New hepatitis C treatment: 2 new medications may increase success rate to 70%

Mayo Clinic: Four million people in the U.S., 100 million worldwide, are infected with Hepatitis C. It's a virus you can get from blood transfusions given before 1990, shared needles, unclean tattoo needles and sometimes sex.

In many cases it leads to cirrhosis of the liver and eventually liver cancer. Standard treatment with interferon and ribavirin only cures about 45% of all patients. But thanks to two new medications, up to 70% of people with hepatitis C may be be cured. More than 40 medications are in development.

17% of U.S. hospitals now provide virtual colonoscopy

Medicare does not currently reimburse routine screening with virtual colonoscopy, but it does cover evaluations with "regular" colonoscopy.

References:

Virtual Colonoscopy Gains in Popularity. Is It Right for You? TIME.

Comments from Twitter:

@DrSilge (Robert Silge, MD): What are your thoughts? Inability to biopsy, extra radiation... I don't see benefit. W/ fam hist of Colon ca, I won't be signing up.

@DrVes: Correct, "physical" colonoscopy is the procedure of choice rather than the virtual one. In any case, the preparation is the toughest part and is the same for both procedures.

Chronic pancreatitis - The Lancet review

There are two forms of chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease that exists in 2 forms:

- large-duct forms (often with intraductal calculi)
- small-duct form

Causes of chronic pancreatitis

Chronic pancreatitis results from a complex mix of:

- environmental factors - alcohol, cigarettes, and occupational chemicals
- genetic factors - mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator (CFTR)
- a few patients have hereditary or autoimmune disease

Management of pain

Pain is the main symptom that occurs in two forms:

- recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells)
- constant and disabling pain

Management of the pain is mainly empirical, involving:

- potent analgesics
- duct drainage by endoscopic or surgical means
- partial or total pancreatectomy
- steroids rapidly reduce symptoms in patients with autoimmune pancreatitis
- micronutrient therapy to correct electrophilic stress is emerging as a promising treatment

Steatorrhoea, diabetes, local complications, and psychosocial issues associated are additional therapeutic challenges.

References

Chronic pancreatitis. Dr Joan M Braganza DSc a , Stephen H Lee FRCR b, Rory F McCloy FRCS c, Prof Michael J McMahon FRCS d. The Lancet, Volume 377, Issue 9772, Pages 1184 - 1197, 2 April 2011.

Image source: Wikipedia, public domain.

Aspirin 75 mg daily reduces incidence and mortality due to colorectal cancer

High-dose aspirin (≥500 mg daily) reduces long-term incidence of colorectal cancer, but adverse effects (bleeding) might limit its potential for long-term prevention. The long-term effectiveness of lower doses (75-300 mg daily) is unknown. This study in The Lancet assessed the effects of aspirin on incidence and mortality due to colorectal cancer over 20 years.

In the four trials of aspirin versus control (mean duration of treatment 6 years), 2·8% of 14,000 patients had colorectal cancer during a follow-up of 18 years.

Aspirin reduced the 20-year risk of colon cancer (incidence hazard ratio [HR] 0·76, but not rectal cancer (0·90).

Where subsite data were available, aspirin reduced risk of cancer of the proximal colon (0·45), but not the distal colon (1·10). Benefit increased with duration of treatment - aspirin taken for 5 years or longer reduced risk of proximal colon cancer by 70% and also reduced risk of rectal cancer (0·58).

There was no increase in benefit at doses of aspirin greater than 75 mg daily. However, risk of fatal colorectal cancer was higher on 30 mg versus 283 mg daily.

Aspirin taken for several years at doses of at least 75 mg daily reduced long-term incidence and mortality due to colorectal cancer. Benefit was greatest for cancers of the proximal colon, which are not otherwise prevented effectively by screening with sigmoidoscopy or colonoscopy.

References:
Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. The Lancet, Volume 376, Issue 9754, Pages 1741 - 1750, 20 November 2010.

Image source: Colon (anatomy), Wikipedia, public domain.

Barrett's esophagus - Mayo Clinic video

Mayo Clinic: Millions of people know what it's like to have to run for the antacids after a big pasta dinner. Most of the time heartburn is harmless, but people who suffer from chronic heartburn are at increased risk of a condition called Barrett's esophagus. And if you have it, your chances of getting esophageal cancer go up.

Doctors at Mayo Clinic studied whether or not burning away the Barrett's cells with heat from radiofrequency ablation gets rid of the problem. What they found was encouraging.

