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.

Tacrolimus Toxicity in Two Renal Transplant Recipients Treated With Nirmatrelvir/Ritonavir: A Case Series | Annals of Internal Medicine: Clinical Cases

Since the onset of the SARS-CoV-2 (COVID-19) pandemic, significant effort has been devoted toward developing therapeutics that decrease the morbidity and mortality of COVID-19 infection. The antiviral nirmatrelvir/ritonavir (Paxlovid) has shown success in reducing hospitalization and death in patients with mild-to-moderate COVID-19 infection. However, enthusiasm over nirmatrelvir/ritonavir's ability has been met with caution as the result of potential drug–drug interactions. Here, we present 2 cases of tacrolimus toxicity, both in renal transplant recipients, following nirmatrelvir/ritonavir use. These cases are significant because, although the potential for pharmacologic interactions with nirmatrelvir/ritonavir is known, few cases of actual harm have been documented.

Renovascular Hypertension: Unraveling a Case of Mixed Histiocytosis | Annals of Internal Medicine: Clinical Cases

Renovascular hypertension is a cause of secondary hypertension. Atherosclerotic renal artery stenosis and fibromuscular dysplasia are the main causes, but other rare entities can involve the renal arteries. Erdheim-Chester disease is a non-Langerhans cell histiocytosis with a heterogenous clinical presentation and prognosis. We report a case of a 63-year-old woman with a history of Langerhans cell histiocytosis presenting with difficult-to-treat hypertension. A literature review is presented, and owing to the pathophysiology and anatomical characteristics of the vascular attainment, we propose that angioplasty with stenting, as preconized for atherosclerotic renal artery stenosis, should be the preferred treatment approach.

Refractory Iron Deficiency Anemia Secondary to Angiodysplasia-Related Gastrointestinal Bleeding Successfully Treated With Bevacizumab | Annals of Internal Medicine: Clinical Cases

Rapidly recurrent iron deficiency anemia secondary to angiodysplasia-related gastrointestinal hemorrhage is usually difficult to treat. Management is limited to endoscopic techniques such as argon plasma coagulation, blood product transfusion, parenteral iron replacement, and elimination of drugs that predispose to bleeding. We describe 2 patients with gastrointestinal angiodysplasia and rapidly recurrent iron deficiency anemia secondary to chronic gastrointestinal bleeding who continued to be symptomatic despite multiple pharmacologic and supportive interventions. They both experienced a dramatic, rapid, and sustained response to bevacizumab. Clear guidelines on the use of bevacizumab in this setting are lacking.

Massive Empyema With Edwardsiella tarda in a Patient With Liver Cirrhosis | Annals of Internal Medicine: Clinical Cases

Although infection caused by Edwardsiella tarda is rare in humans, it can be fatal if contracted. A 78-year-old man with liver cirrhosis who ate raw fish on a regular basis was emergently admitted for treatment of septic shock. Computed tomography scan showed massive empyema in his right lung. The patient was diagnosed with septic shock with empyema caused by E tarda after a positive blood culture and drainage culture from the empyema. His condition improved with multidisciplinary therapy. However, the patient died 36 days after admission because of liver failure. We recommend that patients with liver cirrhosis should avoid raw fish.

Cold Agglutinin Disease–Associated Transient Ischemic Attack, Non-ST Elevation Myocardial Infarction, and Skin Necrosis: A Case Report | Annals of Internal Medicine: Clinical Cases

Cold agglutinin disease is a rare autoimmune hemolytic anemia that preferentially affects female patients and is more common in those older than 60 years. The pathophysiology involves IgM autoantibodies against erythrocytes in areas of the body at cooler temperatures, causing thrombosis and hemolysis. We present the case of a 66-year-old man who was found to have cold agglutinin disease and initially presented with altered mental status, stroke-like symptoms, and non-ST elevation myocardial infarction. Overnight, he also developed striking soft-tissue necrosis of his bilateral feet due to microvascular occlusion. His altered mentation and cardiac ischemia completely resolved; however, he eventually required bilateral phalangeal amputation.

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.

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.

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.

Unmasking of Asymptomatic Celiac Disease and Microscopic Colitis After Acquiring COVID-19 | Annals of Internal Medicine: Clinical Cases

Previous studies have suggested that viruses may trigger the development of autoimmune diseases such as celiac disease. We report a 75-year-old elderly man who developed intractable diarrhea after acquiring COVID-19. We suspect the COVID-19 unmasked or triggered histology-proven celiac disease (CD) and microscopic colitis (MC), which caused the diarrhea. Clinicians should be aware of the existence of CD and MC unmasked by SARS-CoV-2 in a COVID-19 patient who developed intractable diarrhea.

Hepatocellular Carcinoma at Initial Diagnosis of Cirrhosis | Annals of Internal Medicine: Clinical Cases

Cirrhosis is a common diagnosis that clinicians will see throughout their career. We encountered a 36-year-old man who presented to the hospital about concerns of alcohol withdrawal. In the hospital, he was initially diagnosed with cirrhosis via imaging studies, and a subsequent magnetic resonance imaging scan uncovered hepatocellular carcinoma. This patient case underscores the importance of screening individuals with cirrhosis for hepatocellular carcinoma, even early in their diagnosis.