia, keeping the acid regurgitation reflux recycling in the hernia or the fundic pool. I find this treatment inordinately helpful at producing that coating effect, particularly in its liquid, rather than tablet, form.
Number 3, which is particularly important for gastroenterologists, is to consider habituation. When the patient comes in [and starts coughing], I find in the course of my dialogue with them that I can usually tell exactly what is going on. Look at their hoarseness and their patterns of speech, and seek out elements that they may have acquiesced to as a result of their initial symptoms. I do not care if they got it from reflux or postnasal drip; look for symptoms that they are perpetuating because they are now in a cycle of habituation. Once you identify that, you now have to train and work with them to break that cycle.
Number 4 is do not forget diaphragmatic breathing. This sounds kind of hokey, but it is what I call “yoga for the diaphragm”—belly breathing. We found it helpful in specific populations, such as patients with rumination, refractory belching, and refractory hiccups (singultus), and there are some data in patients with persistent symptoms of GERD, particularly belching, but also heartburn symptoms. It is an easy technique. I have done a video on this topic before. Take some time to learn it, and don’t forget it, because it is valuable and [inexpensive]. You do not need a referral.
Number 5, the final pearl, is something I have found to be successful in patients who have so-called “GERD-induced cough.” Look for patients with this bronchogenic cough. They have been cleared by their pulmonologist as not having asthma, but they get into this cough cycle that is difficult to break. If their reflux symptoms are gone and they do not have acid contributing to it, you may study them on a PPI and do pH monitoring. I find what these patients get into is habituation, but they have a bronchogenic cough. My advice for the best way to control that is to consider a low dose of tramadol or a low dose of a tricyclic amitriptyline (Elavil) at bedtime, with which I have had high success rates. Once you come down to that bronchogenic cough, it just does not go away. I have seen patients who have had it for 25-30 years, and after a week or so of this treatment, they come back and say, “Wow, I’m no longer recognized in public because nobody is looking for my cough.”

PURE study
Friday, June 29, 2018

High carbohydrate higher mortality High far both saturated and pufa and mono saturated fat 35 % lower mortality with no change in CVD death and lower stroke

migraine new drug
Thursday, July 5, 2018

Lasmiditan could potentially represent the first major innovation for the treatment of acute migraine in two decades. The drug is a serotonin agonist selective for the 5-HT1F receptor. Triptans activate that receptor, but they are also active at other 5-HT receptor subtypes that are believed to be responsible for these agents’ unwanted cardiovascular effects.

Portal vein thrombosis
Friday, July 6, 2018

Catheter-directed clot lysis and thrombectomy with creation of a bypass shunt is a reasonable alternative to prolonged anticoagulation for treating patients with portal vein thrombosis (PVT) based on the accumulated reported experience since 1993 using this percutaneous treatment.

Lipoprotein Reduction
Friday, July 6, 2018

Thus, Dr. Ference said, “Large absolute reductions in Lp(a) of approximately 100 mg/dL may be needed to produce clinically meaningful reductions in the risk of cardiovascular disease, similar in magnitude to what can be achieved by lowering LDL-C by 38.7 mg/dL (1 mmol/L) with a statin. Smaller absolute reductions in Lp(a) are likely to lead to smaller proportional reductions in cardiovascular risk.”

Extra esophageal GERD
Sunday, July 8, 2018
Proposed extraesophageal manifestations of GERD range from chronic throat clearing and dysphonia to otitis, pulmonary fibrosis, laryngeal cancer, and even lung transplant rejection. Stronger evidence links GERD with symptoms of asthma, cough, and hoarseness, the experts note. “When less stringent criteria are used, the attributions are broader and could include sore throat, sinusitis, ear pain, and pulmonary fibrosis.”

When asked to assess whether GERD is causing extraesophageal symptoms, consider the “constellation” of patient presentation, test results, and treatment response, according to the clinical practice update. No diagnostic tests “unequivocally link any suspected extraesophageal symptom to GERD.” For patients who have both extraesophageal symptoms and typical symptoms of GERD, the authors suggest an evaluator regimen of 6-8 weeks of empiric, aggressive (twice-daily) proton pump inhibitor (PPI) therapy. If aggressive acid suppression therapy appears to improve extra¬esophageal symptoms, patients should be titrated to the lowest effective treatment dose.If symptoms persist despite an aggressive trial of a PPI, and patients have a body mass index under 25, and a seemingly low probability of GERD, then the experts recommend pH testing “off” therapy and seeking other etiologies for extraesophageal symptoms. If symptoms persist and a patients’ BMI exceeds 25 with a high suspicion of GERD, they recommend evaluations for concomitant asthma or lung disease. If these work-ups are positive, they recommend multichannel intraluminal impedance testing or pH monitoring on treatment.

The clinical practice update strongly discourages surgical treatment of extraesophageal GERD symptoms except in specific populations, such as when patients have objective signs of treatment-refractory GERD and have not responded to comprehensive therapy for other possible causes of extraesophageal symptoms. Recent data suggest that surgery can benefit patients with confirmed structural defects, such as hiatal hernia, which are causing symptomatic, volume-based regurgitation, the experts note. Ideally, these patients should first undergo pH and impedance monitoring to objectively measure the effects of reflux. Additionally, surgical fundoplication “might be beneficial” for patients whose extraesophageal symptoms clearly have responded to PPI therapy but who refuse long-term PPI therapy or who develop unacceptable side effects.

The practice update also extensively discusses the role of testing to evaluate the role of GERD in extraesophageal symptoms. Barium esophagography is insensitive for GERD and is useful only for evaluating dysphagia and the size and type of a hiatal hernia, the experts note. Abnormal laryngoscopy or pharyngoscopic findings are more useful but should not be the “initial driving force” behind a GERD diagnosis and do not necessarily link GERD to extraesophageal symptoms. Likewise, esophagogastroduodenoscopy can identify esophagitis, which signifies GERD but does not establish it as etiologic.

Positive ambulatory pH or impedance monitoring or pharyngeal pH tests also do not definitively link reflux to suspected extraesophageal symptoms, the experts note. They suggest considering “on” therapy monitoring to evaluate treatment efficacy and to time reflux events relative to symptoms in patients with esophagitis, Barrett’s esophagus, or a large hiatal hernia. Conversely, they recommend considering “off” treatment testing to rule out GERD in patients who have no history of confirmed or suspected reflux and who have not responded to PPI therapy.

Novel tests, such as salivary pepsin and mucosal impedance, have “no clear role in establishing GERD as the cause of extraesophageal symptoms,” the experts emphasize. Clinician scientists also debate the exact pathophysiology of extraesophageal GERD sequelae. While chronic exposure to gastric refluxate clearly can harm proximal structures such as the pharynx, larynx, and bronchial tree, it remains unclear how much acid is necessary to cause injury and whether bile, pepsin, or neurogenic stimulation play a role.

Hp testing and Rx
Sunday, July 8, 2018

2 bx antrum body and angularis
Check household
Check high risk first gen immigrants
Check Latino and AA
STOOL testing without bismuth or PPI
UBT is ok but same restriction
No serology
Anyone with family history of cancer and prior ulcer

Tb Rx and fitness gut bacteria
Thursday, July 12, 2018

Bedaquiline, a novel drug for drug-resistant tuberculosis, was associated with a reduction in mortality for patients with multidrug- and rifampicin-resistant strains of the infection, according to a South African study. (CIDRAP News)
Study finds individuals with the best cardiovascular fitness had higher firmicute-to-bacteroide ratios, indicative of better overall gut health and composition. (ScienceDaily)

UTI rx
Thursday, July 12, 2018

Achaogen Inc said on Tuesday U.S. health regulators cleared its antibiotic Zemdri (plazomicin) to treat adults with complicated urinary tract infections, but declined approval for treating bloodstream infections.
The U.S. Food and Drug Administration cited lack of evidence of effectiveness of the drug in a clinical study to treat bloodstream infections, the company said in a statement.
The drug is approved for complicated urinary tract infections, including pyelonephritis, caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Enterobacter cloacae, in patients who have limited or no alternative treatment options. Zemdri is an intravenous infusion, administered once daily.