What's new in gastroenterology and hepatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in gastroenterology and hepatology:

Hepatitis C virus (HCV) infection

Peginterferon alfa-2a was superior to peginterferon alfa-2b with regard to virologic response rates in patients with chronic hepatitis C virus infection, genotypes 1, 2, 3, or 4. Patients being treated for chronic hepatitis C virus infection should receive peginterferon alfa-2a rather than peginterferon alfa-2b.

72 weeks of therapy with peginterferon alfa-2a plus ribavirin in patients with HCV genotype 1 or 4 was not better than 48 weeks.

Chronic use of proton pump inhibitors (PPIs)

Chronic use of proton pump inhibitors (PPIs) may lead to an increased risk of fractures. FDA recommends that healthcare professionals who prescribe proton pump inhibitors should consider whether a lower dose or shorter duration of therapy would adequately treat the patient's condition.

Ulcerative colitis

Once daily dosing of delayed-release mesalamine (Asacol 400 mg tablets) 1.6 to 2.4 g/day was as effective as twice daily dosing for maintenance of clinical remission in patients with ulcerative colitis. Remission rates were 85% in both groups.

Crohn's disease

Capsule endoscopy was not a cost-effective third test for establishing the diagnosis of Crohn's disease after a negative ileocolonoscopy and either a CT enterography or small bowel follow-through x-ray.

Azathioprine in combination with infliximab or infliximab alone had a higher rate of glucocorticoid-free clinical remission than those treated with azathioprine alone. Combination therapy and infliximab monotherapy led to significantly more complete bowel healing than azathioprine alone.

Obscure gastrointestinal bleeding

Double balloon enteroscopy (DBE) detected bleeding sources in 78% of patients with obscure gastrointestinal bleeding. Small intestinal ulcers and erosions were the most common findings.

References:
What's new in gastroenterology and hepatology. UpToDate.

Statins Use in Presence of Elevated Liver Enzymes: What to Do?

The beneficial role of statins in primary and secondary prevention of coronary heart disease has resulted in their frequent use in clinical practice.

However, safety concerns, especially regarding hepatotoxicity, have driven multiple trials, which have demonstrated the low incidence of statin-related hepatic adverse effects. The most commonly reported hepatic adverse effect is the phenomenon known as transaminitis, in which liver enzyme levels are elevated in the absence of proven hepatotoxicity.

"Ttransaminitis" is usually asymptomatic, reversible, and dose-related.


Lovastatin, a compound isolated from Aspergillus terreus, was the first statin to be marketed for lowering cholesterol. Image source: Wikipedia, public domain.

The increasing incidence of chronic liver diseases, including nonalcoholic fatty liver disease and hepatitis C, has created a new challenge when initiating statin treatment. These diseases result in abnormally high liver biochemistry values, discouraging statin use.

A PubMed/MEDLINE search of the literature (1994-2008) was performed for this Mayo Clinic Proceedings review. The review supports the use of statin treatment in patients with high cardiovascular risk whose elevated aminotransferase levels have no clinical relevance or are attributable to known stable chronic liver conditions.

References:
Statins in the Treatment of Dyslipidemia in the Presence of Elevated Liver Aminotransferase Levels: A Therapeutic Dilemma. Rossana M. Calderon, MD, Luigi X. Cubeddu, MD, Ronald B. Goldberg, MD and Eugene R. Schiff, MD. Mayo Clinic Proceedings April 2010 vol. 85 no. 4 349-356.

Alcohol consumption and raised body mass index (BMI) act together to increase risk of liver disease

Drinkers of 15 or more units per week in any BMI category and obese drinkers had raised relative rates for all definitions of liver disease, compared with underweight/normal weight non-drinkers.

The relative excess risk due to interaction between BMI and alcohol consumption was 5.58.

Raised BMI and alcohol consumption are both related to liver disease, with evidence of a supra-additive interaction between the two.

The occurrence of both factors in the same populations should inform health promotion and public health policies.

References:

Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. BMJ 2010;340:c1240.

Image source: Wikipedia, public domain.

Rock legend Ronnie James Dio is fighting stomach cancer

On 25 November 2009, Dio's wife and manager announced that he was diagnosed with stomach cancer:

"Ronnie has been diagnosed with the early stages of stomach cancer. We are starting treatment immediately at the Mayo Clinic. After he kills this dragon, Ronnie will be back on stage, where he belongs, doing what he loves best, performing for his fans. Long live rock and roll, long live Ronnie James Dio. Thanks to all the friends and fans from all over the world that have sent well wishes. This has really helped to keep his spirit up." -- "He has had a few hiccups between Christmas and New Year's," she said in a statement to fans. "He has had a blood clot, a trip to the emergency room, and a three-day stay at the hospital."


