Colonoscopy-Ascertained Prevalence of Advanced Neoplasia According to Fecal Hemoglobin Concentration in a Large Cohort of Fecal Immunochemical Test–Negative Screening Participants

How Would You Manage This Patient With Clostridioides difficile Infection?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 8

The Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and the American College of Gastroenterology recently released updated guidelines on management of patients with Clostridioides difficile infection. Although these 2 guidelines generally agree, there are a few important differences in their advice to clinicians. In these rounds, 2 experts, an infectious diseases specialist and a gastroenterologist, discuss antibiotic treatment options for nonsevere disease, the role of fecal microbiota transplantation for fulminant disease, and the use of bezlotoxumab to prevent recurrence in the context of Ms. C, a 48-year-old woman with fulminant C difficile infection.

Disparities in Guideline-Recommended Statin Use for Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and Gender: A Nationally Representative Cross-Sectional Analysis of Adults in the United States: Annals of Internal Medicine: Vol 176, No 8

Background: Although statins are a class I recommendation for prevention of atherosclerotic cardiovascular disease and its complications, their use is suboptimal. Differential underuse may mediate disparities in cardiovascular health for systematically marginalized persons. Objective: To estimate disparities in statin use by race–ethnicity–gender and to determine whether these potential disparities are explained by medical appropriateness of therapy and structural factors. Design: Cross-sectional analysis. Setting: National Health and Nutrition Examination Survey from 2015 to 2020. Participants: Persons eligible for statin therapy based on 2013 and 2018 American College of Cardiology/American Heart Association blood cholesterol guidelines. Measurements: The independent variable was race–ethnicity–gender. The outcome of interest was use of a statin. Using the Institute of Medicine framework for examining unequal treatment, we calculated adjusted prevalence ratios (aPRs) to estimate disparities in statin use adjusted for age, disease severity, access to health care, and socioeconomic status relative to non-Hispanic White men. Results: For primary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors among non-Hispanic Black men (aPR, 0.73 [95% CI, 0.59 to 0.88]) and non-Mexican Hispanic women (aPR, 0.74 [CI, 0.53 to 0.95]). For secondary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors for non-Hispanic Black men (aPR, 0.81 [CI, 0.64 to 0.97]), other/multiracial men (aPR, 0.58 [CI, 0.20 to 0.97]), Mexican American women (aPR, 0.36 [CI, 0.10 to 0.61]), non-Mexican Hispanic women (aPR, 0.57 [CI, 0.33 to 0.82), non-Hispanic White women (aPR, 0.69 [CI, 0.56 to 0.83]), and non-Hispanic Black women (aPR, 0.75 [CI, 0.57 to 0.92]). Limitation: Cross-sectional data; lack of geographic, language, or statin-dose data. Conclusion: Statin use disparities for several race–ethnicity–gender groups are not explained by measurable differences in medical appropriateness of therapy, access to health care, and socioeconomic status. These residual disparities may be partially mediated by unobserved processes that contribute to health inequity, including bias, stereotyping, and mistrust. Primary Funding Source: National Institutes of Health.

How Would You Manage This Patient With Recurrent Diverticulitis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 6

Acute diverticulitis, which refers to inflammation or infection, or both, of a colonic diverticulum, is a common medical condition that may occur repeatedly in some persons. It most often manifests with left-sided abdominal pain, which may be associated with low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction. The American College of Physicians recently published practice guidelines on the diagnosis and management of acute diverticulitis, the role of colonoscopy after resolution, and interventions to prevent recurrence of this condition. Among the recommendations were the use of abdominal computed tomography (CT) scanning in cases where there was diagnostic uncertainty, initial management of uncomplicated cases in the outpatient setting without antibiotics, referral for colonoscopy after an initial episode if not performed recently, and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. Here, 2 gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease.

National Trends in Alcohol Use, Metabolic Syndrome, and Liver Disease From 1999 to 2018

The New European Medical Device Regulation: Balancing Innovation and Patient Safety

The European Union has introduced stricter provisions for medical devices under the new Medical Device Regulation (MDR). The MDR increases requirements for clinical trial testing for many devices before they can legally be placed on the market and extends requirements for rigorous clinical surveillance of benefits and harms to the entire life cycle of devices. New “expert panels” have been established by the European Commission to advise in the assessment of devices toward certification, and the role of previous “notified bodies” (private companies charged by the Commission with ensuring that manufacturers follow the requirements for device testing) is being expanded. The MDR does not contain a grandfathering clause; thus, all existing medical devices must be recertified under the stricter regulation. The recertification deadline has recently been extended to 2027 or 2028, depending on the device's risk class. Whether most device manufacturers can meet these new requirements is uncertain, and the MDR will likely have important consequences for manufacturers, researchers, clinicians, and patients. Enhanced collaborations between the medical device industry and physician partners will be needed to meet the new requirements in a timely manner to avoid shortages of existing devices and to mitigate barriers to development of new devices.