Friday, July 13, 2018

A little-known sexually transmitted disease carries the potential to become the next superbug. Per the BBC, health officials in the UK have set new guidelines regarding the bacterial infection Mycoplasma genitalium, or MG, out of fear improper treatment could lead to antibiotic resistance. Huffington Post UK reports the British Association of Sexual Health and HIV (BASHH) wants the public and healthcare providers to be aware of MG because it’s not one of the infections sexual health officials commonly test for and, if untreated, it can lead to serious and lasting problems, especially in women. For them, untreated MG can lead to pelvic inflammatory disease, which can in turn make it difficult to get pregnant. Men can experience discharge and inflammation of the urethra. It is not known whether MG affects a man’s fertility.

Friday, July 13, 2018

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, chronic, debilitating disease with systemic effects. ME/CFS is characterized by reduced ability to perform pre-illness activities that lasts for more than 6 months and is accompanied by profound fatigue, which is not improved by rest. A hallmark of ME/CFS is that symptoms can worsen after physical, mental, or emotional effort, a manifestation known as post-exertional malaise (PEM). Patients with ME/CFS also have unrefreshing sleep. Other common manifestations are orthostatic intolerance, cognitive impairment, and pain. As can be observed in people with other long-term chronic illnesses, secondary psychological symptoms such as depression and anxiety may also be present in some patients with ME/CFS.

Cv recommendation
Friday, July 13, 2018

In a newly released statement, the US Preventive Services Task Force (USPSTF) has concluded that the evidence currently available is insufficient to properly assess the balance of benefits and harms of adding ankle brachial index (ABI), high-sensitivity C-reactive protein (hsCRP), or coronary artery calcium (CAC) scoring to traditional cardiovascular disease (CVD) risk assessment in asymptomatic adults.

Diabetes with oral treatment in young
Monday, July 16, 2018

Suspect in non obese without any islet cell ab in young

There are two forms of monogenetic diabetes – neonatal diabetes, which is diagnosed by age 6-9 months, and MODY, which is typically diagnosed in those aged between 10 and 25 years, noted Dr. Billings.

Reasons to suspect MODY include early onset of diabetes (under 35 years), a family history of diabetes, a lack of obesity, and negative islet-cell antibodies, she said.

Obese patients may also have the condition: A 2017 American study of 488 overweight and obese children and adolescents diagnosed with type 2 diabetes found that 4.5% actually had monogenetic diabetes. (Genet Med. 2018 Jun;20[6]:583-90).

Once a physician suspects MODY, physicians may consult the University of Exeter’s risk calculator. It provides guidance about whether a test is a good idea. Dr. Billings cautioned, however, that the value of a calculator’s estimate of risk is not all-encompassing. “You should never use the calculator by itself as a reason to not pursue your intuition,” she said.

Sleep medicine
Monday, July 16, 2018

Multiple studies based on phase 3 clinical trials of the investigational drug solriamfetol have found that it may be effective for improving next-day wakefulness and work productivity in people with narcolepsy and obstructive sleep apnea, and that the drug can maintain its effect throughout the day as well as for up to 6 months.

Sarcopenic obesity
Monday, July 16, 2018

Older adults with sarcopenic obesity, or high body fat and low muscle mass, had the lowest scores in cognitive tests of working memory, self-control, orientation and mental flexibility, which are symptoms of dementia, followed by those with only sarcopenia and those who were obese alone, according to a study in the journal Clinical Interventions in Aging. The findings should prompt clinicians to consider sarcopenic obesity as a serious health concern and be aware of at-risk individuals, researchers concluded.

Algorithm for DM
Monday, July 16, 2018
Then, where they really differ from the old guidelines is, what is the second therapy? The first thing you do is ask, Does the patient have known cardiovascular disease or not?
If the answer is yes, they have known cardiovascular disease, then you enter a decision box in the algorithm to consider whether the patient has an eGFR of above or below 45. The recommendation is to start a medication that reduces cardiovascular risk, and those are the SGLT2 inhibitors and some of the GLP-1 receptor agonists, but the SGLT2 inhibitors, as we know, are limited by renal function. You basically go into that box, decide which of those two agents is best for your patient, and treat them accordingly.
If a patient does not have known cardiovascular disease, then they go onto the other side of the algorithm and they basically have all of the medication choices. The new guidelines basically take sulfonylurea agents and put them off to the side. The recommendation is to try to use agents that do not cause hypoglycemia or weight gain, and to allow your patients to achieve their targets without those side effects.
Then, they stress—as we all stress—individualization of targets and treatments. It really depends on your patients and the health system in which you work—the formularies, for example—and the guideline does say that you can use sulfonylurea agents in patients who aren’t at risk for hypoglycemia or weight gain.
Now, you’re probably going to argue that most patients with type 2 diabetes are at risk for hypoglycemia and weight gain, but regardless, it’s still there, it’s still in the list, and I certainly have patients who were on formularies where I was required to use sulfonylurea agents as second-line therapy. Clearly, the writers of these new guidelines are suggesting that they really not be used as a first- or second-line choice in our patients with known cardiovascular disease and type 2 diabetes.
Then, the rest of it more or less follows through the treatment combinations, but there is a specific difference in terms of the use of an injectable therapy. They recommend that the first injectable treatment should be a GLP-1 receptor agonist and, in most cases, not insulin.
Remember, there are going to be patients who look more like they are evolving type 1’s or they are very insulin deficient; they can obviously use insulin first, but by and large, most of the studies suggest that using a GLP-1 receptor agonist is the best injectable therapy for most patients, no matter what their A1c is. Then, if they need another agent, insulin can be adde

Aspirin dose
Monday, July 16, 2018

aspirin dosing for colorectal cancer prevention also depended on weight (P=0.038 for interaction), the investigators said. Low-dose aspirin was tied to lower cancer risk in patients weighing less than 70 kg (154.3 lbs, HR 0.64, 95% CI 0.50 to 0.82) but not in heavier people (HR 0.87, 95% CLow doses of aspirin (75-100 mg) were less effective at reducing

cardiovascular events with increasing weight (P=0.0072 for interaction). For instance, these low doses were associated with fewer events for people weighing 110.2-152.1 lbs (50-69 kg, HR 0.75, 95% CI 0.65 to 0.85) — but not those 154.3 lbs (70 kg) or more (HR 0.95, 95% CI 0.86 to 1.04), according to Peter Rothwell, MD, PhD, of the University of Oxford, John Radcliffe Hospital, in England, and colleagues.I 0.71 to 1.07).

That 75-100 mg aspirin was ineffective in primary prevention of cardiovascular events in the 80% of men and nearly 50% of women who weighed 70 kg [154.3 lbs] or more in our study, even increasing the case fatality of first events, questions the use of once-daily low doses of aspirin irrespective of weight.”

Monday, July 16, 2018
The diagnosis of acute pancreatitis (AP) requires at least 2 of the following features: characteristic abdominal pain; biochemical evidence of pancreatitis (ie, amylase or lipase elevated >3 times the upper limit of normal); and/or radiographic evidence of pancreatitis on cross-sectional imaging.
Presentations of AP occur along a clinical spectrum and can be categorized as mild, moderately severe, or severe, based on the recent revised Atlanta classification.
Most cases of AP (around 80%) are mild, with only interstitial changes of the pancreas without local or systemic complications.
Moderately severe pancreatitis is characterized by transient local or systemic complications or transient organ failure (<48 hours), and severe AP is associated with persistent organ failure.
Necrotizing pancreatitis is characterized by the presence of pancreatic and/or peripancreatic necrosis, and is typically seen in patients with moderately severe or severe AP.
There are 2 overlapping phases of AP, early and late. The early phase of AP takes place in the first 2 weeks after disease onset, and the late phase can last weeks to months thereafter.
In patients with AP, the AGA suggests against the use of hydroxymethyl starch (HES) fluids.
In patients with predicted severe AP and necrotizing AP, the AGA suggests against the use of prophylactic antibiotics.
In patients with acute biliary pancreatitis and no cholangitis, the AGA suggests against the routine use of urgent ERCP.
In patients with AP, the AGA recommends early (within 24 hr) oral feeding as tolerated, rather than keeping the patient nil per os.
In patients with AP and inability to feed orally, the AGA recommends enteral rather than parenteral nutrition.
In patients with predicted severe or necrotizing pancreatitis requiring enteral tube feeding, the AGA suggests either nasogastric or nasojejunal route.
In patients with acute biliary pancreatitis, the AGA recommends cholecystectomy during the initial admission rather than after discharge.
In patients with acute alcoholic pancreatitis, the AGA recommends brief alcohol intervention during admission.
Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018 Mar;154(4):1090-1101.

