Computerized 3-dimensional Localization of a Video Capsule in the Abdominal Cavity: Validation by Digital Radiography

Background: Video capsule endoscopy has become the gold standard for examining the small bowel and defining pathological lesions, however, localization of a specific lesion remains largely guesswork. We report the validation of a new 3D localization software using radiological localization in volunteers. Methods: 30 volunteers with no known prior history of gastrointestinal disease swallowed the EC-10 video capsule. A sensor array with six radiopaque markers was placed on the anterior abdominal wall. Once the capsule was visualized to be in the small intestine using a real time viewer, five sets of low dose x-rays were taken every thirty minutes. Distances between sensor points and the capsule were measured on the x-rays to provide X, Y, and Z coordinates and compared with the distances calculated by the software from the same points. Results: Data from 27 of the 30 subjects were suitable for analysis. There were three technical failures. Our study evaluated the accuracy of the “Capsule 3D Track function” which calculated the capsule position based on the signal strength received at the sensor array. The accuracy of the position was compared to the actual position of the capsule as determined by radiographic images obtained during the capsule’s transit through the small bowel. The average error for the software measurement for each of the three coordinates was: X -2.00 cm (SD 1.64 cm), Y -- 2.64 cm (SD 2.39 cm), and Z --2.51 cm (1.83 cm). Conclusion: The localization error reported here is comparable to the existing system for localization, however, it provides localization across all three spatial dimensions which has never been achieved before. The potential utility of this technology is yet to be seen, however, as it needs to now be studied in a prospective clinical trial for patients with suspected small bowel pathology

Sweet Syndrome, Not so Sweet during an Ulcerative Colitis Flare Especially When You Cannot Eat

Sweet syndrome is a rare skin condition characterized by painful papules, nodules, or plaques with dense neutrophilic infiltrate in the upper dermis. It has been observed as idiopathic (classical), malignancy-associated, and drug-induced. The pathogenesis is not completely understood, but it is thought to involve hypersensitivity reactions to specific triggers. In some cases the etiology is unclear or may be multifactorial. We present a case of Sweet syndrome secondary to ulcerative colitis flare versus adalimumab re-induction

Development and Validation of a Clinical Scoring System to Differentiate Patients with Inflammatory Bowel Disease and Diarrhea-Predominant Irritable Bowel Disease

Background: There is no validated scoring system for differentiating inflammatory bowel disease (IBD) from irritable bowel syndrome (IBS). Studies variably report clinical measures such as radiology, endoscopy, inflammatory markers, and symptoms to separate IBS from IBD. Our study seeks to create a system to IBD patients from IBS. The “REBISS” score incorporates various clinical criteria used commonly for diagnosis. We also studied a second system called “REBISS-PCP” focusing on a subset of criteria that are available to PCPs when faced with this challenge. Methods: This study was approved by the UMass IRB. Two cohorts were identified: 24 IBD patients (Group1) and 24 IBS patients (Group2). Subjects in Group1 were patients with Crohn’s or ulcerative colitis. Subjects in Group2 were identified as having IBS based on ROME III criteria. Retrospective analysis was performed and a score was calculated. One point is assigned for having: radiological findings consistent with IBD, endoscopic findings of inflammation or ulceration, biopsy findings consistent with IBD, elevated inflammatory markers, weight loss, hematochezia, extra-intestinal signs/symptoms, palpable mass on exam, and perianal disease. The maximum score is 10 points. For the REBISS-PCP score, the same clinical criteria were studied with the exclusion of endoscopic and biopsy findings. Maximum score for that system is 8 points. A likelihood ratio chi-square test was performed for both cohorts and scoring systems. Results: The REBISS scoring system showed a significant differentiation of the two cohorts in regards to scoring distribution (chi-square value = 59.8; p\u3c0.0001). The REBISS-PCP scoring system also found a significant differentiation of the two cohorts (chi-square value = 35.7;p\u3c 0.0001). Discussion: The REBISS scoring system could be used to standardize IBD and IBSd populations in an academic research setting, while both the REBISS and REBISS-PCP scoring system could be used as a screening tool in clinical practice

A Year of Gastrointestinal Bleeding: An Epidemiologic Study

Background: For decades the diagnosis and management of gastrointestinal bleeding (GIB) has been based largely on endoscopy. Studying a large cohort of patients presenting to the ED we may find cost-effective alternatives in the management of GIB. We analyzed the epidemiology and initial disposition of all patients who presented to our ED from the perspective of hematemesis versus non-hematemesis, to identify patterns among each cohort’s presentations to aid in this. Methods: Retrospective analysis of medical records for 338 patients presenting to the UMass ED. Two cohorts were identified: those with hematemesis (G1) or non-hematemesis (G2). Results: 105 patients presented to the ED with hematemesis (G1), 233 patients presented with non-hematemesis GIB (G2). G1 was younger than G2 (54.4 years vs. 65.6 years, p\u3c0.001). There were more males in G1 vs. G2 (61% vs. 53%, p=0.154). Comorbities in G1 were liver disease (21%), alcohol abuse (20%), and diabetes (11%). Comorbities in G2 were coronary artery disease (22%), atrial fibrillation (13.7%), and diverticulosis (8%). More patients in G2 than G1 used Coumadin (23% vs. 7%, p\u3c0.001), anti-platelet agents (12% and 3%, p\u3c0.004), and NSAIDs (40% and 32%y, p=0.203). Admission hematocrit was greater in G1 compared to G2 (34.1 vs. 30.0, p\u3c0.001). INR was greater in G2 compared to G1 (1.7 vs. 1.3, p=0.03). BUN was greater in G2 compared to G1 (30.2 vs. 23.6, p=0.021). More patients in G2 were admitted compared to G1 (89.6% vs. 78.1%, p=0.019). More were admitted to the ICU in G1 compared to G2 (46% vs. 38%, p=0.237).Discussion: This study uses a novel approach that elicits different patterns than the traditional delineation of upper versus lower GIB. These results may lead to new decision-making in patients presenting with GIB, allowing for new diagnostic and management paradigms, resulting in cost-effective care