What Is the Current Role of an Over-the-Scope Clip Used as First-Line Endoscopic Hemostasis in Patients With Nonvariceal Upper Gastrointestinal Bleeding?

The Effect of Low-Dose Glucocorticoids Over Two Years on Weight and Blood Pressure in Rheumatoid Arthritis: Individual Patient Data From Five Randomized Trials

Background: Weight gain and hypertension are well known adverse effects of treatment with high-dose glucocorticoids. Objective: To evaluate the effects of 2 years of low-dose glucocorticoid treatment in rheumatoid arthritis (RA). Design: Pooled analysis of 5 randomized controlled trials with 2-year interventions allowing concomitant treatment with disease-modifying antirheumatic drugs. Setting: 12 countries in Europe. Patients: Early and established RA. Intervention: Glucocorticoids at 7.5 mg or less prednisone equivalent per day. Measurements: Coprimary end points were differences in change from baseline in body weight and mean arterial pressure after 2 years in intention-to-treat analyses. Difference in the change of number of antihypertensive drugs after 2 years was a secondary end point. Subgroup and sensitivity analyses were done to assess the robustness of primary findings. Results: A total of 1112 participants were included (mean age, 61.4 years [SD, 14.5]; 68% women). Both groups gained weight in 2 years, but glucocorticoids led, on average, to 1.1 kg (95% CI, 0.4 to 1.8 kg; P < 0.001) more weight gain than the control treatment. Mean arterial pressure increased by about 2 mm Hg in both groups, with a between-group difference of −0.4 mm Hg (CI, −3.0 to 2.2 mm Hg; P = 0.187). These results were consistent in sensitivity and subgroup analyses. Most patients did not change the number of antihypertensive drugs, and there was no evidence of differences between groups. Limitation: Body composition was not assessed, and generalizability to non-European regions may be limited. Conclusion: This study provides robust evidence that low-dose glucocorticoids, received over 2 years for the treatment of RA, increase weight by about 1 kg but do not increase blood pressure. Primary Funding Source: None.

Role of Artificial Intelligence in Colonoscopy Detection of Advanced Neoplasias: A Randomized Trial: Annals of Internal Medicine: Vol 176, No 9

Background: The role of computer-aided detection in identifying advanced colorectal neoplasia is unknown. Objective: To evaluate the contribution of computer-aided detection to colonoscopic detection of advanced colorectal neoplasias as well as adenomas, serrated polyps, and nonpolypoid and right-sided lesions. Design: Multicenter, parallel, randomized controlled trial. (ClinicalTrials.gov: NCT04673136) Setting: Spanish colorectal cancer screening program. Participants: 3213 persons with a positive fecal immunochemical test. Intervention: Enrollees were randomly assigned to colonoscopy with or without computer-aided detection. Measurements: Advanced colorectal neoplasia was defined as advanced adenoma and/or advanced serrated polyp. Results: The 2 comparison groups showed no significant difference in advanced colorectal neoplasia detection rate (34.8% with intervention vs. 34.6% for controls; adjusted risk ratio [aRR], 1.01 [95% CI, 0.92 to 1.10]) or the mean number of advanced colorectal neoplasias detected per colonoscopy (0.54 [SD, 0.95] with intervention vs. 0.52 [SD, 0.95] for controls; adjusted rate ratio, 1.04 [99.9% CI, 0.88 to 1.22]). Adenoma detection rate also did not differ (64.2% with intervention vs. 62.0% for controls; aRR, 1.06 [99.9% CI, 0.91 to 1.23]). Computer-aided detection increased the mean number of nonpolypoid lesions (0.56 [SD, 1.25] vs. 0.47 [SD, 1.18] for controls; adjusted rate ratio, 1.19 [99.9% CI, 1.01 to 1.41]), proximal adenomas (0.94 [SD, 1.62] vs. 0.81 [SD, 1.52] for controls; adjusted rate ratio, 1.17 [99.9% CI, 1.03 to 1.33]), and lesions of 5 mm or smaller (polyps in general and adenomas and serrated lesions in particular) detected per colonoscopy. Limitations: The high adenoma detection rate in the control group may limit the generalizability of the findings to endoscopists with low detection rates. Conclusion: Computer-aided detection did not improve colonoscopic identification of advanced colorectal neoplasias. Primary Funding Source: Medtronic.

Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial: Annals of Internal Medicine: Vol 176, No 3

Background: Although cold snare polypectomy (CSP) is considered effective in reducing delayed postpolypectomy bleeding risk, direct evidence supporting its safety in the general population remains lacking. Objective: To clarify whether CSP would reduce delayed bleeding risk after polypectomy compared with hot snare polypectomy (HSP) in the general population. Design: Multicenter randomized controlled study. (ClinicalTrials.gov: NCT03373136) Setting: 6 sites in Taiwan, July 2018 through July 2020. Participants: Participants aged 40 years or older with polyps of 4 to 10 mm. Intervention: CSP or HSP to remove polyps of 4 to 10 mm. Measurements: The primary outcome was the delayed bleeding rate within 14 days after polypectomy. Severe bleeding was defined as a decrease in hemoglobin concentration of 20 g/L or more, requiring transfusion or hemostasis. Secondary outcomes included mean polypectomy time, successful tissue retrieval, en bloc resection, complete histologic resection, and emergency service visits. Results: A total of 4270 participants were randomly assigned (2137 to CSP and 2133 to HSP). Eight patients (0.4%) in the CSP group and 31 (1.5%) in the HSP group had delayed bleeding (risk difference, −1.1% [95% CI, −1.7% to −0.5%]). Severe delayed bleeding was also lower in the CSP group (1 [0.05%] vs. 8 [0.4%] events; risk difference, −0.3% [CI, −0.6% to −0.05%]). Mean polypectomy time (119.0 vs. 162.9 seconds; difference in mean, −44.0 seconds [CI, −53.1 to −34.9 seconds]) was shorter in the CSP group, although successful tissue retrieval, en bloc resection, and complete histologic resection did not differ. The CSP group had fewer emergency service visits than the HSP group (4 [0.2%] vs. 13 [0.6%] visits; risk difference, −0.4% [CI, −0.8% to −0.04%]). Limitation: An open-label, single-blind trial. Conclusion: Compared with HSP, CSP for small colorectal polyps significantly reduces the risk for delayed postpolypectomy bleeding, including severe events. Primary Funding Source: Boston Scientific Corporation.

Case of Ibuprofen-Induced Liver Injury | Annals of Internal Medicine: Clinical Cases

Drug-induced liver injury (DILI) resulting from nonsteroidal anti-inflammatory drugs (NSAIDs) is a rare phenomenon; however, several cases have been reported in the literature and the LiverTox database. For ibuprofen in particular, only 22 cases have been reported, and the mechanism for liver injury is unclear. In this report, we discuss a case of ibuprofen-induced liver injury to highlight the evaluation of NSAID-induced DILI, as well as the likely mechanism of injury.

Abdominal Pain, Conjunctival Icterus, and Melena in a Man With Recent Endocarditis | Annals of Internal Medicine: Clinical Cases

Gastrointestinal bleeding is a common clinical entity associated with substantial morbidity and mortality. Upper gastrointestinal hemorrhage in particular requires swift recognition and management, and additionally engenders a broad differential diagnosis. Although rare, hemobilia, bleeding from or into the biliary tract, is an important diagnosis to consider at the bedside because of its unique risk factors, as well as diagnostic and therapeutic considerations. Here, we describe the clinical presentation of a man with hemobilia, highlighting key contemporary risk factors, diagnostic modalities, and therapeutic interventions.

Iatrogenic Hyperkalemia Induced by Hypermagnesemia From Administration of Laxatives in a Patient With Gastroparesis | Annals of Internal Medicine: Clinical Cases

Magnesium-containing drugs such as magnesium citrate are popular over-the-counter laxatives used to treat constipation. Although generally well tolerated, excessive intake can result in potentially dangerous electrolyte abnormalities. Of these abnormalities, hyperkalemia is one that is heavily underreported. We report an elderly woman who presented for gastroparesis flare-up and constipation. She was given magnesium citrate and subsequently developed hypermagnesemia, which resulted in hyperkalemia. By presenting this case, we hope to increase awareness of this heavily underreported side effect of magnesium-based laxatives, especially in the setting of gastrointestinal disturbances that may affect the absorption of these electrolytes.