Monday, July 16, 2018
Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended.
For diagnosis, direct microscopy, preferably using optical brighteners, histopathology, and culture are strongly recommended.
Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA.

Ascites Mx
Monday, July 16, 2018
A moderate restriction of sodium intake (80–120 mmol/day, corresponding to 4.6–6.9 g of salt) is recommended in patients with moderate, uncomplicated ascites. This is generally equivalent to a no-added-salt diet with avoidance of pre-prepared meals. Adequate nutritional education of patients on how to manage dietary sodium is also recommended.
Diets with a very low sodium content (<40 mmol/day) should be avoided, as they favor diuretic-induced complications and can endanger a patient’s nutritional status. Patients with the first episode of grade 2 (moderate) ascites should receive an anti-mineralocorticoid drug alone, starting at 100 mg/day with stepwise increases every 72 hr (in 100 mg steps) to a maximum of 400 mg/day if there is no response to lower doses. In patients who do not respond to anti-mineralocorticoids, as defined by a body weight reduction of less than 2 kg/wk, or in patients who develop hyperkalemia, furosemide should be added at an increasing stepwise dose from 40 mg/day to a maximum of 160 mg/day (in 40 mg steps). Patients with long-standing or recurrent ascites should be treated with a combination of an anti-mineralocorticoid drug and furosemide, the dose of which should be increased sequentially according to the response. Torasemide can be given in patients exhibiting a weak response to furosemide. During diuretic therapy, a maximum weight loss of 0.5 kg/day in patients without edema and 1 kg/day in patients with edema is recommended. Once ascites has largely resolved, the dose of diuretics should be reduced to the lowest effective dose. In patients presenting with GI hemorrhage, renal impairment, hepatic encephalopathy, hyponatremia, or alterations in serum potassium concentration, these abnormalities should be corrected before starting diuretic therapy. In these patients, cautious initiation of diuretic therapy and frequent clinical and biochemical assessments should be performed. Diuretic therapy is generally not recommended in patients with persistent overt hepatic encephalopathy. Diuretics should be discontinued if severe hyponatremia (serum sodium concentration <125 mmol/L), acute kidney injury (AKI), worsening hepatic encephalopathy, or incapacitating muscle cramps develop. Furosemide should be stopped if severe hypokalemia occurs (<3 mmol/L). Anti-mineralocorticoids should be stopped if severe hyperkalemia occurs (>6 mmol/L).
Albumin infusion or baclofen administration (10 mg/day, with a weekly increase of 10 mg/day up to 30 mg/day) is recommended in patients with muscle cramps.
Large volume paracentesis (LVP) is the first-line therapy in patients with large ascites (grade 3 ascites), which should be completely removed in a single session. LVP should be followed with plasma volume expansion to prevent post-paracentesis circulatory dysfunction (PPCD).
In patients undergoing LVP greater than 5 L of ascites, plasma volume expansion should be performed by infusing albumin (8 g/L of ascites removed), as it is more effective than other plasma expanders, which are not recommended for this setting.
In patients undergoing LVP less than 5 L of ascites, the risk of developing PPCD is low. However, it is generally agreed that these patients should still be treated with albumin because of concerns about use of alternative plasma expanders.
Non-steroidal anti-inflammatory drugs should not be used in patients with ascites because of the high risk of developing further sodium retention, hyponatremia, and AKI.
Repeated LVP plus albumin (8 g/L of ascites removed) is recommended as first-line treatment for refractory ascites.
Diuretics should be discontinued in patients with refractory ascites who do not excrete >30 mmol/day of sodium under diuretic treatment.
Antibiotic prophylaxis is recommended in cirrhotic patients with acute GI bleeding because it reduces the incidence of infections and improves control of bleeding and survival. Treatment should be initiated on presentation of bleeding and continued for up to 7 days. Ceftriaxone (1 g/24 hr) is the first choice in patients with decompensated cirrhosis, those already on quinolone prophylaxis, and in hospital settings with high prevalence of quinolone-resistant bacterial infections. Oral quinolones (norfloxacin 400 mg bid) should be used in the remaining patients.

C diff regimen
Monday, July 16, 2018
Patients with unexplained and new-onset ≥3 unformed stools in 24 hours are the preferred target population for testing for CDI.
Use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than NAAT alone for all specimens when there are no preagreed institutional criteria for patient stool submission.
Use NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are preagreed institutional criteria for patient stool submission.
Do not perform repeat testing (within 7 days) during the same episode of diarrhea and do not test stool from asymptomatic patients, except for epidemiologic studies.
Diagnosis (pediatric)
Because of the high prevalence of asymptomatic carriage of toxigenic C. difficile in infants, testing for CDI should never be routinely recommended for neonates or infants ≤12 months of age with diarrhea.
C. difficile testing should not be routinely performed in children with diarrhea who are 1-2 years of age unless other infectious or noninfectious causes have been excluded.
In children ≥2 years of age, C. difficile testing is recommended for patients with prolonged or worsening diarrhea and risk factors (eg, underlying inflammatory bowel disease or immunocompromising conditions) or relevant exposures (eg, contact with the healthcare system or recent antibiotics).
Treatment (adults)
Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence.
Antibiotic therapy for CDI should be started empirically for situations where a substantial delay in laboratory confirmation is expected, or for fulminant CDI.
Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days.
In settings where access to vancomycin or fidaxomicin is limited, metronidazole is suggested for an initial episode of nonsevere CDI only. The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity.
For fulminant CDI, vancomycin administered orally is the regimen of choice. If ileus is present, vancomycin can also be administered per rectum. The vancomycin dosage is 500 mg orally 4 times per day and 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema. Intravenously administered metronidazole should be administered together with oral or rectal vancomycin, particularly if ileus is present. The metronidazole dosage is 500 mg intravenously every 8 hours.
If surgical management is necessary for severely ill patients, perform subtotal colectomy with preservation of the rectum. Diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes is an alternative approach that may lead to improved outcomes.
Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin; OR treat a first recurrence of CDI with a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin; OR treat a first recurrence of CDI with a standard 10-day course of vancomycin rather than a second course of metronidazole if metronidazole was used for the primary episode.
Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments.
Treatment (pediatric)
Either metronidazole or vancomycin is recommended for the treatment of children with an initial episode or first recurrence of nonsevere CDI.
For children with an initial episode of severe CDI or with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole.