ArtisanNewsService — April 13, 2010 — "One of heavy metal's premiere vocalists Ronnie James Dio shares his thoughts on his battle with stomach cancer at the Revolver Golden Gods awards."

On 14 March 2010, Dio's wife and manager Wendy posted an online update on his condition:

"It has been Ronnie's 7th chemo, another cat scan and another endoscopy, and the results are good - the main tumour has shrunk considerably, and our visits to Houston (MD Anderson Cancer Center in Texas) are now every three weeks instead of every two weeks."

Ronnie James Dio passed away on May 16, 2010 at age 67. The music lives on: http://www.ronniejamesdio.com

References:
Ronnie James Dio. Wikipedia.
Black Sabbath, Dio singer Ronnie James Dio gives cancer update. NME.com.

Eddie Trunks Metal show with guests Ronnie James Dio & Geezer Butler, May 30, 2009.

Metal legend Ronnie James Dio dead at 67. USA Today, 2010.
Ronnie James Dio, Rock Singer, Dies at 67. NYTimes, 2010.
Ronnie James Dio died at age 67. YouTube.
Ronnie James Dio Remembered By Metallica's Lars Ulrich. MTV.
The Lighter Side of Ronnie James Dio. NYTimes.
Lars Ulrich's letter to Dio.

Dio, another day. Nigel Britto, TOI Crest, May 22, 2010.
Dio monument in Bulgaria - source one, two, three (in Bulgarian), 10/2010.

Updated: 10/24/2010

The Colonoscopy Song - March is National Colorectal Cancer Awareness Month

Peter Yarrow of the musical group Peter, Paul and Mary appeared on the CBS Early Show to sing a song he composed about his own colonoscopy:



In the video below, Dr. Paul Limburg, a Mayo Clinic Gastroenterologist, provides background on colorectal cancer and the screening methods:

Related:

Dr. Oz Has Colon Cancer Scare During Taping of His Colonoscopy for the TV Show http://goo.gl/F4CX

Fear was the No. 1 reason people gave to explain why they hadn’t gone in for a colonoscopy to screen for colon cancer. NYTimes.

Get your colonoscopy in the morning - each hour brings a 4% reduction in the number of polyps the doctors spotted http://goo.gl/2FGQt

Dr. Oz: What I Learned from My Colon Cancer Scare http://goo.gl/q7rjD

Monoclonal antibodies against C. difficile toxins reduce recurrence of the infection

New therapies are needed to manage the increasing incidence, severity, and high rate of recurrence of Clostridium difficile infection.

A randomized, double-blind, placebo-controlled study included 2 neutralizing, fully human monoclonal antibodies against C. difficile toxins A (CDA1) and B (CDB1). The antibodies were administered together as a single infusion, each at a dose of 10 mg per kilogram of body weight, in patients with symptomatic C. difficile infection who were receiving either metronidazole or vancomycin.

Among the 200 patients who were enrolled (101 in the antibody group and 99 in the placebo group), the rate of recurrence of C. difficile infection was lower among patients treated with monoclonal antibodies (7% vs. 25%).

However, the mean duration of the initial hospitalization for inpatients did not differ significantly between the antibody and placebo groups (9.5 and 9.4 days, respectively).

The addition of monoclonal antibodies against C. difficile toxins to antibiotic agents significantly reduced the recurrence of C. difficile infection.

My opinion: It is always encouraging to add new tools to the treatment armamentarium aimed at defeating dangerous infections such as C. diff. colitis. However, monoclonal antibodies are generally very expensive and require intravenous administration.

References:
Treatment with Monoclonal Antibodies against Clostridium difficile Toxins. Israel Lowy. NEJM Volume 362:197-205 January 21, 2010 Number 3.

Image source: Micrograph of a colonic pseudomembrane in Clostridium difficile colitis, a type of pseudomembranous colitis. H&E stain. Wikipedia, Nephron, Creative Commons Attribution-Share Alike 3.0 Unported license.

CNN video: Life with Hepatitis C

18-year-old London teenager talks about life with the "silent killer" Hepatitis C and shares the dramatic story of how she came to be infected.

References:
Life with Hepatitis C for London's teenage 'It Girl'. CNN.

Gastroenterology

Editor: V. Dimov, M.D., Assistant Professor at the University of Chicago

Gastroenterology Cases at ClinicalCases.org

Gastroenterology News at CasesBlog

Gastroenterology: Images in Clinical Medicine

Patient Information

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Published: 01/12/2010
Updated: 06/28/2010

Video: Clinical Pearls in Gastroenterology from Mayo Clinic

The social media department of Mayo Clinic is combining journal articles and videos from the lead authors. This is a useful approach and I suggested it to the NEJM editors during the NEJM Horizons Conference in 2008.