Novel dilation technique and stent selection to reduce periprocedural adverse events in left hepaticogastrostomy

Our case is instructive in demonstrating the utility of small-caliber devices (eg, a 0.018-inch guidewire and angioplasty balloon) for the endoscopic creation of left hepaticogastrostomy

Pathogenic Huntingtin Repeat Expansions in Patients with Frontotemporal Dementia and Amyotrophic Lateral Sclerosis.

We examined the role of repeat expansions in the pathogenesis of frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS) by analyzing whole-genome sequence data from 2,442 FTD/ALS patients, 2,599 Lewy body dementia (LBD) patients, and 3,158 neurologically healthy subjects. Pathogenic expansions (range, 40-64 CAG repeats) in the huntingtin (HTT) gene were found in three (0.12%) patients diagnosed with pure FTD/ALS syndromes but were not present in the LBD or healthy cohorts. We replicated our findings in an independent collection of 3,674 FTD/ALS patients. Postmortem evaluations of two patients revealed the classical TDP-43 pathology of FTD/ALS, as well as huntingtin-positive, ubiquitin-positive aggregates in the frontal cortex. The neostriatal atrophy that pathologically defines Huntington's disease was absent in both cases. Our findings reveal an etiological relationship between HTT repeat expansions and FTD/ALS syndromes and indicate that genetic screening of FTD/ALS patients for HTT repeat expansions should be considered

Association of Variants in the SPTLC1 Gene With Juvenile Amyotrophic Lateral Sclerosis

Importance: Juvenile amyotrophic lateral sclerosis (ALS) is a rare form of ALS characterized by age of symptom onset less than 25 years and a variable presentation.Objective: To identify the genetic variants associated with juvenile ALS.Design, Setting, and Participants: In this multicenter family-based genetic study, trio whole-exome sequencing was performed to identify the disease-associated gene in a case series of unrelated patients diagnosed with juvenile ALS and severe growth retardation. The patients and their family members were enrolled at academic hospitals and a government research facility between March 1, 2016, and March 13, 2020, and were observed until October 1, 2020. Whole-exome sequencing was also performed in a series of patients with juvenile ALS. A total of 66 patients with juvenile ALS and 6258 adult patients with ALS participated in the study. Patients were selected for the study based on their diagnosis, and all eligible participants were enrolled in the study. None of the participants had a family history of neurological disorders, suggesting de novo variants as the underlying genetic mechanism.Main Outcomes and Measures: De novo variants present only in the index case and not in unaffected family members.Results: Trio whole-exome sequencing was performed in 3 patients diagnosed with juvenile ALS and their parents. An additional 63 patients with juvenile ALS and 6258 adult patients with ALS were subsequently screened for variants in the SPTLC1 gene. De novo variants in SPTLC1 (p.Ala20Ser in 2 patients and p.Ser331Tyr in 1 patient) were identified in 3 unrelated patients diagnosed with juvenile ALS and failure to thrive. A fourth variant (p.Leu39del) was identified in a patient with juvenile ALS where parental DNA was unavailable. Variants in this gene have been previously shown to be associated with autosomal-dominant hereditary sensory autonomic neuropathy, type 1A, by disrupting an essential enzyme complex in the sphingolipid synthesis pathway.Conclusions and Relevance: These data broaden the phenotype associated with SPTLC1 and suggest that patients presenting with juvenile ALS should be screened for variants in this gene.</p

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Video Capsule Endoscopy and Device-Assisted Enteroscopy

The paradigm of video capsule endoscopy (VCE) is changing. Once dismissed as a pipedream, VCE has overcome technological constraints and perceptions of limited demand and established itself as an important tool in the practicing gastroenterologist’s panoply. Introduced to the public in 2001, VCE has proliferated over the past two decades to become a standard diagnostic test for a multitude of diseases, including small bowel bleeding (SBB), Crohn’s disease (CD), and small intestinal neoplasia. Newer platforms are no longer limited to the small intestine alone, with recent developments introducing esophageal capsule endoscopy (ECE) and colon capsule endoscopy (CCE). In the near future, VCE is also poised to revolutionize the approach to gastrointestinal bleeding (GIB) in the acute care setting. Indeed, capsule endoscopic technologies have come far since their debut in 2001 and, with more hardware and software advancements on the horizon, show no sign of abating