IBD Rx. Natalizumab
Monday, July 16, 2018
Fecal calprotectin is a helpful test that should be considered to help differentiate the presence of inflammatory bowel disease (IBD) from irritable bowel syndrome (IBS).
In patients at particularly high risk for colorectal neoplasia (eg, personal history of dysplasia, primary sclerosing cholangitis), chromoendoscopy should be used during colonoscopy, as it may increase the diagnostic yield for detection of colorectal dysplasia, especially compared with standard-definition white light endoscopy.
For patients undergoing surveillance colonoscopy, there is insufficient evidence to recommend universal chromoendoscopy for IBD colorectal neoplasia surveillance if the endoscopist has access to high-definition white light endoscopy.
Narrow-band imaging should not be used during colorectal neoplasia surveillance examinations for Crohn’s disease.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may exacerbate disease activity and should be avoided when possible in patients with Crohn’s disease.
Cigarette smoking exacerbates disease activity and accelerates disease recurrence and should be avoided.
Usage of antibiotics should not be restricted in Crohn’s disease patients in order to prevent disease flares.
Perceived stress, depression, and anxiety, which are common in IBD, are factors that lead to decreased health-related quality of life in patients with Crohn’s disease, and lead to lower adherence to provider recommendations. Assessment and management of stress, depression, and anxiety should be included as part of the comprehensive care of the Crohn’s disease patient.
Sulfasalazine is effective for treating symptoms of colonic Crohn’s disease that is mild to moderately active and can be used as treatment for this patient population.
Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild-to-moderate ileocecal Crohn’s disease.
Metronidazole is not more effective than placebo as therapy for luminal inflammatory Crohn’s disease and should not be used as primary therapy.
For patients with low risk of progression, treatment of active symptoms with antidiarrheals, other non-specific medications, and dietary manipulation, along with careful observation for inadequate symptom relief, worsening inflammation, or disease progression, is acceptable.
Oral corticosteroids are effective and can be used for short-term use in alleviating signs and symptoms of moderate to severely active Crohn’s disease. Thiopurines (azathioprine, 6-mercaptopurine) are effective and should be considered for use for steroid sparing in Crohn’s disease.
Azathioprine and 6-mercaptourine are effective therapies and should be considered for treatment of patients with Crohn’s disease for maintenance of remission.
Thiopurine methyltransferase (TPMT) testing should be considered before initial use of azathioprine or 6-mercaptopurine to treat patients with Crohn’s disease.
Methotrexate (up to 25 mg once weekly IM or SC) is effective and should be considered for use in alleviating signs and symptoms in patients with steroid-dependent Crohn’s disease and for maintaining remission.
Anti-TNF agents (infliximab, adalimumab, certolizumab pegol) should be used to treat Crohn’s disease that is resistant to treatment with corticosteroids.
Anti-TNF agents should be given for Crohn’s disease refractory to thiopurines or methotrexate.
Combination therapy of infliximab with immunomodulators (thiopurines) is more effective than treatment with either immunomodulators alone or infliximab alone in patients who are naive to those agents.
For patients with moderately to severely active Crohn’s disease and objective evidence of active disease, anti-integrin therapy (with vedolizumab) with or without an immunomodulator is more effective than placebo and should be considered to be used for induction of symptomatic remission in patients with Crohn’s disease.
Natalizumab is more effective than placebo and should be considered to be used for induction of symptomatic response and remission in patients with active Crohn’s disease.
Natalizumab should be used for maintenance of natalizumab-induced remission of Crohn’s disease only if serum antibody to John Cunningham (JC) virus is negative. Testing for anti-JC virus antibody should be repeated every 6 months and treatment stopped if the result is positive.
Ustekinumab should be given for moderate-to-severe Crohn’s disease patients who failed previous treatment with corticosteroids, thiopurines, methotrexate, or anti-TNF inhibitors or who have had no prior exposure to anti-TNF inhibitors.
Intravenous corticosteroids should be used to treat severe or fulminant Crohn’s disease.
Anti-TNF agents (infliximab, adalimumab, certolizumab pegol) can be considered to treat severely active Crohn’s disease.
Infliximab may be administered to treat fulminant Crohn’s disease. Infliximab is effective and should be considered in treating perianal fistulas in Crohn’s disease. Infliximab may be effective and should be considered in treating enterocutaneous and rectovaginal fistulas in Crohn’s disease.
Adalimumab and certolizumab pegol may be effective and should be considered in treating perianal fistulas in Crohn’s disease.
Thiopurines (azathioprine, 6-mercaptopurine) may be effective and should be considered in treating fistulizing Crohn’s disease.
The addition of antibiotics to infliximab is more effective than infliximab alone and should be considered in treating perianal fistulas.
Drainage of abscesses (surgically or percutaneously) should be undertaken before treatment of fistulizing Crohn’s disease with anti-TNF agents.
Once remission is induced with corticosteroids, a thiopurine or methotrexate should be considered.
Anti-TNF therapy, specifically infliximab, adalimumab, and certolizumab pegol, should be used to maintain remission of anti-TNF-induced remission.
Anti-TNF monotherapy is effective at maintaining anti-TNF induced remission, but because of the potential for immunogenicity and loss of response, combination with azathioprine/6-mercaptopurine or methotrexate should be considered.
Imidazole antibiotics (metronidazole and ornidazole) at doses between 1 and 2 g/day can be used after small intestinal resection in Crohn’s disease patients to prevent recurrence.
In high-risk patients, anti-TNF agents should be started within 4 weeks of surgery in order to prevent postoperative Crohn’s disease recurrence.
An intra-abdominal abscess should be treated with antibiotics and a drainage procedure, either radiographically or surgically.

HEV testing and Mx
Monday, July 16, 2018
Pregnant women with HEV gt 1 or 2 should be cared for in a high-dependency setting and transferred to a liver transplant unit if liver failure occurs.
EASL recommends HEV testing, irrespective of LFT results, in patients presenting with neuralgic amyotrophy (NA) and GBS (Guillain-Bare syndrome) and suggests HEV testing for patients with encephalitis/myelitis.
EASL suggests testing patients with HEV infection for proteinuria.
Patients with acute or chronic HEV infection who develop new-onset proteinuria may be considered for a renal biopsy.
EASL suggests antiviral treatment for patients with chronic HEV infection and associated glomerular disease.
EASL recommends using a combination of serology and nucleic acid amplification technique (NAT) testing to diagnose HEV infection.
EASL recommends NAT testing to diagnose chronic HEV infection.
All patients with hepatitis should be tested for HEV, as part of the first-line virological investigation, irrespective of travel history.
Patients presenting with suspected drug-induced liver injury (DILI) should be tested for HEV.
Patients with abnormal LFTs after receiving blood products should be tested for HEV.
EASL recommends that blood donor services screen blood donors for HEV by NAT, informed by local risk-assessment and cost-effectiveness studies, both of which may vary considerably by geographic location.
Ribavirin treatment may be considered in cases of severe acute hepatitis E or acute-on-chronic liver failure.
EASL recommends decreasing immunosuppression at diagnosis of chronic HEV infection in solid organ transplant recipients, if possible.
In patients with persisting HEV replication three months after detection of HEV RNA, EASL recommends ribavirin monotherapy for a duration of 12 weeks.
At the end of the scheduled period of therapy, HEV RNA should be assessed in the serum and in the stool. If HEV RNA is undetectable in both, EASL suggests stopping ribavirin.
In patients in whom HEV RNA is still detectable in the serum and/or in the stool after 12 weeks, ribavirin monotherapy may be continued for an additional three months (six months therapy overall).
Liver transplant recipients who show no response to ribavirin can be considered for treatment with PEGylated-interferon-α.
Immunocompromised individuals and those with chronic liver diseases should avoid consumption of undercooked meat (pork, wild boar, and venison) and shellfish.
EASL suggests that immunocompromised patients consume meat only if it has been thoroughly cooked to temperatures of at least 70 °C.

Gastric bypass vitamins
Monday, July 16, 2018

Routine fat-soluble vitamin supplementation is recommended in all patients having undergone biliopancreatic diversion or biliopancreatic diversion with duodenal switch.
Suggested daily supplementation for patients with gastric bypass and sleeve gastrectomy includes 2 adult multivitamin plus mineral supplements (containing iron, folic acid, and thiamine); 1,200-1,500 mg of elemental calcium (in diet and as citrated supplement in divided doses); at least 3,000 IU of vitamin D (titrated to therapeutic 25-hydroxyvitamin D levels >30 ng/ml); and vitamin B12 titrated to maintain normal levels. Routine supplementation with adequate amounts of fat-soluble vitamins should be added to this regimen after biliopancreatic diversion or duodenal switch. In the case of gastric banding, the suggested daily supplementation may be reduced to adult multivitamin plus mineral supplement and at least 3,000 IU of vitamin D (titrated to vitamin D levels) with or without 1,200-1,500 mg of elemental calcium (in diet and as citrated supplement in divided doses).h

Dumping refers to the postprandial occurrence of a constellation of symptoms elicited by the rapid transit of calorie-dense food to the small bowel. Nutritional manipulation is usually sufficient to control dumping. Nutritional tips comprise eating small but frequent meals, avoiding ingestion of liquids within 30 minutes of a solid-food meal, avoiding simple sugars, increasing intake of fiber and complex carbohydrates, and increasing protein intake

DAA failure to reduce CPT score in cirrhosis
Monday, July 16, 2018

The presence of ascites or encephalopathy, serum level of albumin <3.5 g/dL or alanine aminotransferase <60 U/L, and body mass index >25 kg/m2 were associated with an increased risk of not achieving a reduction in CPT to class A, independent of sustained viral response to therapy. Serum level of albumin <2.8 g/dL and abnormal level of bilirubin were associated with an increased risk of liver transplantation or death. We developed a scoring system based on five baseline factors (body mass index, encephalopathy, ascites, and serum levels of alanine aminotransferase and albumin) associated significantly with patient outcomes, which we called the “BE3A score.” For patients with scores of 4–5, the hazard ratio for reduction of CPT score to class A was 52.3 (95% confidence interval, 15.2–179.7).