Uphill and Downhill Esophageal Varices Secondary to Pulmonary Hypertension | Annals of Internal Medicine: Clinical Cases

Downhill esophageal varices (EVs) are rare endoscopic findings and coincide with superior vena cava (SVC) obstruction. Historically, downhill EVs have been associated with malignancy, thrombosis, or iatrogenic SVC obstruction. Few cases of “benign obstruction”, as in pulmonary hypertension (PH) with tricuspid regurgitation (TR), have been reported. Downhill EV can result in life-threatening bleeds; however, there are no current guidelines regarding treatment or surveillance endoscopy. We report a case of both uphill and downhill EV due to benign obstruction from PH and TR, leading to the diagnosis of decompensated cirrhosis.

Milk Alkali Syndrome Complicated by Calcium Impaction Causing Bowel Perforation | Annals of Internal Medicine: Clinical Cases

The milk-alkali syndrome consists of hypercalcemia, metabolic alkalosis, and acute kidney injury associated with the ingestion of large amounts of calcium and absorbable alkali. There has been a resurgence of this condition because of calcium therapy for prevention and treatment of osteoporosis, easy access to over-the-counter calcium carbonate preparations, and use of calcium carbonate to minimize secondary hyperparathyroidism in patients with chronic kidney disease. We report a rare patient case of severe milk-alkali syndrome resulting in hemodynamic instability and multiple metabolic derangements with severe intestinal obstruction in the setting of fecal impaction.

Tics in the Small Intestine: An Unusual Case of Jejunal Diverticulitis | Annals of Internal Medicine: Clinical Cases

Small bowel (SB) diverticulosis is rare and usually has an asymptomatic presentation. Diverticular microperforations provoke inflammation and diverticulitis. Given the disease rarity, no current treatment guidelines exist. Little is known regarding malignancy-associated SB diverticulitis and screening with endoscopic procedures, capsule endoscopy, or radiographic imaging may be difficult or inadequate. In this case, we report on a 64-year-old woman who presented with abdominal pain secondary to jejunal diverticulitis, received antibiotics with radiographic disease resolution, and will undergo malignancy screening with balloon enteroscopy.

Fecal Transplant Sustained Colitis Remission on Immunotherapy Resumption | Annals of Internal Medicine: Clinical Cases

Immune checkpoint inhibitors are increasingly used to treat various cancers, but they can cause immune-related adverse events that lead to treatment cessation. Here we report 2 cases of immune-mediated colitis that were treated with fecal microbiota transplant. Both cases had sustained colitis remission, which allowed resumption of immunotherapy.

Pancreatic-Pleural Fistula in a Patient With Recurrent Pancreatitis and Unknown Pancreatic Divisum | Annals of Internal Medicine: Clinical Cases

Recurrent acute pancreatitis (RAP) affects less than 1% of the population and can rarely be associated with severe extra-abdominal complications. We herein present a case of RAP due to a congenital anomaly with a rare thoracic complication that was undiagnosed by classic imaging method to highlight a unique presentation of an uncommon clinical entity.

Metastatic Lobular Carcinoma of the Breast Masquerading as Gallstone Disease – A Case Report | Annals of Internal Medicine: Clinical Cases

The gallbladder is a rare site of breast cancer metastasis. We report the patient case of a 60-year-old woman with isolated metastasis to the gallbladder, which was surgically removed for symptomatic cholelithiasis, with a subsequent new diagnosis of infiltrating lobular carcinoma (ILC) of the breast. ILC tends to metastasize to unusual sites such as the gastrointestinal and genitourinary tracts, but these usually occur concurrently with other more common sites of distant metastasis such as the bone, lungs, and liver. Our case underscores the need for routine histologic examination of gallbladder after cholecystectomy.

Chronic Lymphocytic Leukemia Involving the Liver Without High-Grade Transformation | Annals of Internal Medicine: Clinical Cases

Chronic lymphocytic leukemia is most frequently encountered among the elderly population. Hepatic infiltration may be present at the time of diagnosis, but significant extranodal involvement rarely occurs without high-grade transformation. Abnormal liver enzymes have important prognostic implications in terms of staging the disease and initiating treatment. We describe an atypical presentation of chronic lymphocytic leukemia in a patient who presented with rising liver enzyme levels, extensive hepatic infiltration, and portal hypertension but with no evidence of high-grade transformation on liver biopsy.