Weightlessness in space
Wednesday, July 18, 2018
Anywhere mass and space exist, gravity exists. Gravity is the curvature of spacetime due to the presence of mass. The gravitational influence from the Sun that keeps the Earth in orbit around the Sun is felt equally by the astronauts in space. The gravitational influence from the Earth that keeps the Moon and the ISS in Earth orbit is also felt by the astronauts floating inside and outside the spacecraft. If these influences were not felt, the astronauts would not stay in orbit.

At the altitude the astronauts in the ISS inhabit, the gravitational influence from the Earth is 8.75 m/s^2. That is only about 11% less than the 9.81 m/s^2 felt by you and me, on the Earth’s surface.

They are weightless and appear to float because they are in freefall. A spacecraft in Earth orbit is falling towards the Earth (because of gravity) but also moving forward at a speed high enough that the path traveled isn’t straight down, but instead a curve that circles the Earth.[1] The astronaut is falling and so is their spacecraft. If both are falling, there is no force of one against the other and thus no sensation of weight. We can emulate this freefall here on Earth, in a tall chamber that is pumped to vacuum.

Let’s do a thought experiment.

Imagine an astronaut on Earth standing on a scale. The scale would indicate weight because gravity is pulling the astronaut towards the center of the Earth but the Earth isn’t willing to get out of the way. Weight is the perception of the Earth not getting out of the way.

Now imagine that same astronaut in space, orbiting the Earth. He has the same scale, and he stands upon it. Will it show weight? No. It won’t show weight because the astronaut and scale are falling together and there is no contact with the Earth to allow the Earth to push back.

The ISS and its crew are in free fall. They are falling towards the center of the Earth but since they are also moving quickly, sideways, they keep missing the Earth. Since there is no Earth surface to push back against the ISS or its crew, there is weightlessness.

Meat and mania
Wednesday, July 18, 2018
Diets high in nitrates were associated with higher risk for experiencing a manic episode, according to a prospective cohort study.
Among those with a history of psychiatric disorders, people who reported eating a history of dried meats cured with nitrates had increased odds of currently experiencing mania, a principal feature of bipolar disorder (adjusted odds ratio 3.49, 95% CI 2.24 to 5.45, P<8.97 × 10-8), found Robert Yolken, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues, as reported in Molecular Psychiatry.

Thursday, July 19, 2018

Saturday, July 21, 2018

Debulking and cleansing dose
Two doses 10-12 hours apart. If procedure at 10, start at 5 get done by 6 then hour break then more fluid from 7 to 8

Cold snare polypectomy
Saturday, July 21, 2018

Exacto or captivator snare
Ultra slim colonoscopy

Gut flora
Saturday, July 21, 2018

Faecalobacterium Prasnutzii anti inflammatory property. Decreased in crohns

Kyo-dophilus probiotic helps allergies

Have you thought of 21 days 200 mg fluconazole daily or Or nystatin 1 million units 4 times a day for 14 days. For SIFO FUNGAL overgrowth
And some of the either polymorphisms that are looked at or just genetic changes, I guess you could say if it’s not specifically a polymorphism, are things like the Dectin-1 and CARD9. And I know these can alter the ability of the immune system to regulate fungal growth in the gut.
Dr Satish Rao Augusta

Erythromycin 50 mg at night time for SIBO after xifaxan


Monday, July 23, 2018

Increased plasma pro-NT levels identify the presence/severity of NAFLD; in dysmetabolic individuals, NT may specifically promote hepatic fat accumulation through mechanisms likely related to increased insulin resistance.
Neurotensin (NT), a 13–amino acid peptide mainly secreted by neuroendocrine cells in the small intestine (18), displays an important role in regulating food ingestion and fat absorption (19). By doing so, NT influences energy balance and body weight (20). NT mainly acts as a neurotransmitter in the central nervous system and as a hormone in the periphery, exerting its physiological action by binding the specific NT receptors, NTSR1, NTSR12, and NTSR13 (21, 22). Experimental evidence has shown that the NT/NTSR1 system is involved in adaptive energy balance (23–25).

Tuesday, July 24, 2018

So how did something called “autonomous sensory meridian response” get so big? It’s all in how it makes its targets feel — and science says that could come with tangible health benefits.
Soothing touch in brain down to spinal cord triggered by inaudible sounds like nail scratching heard on YouTube etc.

Elagolix for endometrial
Tuesday, July 24, 2018

Orlissa is a GnRH. Causes osteoporosis long term use

Celafen for fibromyalgia
Wednesday, July 25, 2018

News report not a journal study

Sunday, July 29, 2018

a mucinous histology, microsatellite instability (MSI), and CpG island methylation are more common in proximal CRCs, whereas chromosomal instability (CIN) is a prominent feature of distal CRCs [14,15]. These differences imply that separate mechanisms may be responsible for the development and growth of tumors arising from different anatomic locations. Second, compared with those in the distal colon, lesions arising from the proximal colon tend to be smaller and morphologically nonpolypoid and flat, which make their detection with colonoscopy more difficult [16]. Third, a wide variation exists in adenomatous polyp detection rate, even among experienced gastroenterologists. Successful detection of I-CRCs is associated with the quality of the colonoscopy. Lesions may be easily missed when endoscopists fail to reach the cecum during colonoscopy and/or if the lesion is nonpolypoid, as it is more common in the proximal colon, which is more difficult to examine with colonoscopy [16].

Interval cancer within 60 months of index colon
Experience matters and training
Right sided more in women ,
Diverticula disease suggests higher incidence
More common in right side , harder to prep

I-CRC, we will focus on describing the three aberrant pathways involved in CRC pathogenesis: CIN, MSI, and CpG island methylator phenotype (CIMP). A proportion of I-CRCs have more recently been shown to have one or more of these genomic instability phenotypes. Chromosomal instability CIN. CpG island methylation phenotype

The prevalence of I-CRCs varies from 2.8% to 4.9% of all CRCs. Compared with Sp-CRCs, I-CRCs were found 2.4 times more frequently in the proximal colon than in the distal colon. The patient-related risk factors include female sex, old age, family history of CRC, diverticulosis, comorbidities, and skill of the endoscopist. The risk factors associated with the endoscopist were low polypectomy rate and low colonoscopy completion rate. The specialty of the endoscopist is another risk factor for I-CRCs.

IgG4 disease
Sunday, July 29, 2018

It affectsbut most commonly in the pancreas, bile duct, retroperitoneum, kidneys, lungs, salivary and lacrimal glands, orbit, and lymph nodes. In all organs, inflammation can be reduced by corticosteroids and drugs that deplete B cells such as rituximab.

Gut Alzheimer’s link
Sunday, July 29, 2018
reported that people with Alzheimer’s disease had increased gut microbiome-produced bile acids, which were associated with changes in cognitive decline, reduced brain glucose metabolism, and greater brain atrophy.
These same bile acids were linked to increased amyloid and tau accumulation, said Nho and co-authors in an analysis of 1,562 patients from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) cohort.

MRI for crohns
Sunday, July 29, 2018

The simplified version of the MaRIA [Magnetic Resonance Index of Activity] score allows a faster and easier assessment of inflammation and quantification of severity in Crohn’s disease by keeping high accuracy for diagnosis and therapeutic response,” Ingrid Ordás, MD, said at the annual Digestive Disease Week®. The main advantage of the simplified MaRIA is that it is a “less time-consuming calculation that is not confounded by missing segments,” said Dr. Ordás, a gastroenterologist at the Hospital Clinic of Barcelona.

The derivation phase of the study identified four features that significantly correlated with disease activity and severity: bowel wall thickening to more than 3 mm, mural edema, perienteric fat stranding, and mucosal ulcerations. Limiting assessment to these four features cut in half the elements in the original MaRIA (Inflamm Bowel Dis. 2011 Aug;17[8];1759-68). Fat stranding – loss of the usual sharp interface between the wall and mesentery because of fluid – is a new parameter in the simplified MaRIA. The other three elements had been in the original index, but several other elements are now gone, including relative contrast enhancement wall signal intensity and consideration of lymph nodes.

UC Otezla
Monday, July 30, 2018

Patients with active ulcerative colitis treated with the phosphodiesterase-4 inhibitor apremilast (Otezla) had clinically meaningful improvements on multiple efficacy measures in a 12-week phase II trial. At week 12, 31.6% of patients…

Weight loss drug in mice brown fat
Monday, July 30, 2018

The winning chemical is an anti-cancer drug called bexarotene (Bex). It targets a protein that was not previously shown to be involved in generating brown fat.
To test how well Bex controls body weight, the scientists fed mice a high-calorie diet for 4 weeks, but they only treated half of the mice with the drug.
The mice that were given Bex had more brown fat, burned more calories, had less body fat, and gained less weight than mice that were fed the same diet but were not given the drug.
The researchers say the technique, which uses cellular reprogramming, could be a new way to combat obesity and type II diabetes.

Sauna benefits
Friday, August 3, 2018
Several key studies included in the review showed a decreasing risk for certain acute and chronic conditions associated with greater sauna use. For example, in one study the risk ratio of hemorrhagic stroke among people who had four to seven sessions per week was 0.33 (95% confidence interval [CI], 0.07-1.51) compared with people who used the sauna only once per week. In another study, four to seven sauna sessions per week was associated with a relative risk for dementia and Alzheimer disease of 0.34 (95% CI, 0.16 – 0.71) and 0.35 (95% CI, 0.14 – 0.90), respectively, compared with one session per week. Similarly, sessions of 19 minutes or more were associated with a relative risk for sudden cardiac death and all-cause mortality of 0.48 (95% CI, 0.31 – 0.75) and 0.83 (95% CI, 0.87 – 1.20), respectively, compared with sessions lasting 11 minutes.
Two experimental studies on middle-aged adults have shown beneficial effects on systolic and diastolic blood pressure after single, 30-minute sessions in a sauna, whereas in one long-term prospective study, the risk of developing hypertension was reduced by 47% in white men followed for 24.7 years, leading Kunutsor and colleagues to caution that any protective effect of regular sauna bathing on the risk for hypertension will have to be confirmed in a more robust, randomized clinical trial.

Many physiologic pathways have been implicated as possible mediators of sauna benefits, including reduced blood pressure, “improvement in endothelial function; reduction in oxidative stress and inflammation; beneficial modulation of the autonomic nervous system; positive alteration in levels of circulating vascular risk factors such as natriuretic peptides and lipids; hormonal changes; improved arterial stiffness, arterial compliance, and intima media thickness; and improvement in the cardiorespiratory system as well as cardiovascular function,” the authors write.

Friday, August 3, 2018


Friday, August 3, 2018

Acg site

weight adjusted aspirin
Friday, August 3, 2018
Low-dose aspirin intended for primary prevention, typically 75 to 100 mg once daily, doesn’t protect against cardiovascular events in persons who weigh at least 70 kg (about 154 pounds), suggests a patient-level analysis of randomized trials that included more than 100,000 patients.
But daily aspirin at higher dosages, usually at least 300 mg, was cardioprotective in that group, as was low-dose aspirin in people who weighed less than 70 kg.

Statin reduction benefit
Friday, August 3, 2018

With statin therapy, the relative risk for major vascular events (coronary heart disease death, myocardial infarction, ischemic stroke, or coronary revascularization) was 22% lower for every 1-mmol/L (38.7 mg/dL) decrease in LDL-C (relative risk [RR], 0.78; 95% confidence interval [CI], 0.65 – 0.94).

Friday, August 3, 2018
Infusion of risankizumab increased clinical response and remission rates in moderate to severe refractory Crohn’s disease (CD), with 53% of patients in remission at 26 weeks, an open-label extension study found.
Furthermore, subcutaneous delivery of the selective anti-interleukin 23 antibody (IL-23), a more convenient route, maintained remission until week 52 in 71% of patients who had achieved clinical remission at week 26, reported Brian G. Feagan, MD, of Western University in Ontario, and colleagues.

Capgras and frepgoli syndrome
Saturday, August 4, 2018

occurs in dementia, schizophrenia
Capgras – sees duplicate images of person
Frepgoli syndrome – different people seem to be the same person by devious acting makeup

Best DM diet bacteria
Monday, August 6, 2018

China, has found that prebiotic mannan-oligosaccharides increase the hypoglycemic effects of metformin in parallel with changes in the gut microbiota in mice.

Treatments with MOS alone or in combination with metformin led to different changes in the structure of the gut microbiota. A combination treatment of both metformin and MOS modulated a higher number of operational taxonomic units when compared with only metformin and only MOS treatments. It is worth noting that key bacterial species were modulated by metformin and MOS: the relative abundances of family Rikenellaceae and order Clostridiales decreased while an unnamed OTU05945 of family S24-7, Akkermansia muciniphila and Bifidobacterium pseudolongum increased. Furthermore, several associations were found between the alterations in gut microbial populations and host parameters related to diabetes, including fasting blood glucose, HOMA-IR, HbA1c and the area under the glucose concentration-time curve following oral glucose tolerance tests at different times.

MOS sources. Glucomannan comprises 40% by dry weight of the roots, or corm, of the konjac plant. Another culinary source is salep, ground from the roots of certain orchids and used in Turkish cuisine. Glucomannan is also a hemicellulose that is present in large amounts in the wood of conifers and in smaller amounts in the wood of dicotyledons.[citation needed] Glucomannan is also a constituent of bacterial, plant and yeast cell wall with differences in the branches or glycosidic linkages in the linear structure.[10][11][12]

Bad probiotics?
Tuesday, August 7, 2018
In a new study from Augusta University, researchers find that probiotic use can result in a significant accumulation of bacteria in the small intestine.
This can lead to disorienting brain fogginess as well as rapid, significant belly bloating.
In the study, the team found that among 30 patients, the 22 who reported problems like confusion and difficulty concentrating, in addition to their gas and bloating, were all taking probiotics.
When the researchers looked further, they found large colonies of bacteria breeding in the patients’ small intestines, including high levels of D-lactic acid.
D-lactic acid is known to be temporarily toxic to brain cells, interfering with cognition, thinking and sense of time.
Some patients had two to three times the normal amount of D-lactic acid in their blood.
Some said their brain fogginess—which lasted from a half hour to many hours after eating—was so severe that they had to quit their jobs.
When brain-foggy patients stopped taking probiotics and took a course of antibiotics, their brain fogginess resolved.
While probiotics can be beneficial in some scenarios, like helping a patient restore his gut bacteria after taking antibiotics, the team advised caution against its excessive and indiscriminate use.
They suggest that if one inadvertently colonizes the small bowel with probiotic bacteria, then the person has set the stage for potentially developing lactic acidosis and brain fogginess.
They also suggest that probiotics should be treated as a drug, not as a food supplement.
Many people self-prescribe the live bacteria, which are considered good for digestion and overall health.
Others have implicated probiotics in the production of D-lactic acid—and brain fogginess—in patients with a short bowel so their small intestine does not function properly, and in newborns fed formula containing the popular product.
Short bowel syndrome results in a lot of undigested carbohydrates that are known to cause small intestinal bacterial overgrowth, or SIBO, and the high levels of D-lactic acid.
Severe liver and kidney problems can produce similar problems.
The team also suggests that probiotic use may be particularly problematic for patients who have known problems with motility.
Those taking opioids and proton pump inhibitors, which reduce stomach acid secretion and so the natural destruction of excessive bacteria, should use probiotic under doctors’ advice.
Probiotics definitely can help, for example, people who have gastroenteritis, or stomach flu, or are left with diarrhea and other problems after antibiotics wipe out their natural gut bacteria, Rao says.
Good food sources of probiotics include yogurt, sauerkraut, kimchi, kefir and dark chocolate, which are generally safe because of the small amounts of bacteria present.
Helpful gut bacteria, or microbiome, which are essential to things like a well-functioning immune system and general health, are largely in the large intestine and colon.
The study lead researcher is Dr. Satish S.C. Rao, director of neurogastroenterology/motility and the Digestive Health Clinical Research Center at the Medical College of Georgia at Augusta University.
The study is published in the journal Clinical and Translational Gastroenterology.

NASH diet changes
Wednesday, August 22, 2018
9:39 AM

eliminate all alcohol
eliminate most saturated fat and no red meat
eliminate all non skim dairy products
eliminate trans-fat and all hydrogenated oils
eliminate all high fructose corn syrup
eliminate most sodium — the goal 1,500 mg of salt.
eliminate all added dietary sugar
eliminate processed grains, no white flour or white rice
Avoid most products hustled by the supplement industry
Make sure that any medications you take are not harming your liver

Mediterranean diet
Wednesday, October 10, 2018
11:45 AM

Always try to choose the least-processed option. Organic is best, but only if you can easily afford it.
• Vegetables: Carrots, onions, broccoli, spinach, kale, garlic, etc.
• Fruits: Apples, bananas, oranges, grapes, etc.
• Berries: Strawberries, blueberries, etc.
• Frozen veggies: Choose mixes with healthy vegetables.
• Grains: Whole-grain bread, whole-grain pasta, etc.
• Legumes: Lentils, pulses, beans, etc.
• Nuts: Almonds, walnuts, cashews, etc.
• Seeds: Sunflower seeds, pumpkin seeds, etc.
• Condiments: Sea salt, pepper, turmeric, cinnamon, etc.
• Fish: Salmon, sardines, mackerel, trout.
• Shrimp and shellfish.
• Potatoes and sweet potatoes.
• Cheese.
• Greek yogurt.
• Chicken.
• Pastured or omega-3 enriched eggs.
• Olives.
• Extra virgin olive oil.
It’s best to clear all unhealthy temptations from your home, including sodas, ice cream, candy, pastries, white bread, crackers and processed foods.

Statin in liver disease
Friday, August 10, 2018

DILI is characterized by elevations of threefold or more in serum alanine aminotransferase (ALT) or aspartate aminotransferase and at least a doubling of total serum bilirubin with no other identifiable cause of these aberrations except the suspect drug. Statins rarely cause a DILI (1 in 100,000 patients), but can cause transient, benign ALT elevations. Statins should be discontinued if ALT or aspartate aminotransferase levels exceed a tripling of the upper limit of normal with concomitant bilirubin elevations. They should not be prescribed to patients with acute liver failure or decompensated liver disease, but otherwise they are safe for most patients with liver disease.


Many patients with NAFLD also have dyslipidemia. All NAFLD patients have an increased risk of cardiovascular disease, although NAFLD and nonalcoholic steatohepatitis are not traditional cardiovascular risk factors. Nevertheless, statins and the accompanying improvement in dyslipidemia have been shown to decrease cardiovascular mortality in these patients. The IDEAL study, for example, showed that moderate statin treatment with 80 mg atorvastatin was associated with a 44% decreased risk in secondary cardiovascular events. Other studies show similar results.

NAFLD patients with elevated LDL may benefit from ezetimibe as primary or add-on therapy. However, none of the drugs used to treat dyslipidemia will improve NAFLD or nonalcoholic steatohepatitis histology.

Monday, August 13, 2018
Two new agents — inotersen and patisiran — each show promise in the treatment hereditary transthyretin amyloidosis (hATTR), results of two trials suggest.
In the NEURO-TTR trial, investigators randomly assigned patients with stage 1 or stage 2 hATTR to receive weekly injections of inotersen or placebo for 15 months.

Prostate cancer spread
Tuesday, August 14, 2018
They saw a particular enzyme called MAOA activate a cascade of signals that made it easier for tumor cells to invade and grow in bone.

Ordinarily, bone is built up by cells called osteoblasts and reabsorbed during growth and healing by cells called osteoclasts.

But the MAOA enzyme triggers three proteins that enhance the function of the destructive osteoclasts.

This means the cancer cells can specifically activate the osteoclasts for bone degradation.

IBD infection
Sunday, August 19, 2018

those with CD had a higher prevalence of norovirus (P=0.05) and Campylobacter (P=0.043), while the UC group had a lower prevalence of norovirus (P=0.001) and a higher prevalence of Campylobacter(P=0.013), Plesiomonas (P=0.049), and Escherichia coli (P=0.004).

DVT risk
Wednesday, August 22, 2018
The data were pooled from eight observational studies involving almost 1 million participants and more than 9000 patients with VTE.
They found that each antidepressant drug class studied was associated with an elevated risk. These included tricyclics, selective serotonin reuptake inhibitors, and other antidepressants.
They couldn’t determine whether the link was driven mainly by depression or antidepressants or both. We’ll need further research to isolate the etiology of these effects.

Frank sign
Wednesday, August 22, 2018

The association between CAD and the Frank sign was studied in 430 individuals without a history of coronary heart disease using coronary computed tomography. The Frank sign was present in 71% of the patients with documented CAD (a 50% stenosis at least in one of the coronary arteries). The prevalence of coronary significant lesions in 307 patients with the Frank sign was 77%, significantly greater compared with 55% of 123 patients without the Frank sign (P < 0.001). The sensitivity, specificity, and positive and negative predictive values for the Frank sign to diagnose any CAD were 78%, 43%, 77%, and 45%, respectively.[24] Adding the Frank sign to the cardiovascular risk assessment of patients with angina pectoris improved the prediction of CAD beyond the Diamond-Forrester classification.[25]

Clinical observations found an association between the Frank sign and CAD. Many prospective studies have shown that the association is not solely with CAD, but with the general phenomenon of atherosclerosis. The Frank sign was associated with ischemic stroke and with cardiovascular risk factors. Many suggested that the Frank sign be added to the classic risk factors of cardiovascular disease and to consider early evaluation of subjects with the Frank sign as a preventive procedure to detect early preclinical cardiovascular disease

Dual SGLT inhibito sotagliflozin
Wednesday, August 22, 2018

Sotagliflozin is an oral potent dual inhibitor of the insulin-independent SGLT1 and SGLT2. Preliminary data released from phase 2 and 3 clinical studies in adults with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) showed improved glycemic control, and met efficacy endpoints beyond A1c with a safety profile consistent with the SGLT class: significant reduction in body weight, systolic blood pressure, and efficacy maintained in lower estimated glomerular filtration rate levels with no increased hypoglycemia.

SSRI GI Effects
Friday, August 24, 2018

SSRI meta analysis shows it leads to acute pancreatitis OR 1.26 and T2D 1.38. OR

Central T2D drugs
Friday, August 24, 2018

Bromocriptine. Best taken in AM.
Resets dopamine in hypothalamus
Works via increasing prolactin. Low dose prolactin helps increase dopamine. High dose works adversely

Pancreas and gut flora
Friday, August 31, 2018

Patients with acute pancreatitis are more likely than healthy volunteers to have gut dysbiosis,exhibiting higher populations ofEnterobacteriaceae and Enterococcus populations and lower populations of Bifidobacteria.

Probiotics after antibiotics
Sunday, September 9, 2018

Cell 2018.
Small study
Probiotics get usually flushed out in normal individuals
If antibiotics are given it causes dysbiosis
If aFMT done then normal flora in 1 day
No probiotics 21 day
Probiotics given it takes 5 months. Plus the probiotics generate an immune repose to healthy flora

Thursday, July 26, 2018

CKD – highercardiac mortality
Increased hepcidin, less iron absorption and increased iron storage in RE and liver. Hypoxia inductive factor (HIF)Prolyl hydroxylase inhibitor ( roxadustat) lowers hepcidin gn13.5 and 12 in male or female is target more than those numbers
HIF Inhibitir promotes erythropoietin

Post infectious IBS
Monday, August 20, 2018

Oral dietary Glutamine controls symptoms 80%versus 6 % placebo
Restores gut permeability looking at lactulose / mannitol ratio.

Crohns diet
Tuesday, September 18, 2018

inflammation from High animal or dairy fat, animal protein, wheat, emulsifiers, and thickeners appear to top the list of candidate foods associated with intestinal inflammation in animal models,” Levine and co-authors wrote.
exclusive elemental and partial elemental
Elemental is liquid diet

EEN and PEN, Low-FODMAP Diets
EEN, involving the exclusive use of liquid nutrition in medical formulas without exposure to table foods for 6 to 8 weeks, is a regimen not easy to follow, especially for children. But it has been found to induce remission of pediatric IBD at time of onset. In a study of children with active CD, Lee et al found that 88% of those on EEN achieved a clinical response with reduced mucosal inflammation versus 84% of those on anti-TNF and 64% of those on partial enteral nutrition (PEN).
Promisingly, clinical studies have suggested that EEN and PEN as well as elimination diets, though also hard to follow, may induce remission in newly diagnosed adults, maintain remission when biologic therapy has failed, and help avoid surgery in those with disease complications.

probiotics role Delphi method from 72 RCT
Tuesday, October 2, 2018

Collectively, the 70 studies investigated a total of 54 different probiotic products (containing 108 strains either alone or in combination) at doses ranging from 1×106 to 4.5×1011colony forming units (CFU) per day, administered as one, two or three doses. They predominantly contained bacteria (mostly lactobacilli and/or bifidobacteria); a few contained the yeast Saccharomyces.
With a grade of evidence for effect being “high”, specific probiotics may help relieve overall symptom burden in some patients with IBS. Among 15 studies that evaluated overall symptoms as a primary endpoint in patients with IBS, 8 studies reported a significant beneficial effect of 8 different probiotic products (dosed at 3.4 x 107 to 2.5 x 1010 CFU per day) compared with placebo. However, the grade of evidence for the use of specific probiotics in relieving overall symptom burden in patients with constipation-predominant IBS and patients with diarrhoea-predominant IBS was very low and low, respectively.
Regarding abdominal pain, among 9 studies that evaluated abdominal pain as a primary endpoint, 7 studies showed a significant beneficial effect of specific probiotic treatments compared with placebo in some patients with IBS with a high grade of evidence.
On the other hand, probiotics showed a moderate grade of evidence in reducing bloating/distension in some patients with IBS. The role of probiotics in reducing flatus in patients with IBS is still unclear.
Although probiotics showed a moderate grade of evidence for improving frequency and/or consistency of bowel habits in some patients with IBS, its role for relief of constipation had low evidence.
In patients receiving antibiotic therapy or H. pylori eradication therapy, specific probiotics at doses of between 2 x 106 to 2 x 1010 CFU per day appeared helpful as adjuvant therapies to prevent or reduce the duration of associated diarrhoea, with a high grade of evidence. Based on 13 studies of 10 different probiotics in 6091 patients who received antibiotics, probiotics were helpful as adjuvant therapy to prevent or reduce the duration of antibiotic-associated diarrhoea.

Friday, October 12, 2018

ACG2018 URI and pneumonia prevention in #IBD patients: higher risk of pneumonia (and complications) specially if on steroids, biologics or immunomodulators. Recommendations: Flu shot yearly; Pneumococcal vaccines: PCV13 (Prevnar) then PPSV23 (Pneumovax) 2-12 months later; second PPSV23 at 5 years. If PPSV23 was given first, wait at least 1 year to give Prevnar 13.

IBD and MI
Saturday, October 20, 2018

In a population-based cohort study, we found that despite a lower prevalence of traditional risk factors for AMI and heart failure, patients with IBD are at increased risk for these cardiovascular disorders.

Dementia causing drugs
Saturday, October 20, 2018

They found that there was a greater incidence of dementia among patients prescribed greater quantities of anticholinergic antidepressants, and anticholinergic medication for bladder conditions and Parkinson’s.

Flu treatment
Wednesday, October 24, 2018

Shortens duration from 80 hours to 52 hours
One dose.
Better than tamiflu

The US Food and Drug Administration (FDA) has approved baloxavir marboxil tablets (Xofluza, Shionogi) for the treatment of acute uncomplicated influenza in people age 12 years and older who have been symptomatic for no more than 48 hours.

HILI Green tea
Thursday, October 25, 2018
While millions of people take green tea supplements safely, at least 80 cases of liver injury linked to green tea supplements have been reported around the world, ranging from lassitude and jaundice to cases requiring liver transplants. Those harmed after taking green tea pills have included teenagers, like 17-year-old Madeline Papineau from Ontario, Canada who developed liver and kidney injury, and an 81-year-old woman diagnosed with toxic acute hepatitis.
A recent investigation by the European Food Safety Authority into the safety of green teaconcluded that catechins from green tea drinks are “generally safe”, but when taken as supplements catechin doses at or above 800mg per day “may pose health concerns”. The EFSA could not identify a safe dose on the basis of available data and called for more research to be carried out.

Gut flora
Friday, January 26, 2018
4:42 PM

Colectomy increases chance of DM
Sunday, November 4, 2018

Due to gut Flora change

Depression enzyme supplement
Saturday, November 10, 2018

In a recent study, Stanford researchers found that people with depression have low blood levels of a substance called acetyl-L-carnitine.
Acetyl-L-carnitine can be naturally produced in the body. It is also widely available in drugstores, supermarkets, and health food catalogs as a nutritional supplement.

K2 supplement
Saturday, November 10, 2018

A 2017 systematic literature review recommended considering K2 alongside vitamin D and calcium as an adjunct osteoporosis treatment “rivaling bisphosphonate therapy without toxicity.”[11]

A cohort study of over 16,000 women free of cardiovascular disease also reported a strong correlation between increased K2 intake and reduced coronary events, but not for K1.[13]

Vitamin K’s bone-building reputation is well earned, as it is necessary for activating proteins secreted by osteoblasts.[2] K2 draws calcium into the bone matrix and can inhibit bone resorption when administered with vitamin D3.[2] The MK-7 form of vitamin K2 has proven particularly adept in this process.[6]
Supplemental K2 has been associated with significant reductions (approximately 25%-80%) in fracture risk when used alone or combined with vitamin D and calcium,[7,8] as well as with maintenance of bone density in osteoporotic patients.[9,10] K1 supplementation has shown comparatively less benefit for such outcomes.[11]

• Natto: 1,062 mcg
• Pork sausage: 383 mcg
• Hard cheeses: 76 mcg
• Pork chop (with bone): 75 mcg
• Chicken (leg/thigh): 60 mcg
• Soft cheeses: 57 mcg
• Egg yolk: 32 mcg

Travelers diarrhea
Monday, November 19, 2018
The US Food and Drug Administration (FDA) has approved the antibacterial agent rifamycin delayed-release tablets (Aemcolo, Cosmo Technologies) to treat adults with travelers’ diarrhea caused by noninvasive strains of Escherichia coli not complicated by fever or blood in the stool.
“Travelers’ diarrhea affects millions of people each year and having treatment options for this condition can help reduce symptoms of the condition,” Edward Cox, MD, director of the Office of Antimicrobial Products, FDA Center for Drug Evaluation and Research, said in a news release.

Monday, November 19, 2018

SELADELPAR peroxisome receptor helps it

Ntg for tendon injury
Monday, November 19, 2018
Nitroglycerin patches help patients with common injuries to tendons, a research review suggests.
The study team focused on overuse tendon injuries in the shoulders, wrists, heels and knees. Depending on its severity, the condition may be treated with physical therapy, corticosteroid injections to provide short-term pain relief or surgery to repair or replace damaged tendons.
The current study examined another treatment option, nitroglycerin patches, which can have fewer side effects than injections or surgery, said senior author Neal Millar of the University of Glasgow in Scotland. While topical nitroglycerin has been examined for tendon pain for more than two decades, research to date has offered a mixed picture of how well it works for this purpose, Millar said.

Platelet mapping
Tuesday, November 20, 2018

TEG-AA percent for aspirin

Weight loss video
Tuesday, November 20, 2018

Dr. Jason Fung – ‘Therapeutic Fasting – Solving the Two-Compartment Problem’

Friday, November 23, 2018

Calcific aortic stenosis progression
Saturday, November 24, 2018

Valve stenosis was more likely to progress rapidly (Vpeak going up by at least 0.20 m/s per year) with increasing baseline levels of:
• Lipoprotein(a): OR 1.10 per 10 mg/dL (95% CI 1.03-1.19)
• Oxoidized phospholipids on apolipoprotein B (OxPL-apoB): OR 1.06 per 1 nM (95% CI 1.01-1.12)
• Oxoidized phospholipids on apolipoprotein(a) (OxPL-apo[a]): OR 1.16 per 10 nM (95% CI 1.05-1.27)
These findings stayed robust after multivariable adjustment. Notably, aortic jet velocity progressed especially fast in patients 57 years or younger with these same increases in the markers, according to Philippe Pibarot, DVM, PhD, of Institut Universitaire de Cardiologie et de Pneumologie de Québec in Québec City, and colleagues reporting online in JAMA Cardiology.
“This study demonstrates that the association of Lp(a) [lipoprotein(a)] levels and its content in OxPL with faster CAVS [calcific aortic valve stenosis] progression is linear, reinforcing the concept that Lp(a) levels should be measured in patients with mild to moderate CAVS to enhance management and risk stratification,” they said.
But the idea of a certain threshold value of these lipoproteins and components for worsening valve stenosis was not supported by the data, the authors suggested.