Dr. Amy Oxentenko, Assistant Professor of Medicine at Mayo Clinic, discusses "Clinical Pearls in Gastroenterology" (http://tinyurl.com/ydwqtk7 for complete article).

References:
Clinical Pearls in Gastroenterology. Amy S. Oxentenko, MD and Scott C. Litin, MD. Mayo Clinic Proceedings October 2009 vol. 84 no. 10 906-911.

American College of Gastroenterology 2008 Guidelines for Colorectal Cancer Screening

Some highlights from the American College of Gastroenterology Guidelines for Colorectal Cancer Screening, 2008:

• Guidelines for Colorectal Cancer Screening: beginning at age 45 years in African Americans.
  
  
• FIT, fecal immunochemical test, replaces older guaiac fecal occult blood test.
  
  
• Individuals with a single 1st-degree relative with CRC or advanced adenomas at age older than 60 should be screened like average-risk persons.
  
  
• Screening in high-risk patients: colonoscopy every 5 years beginning at 40, or 10 years younger at diagnosis of the youngest relative.

Video: See What to Expect During a Colonoscopy.

The CBS news anchor Katie Couric (formerly of the NBC Today show) lost her husband to colon cancer ten years ago. According to the press release, "since then colon cancer awareness and prevention has been a cause near to her heart. March is Colon Cancer Awareness Month and Katie Couric put together a video for her YouTube channel with recognizable faces who have loaned their talent for Public Service Announcements about the disease."


Colon Cancer Awareness

Related:

Fear was the No. 1 reason people gave to explain why they hadn’t gone in for a colonoscopy to screen for colon cancer. NYTimes.
Image source: Colon (anatomy), Wikipedia, public domain.
10 Questions You Need to Ask About Colonoscopy

Children have chewed gum since the Stone Age

Black lumps of prehistoric tar with human tooth impressions have been found in Northern Europe dating from approximately 7000 BC (Middle Stone Age) to 2000 BC (Bronze Age). The bite impressions suggest that most chewers were between 6 and 15 years of age.

The Greeks chewed resin from the mastic tree (mastic gum) (shown on the right). North American Indians chewed spruce gum.

The first manufacturing patent for chewing gum was issued in 1869 for a natural gum, chicle, derived from the Sopadilla tree, indigenous to Central America.

Chewing gum sold today is a mixture of natural and synthetic gums and resins, with added color and flavor sweetened with corn syrup and sugar.

The medical literature contains very little information about the adverse effects of chewing gum.

A report (see below) describes 3 children who developed intestinal tract and esophageal obstruction as a consequence of swallowing gum.

References:
Chewing gum bezoars of the gastrointestinal tract. Milov DE, Andres JM, Erhart NA, Bailey DJ. Pediatrics. 1998 Aug;102(2):e22.
A moment on your lips, forever in your intestine. NCBI ROFL.
Image source: Mastic resin. Wikipedia, GNU Free Documentation License, Version 1.2.

Video: Routine Miracles with Dr. Conrad Fischer: Gastroenterology

"This book covers medical advances that would once have been called miracles but are now merely routine. The patients' stories within this book yield hope, optimism, and triumph. This is the best time to come out of medical school and training. This fact will inspire and uplift everyone in the medical profession as well as all of us who must, at some point, rely on the art of medicine to see us through." -- Conrad Fischer, M.D.

Visit http://seefisch.wordpress.com for more information about Dr. Fischer and Routine Miracles or follow Dr. Fischer on Twitter: @SeeFisch

See all videos of Routine Miracles with Dr. Conrad Fischer on YouTube: http://bit.ly/2TPUkU

Celiac disease 4 times as common today as it was 50 years ago, silent disease may increase mortality 4 times

From Mayo Clinic:

Celiac disease, an immune system reaction to gluten in the diet, is at least four times as common today as it was 50 years ago, according to findings of a Mayo Clinic study published this month in the journal Gastroenterology.

The study also found that subjects who unknowingly had celiac disease were nearly four times as likely as celiac-free subjects to have died during the 45 years of follow-up.

In the video files below, Joseph Murray, M.D., the Mayo Clinic gastroenterologist who led the study, describes the study findings and provides background on the disease, its symptoms and treatment.







ClevelandClinic, October 11, 2010: Celiac disease is when the body doesn't tolerate gluten very well - the protein found in wheat, barley and rye. When people with celiac disease eat gluten it damages the small instestines. Symptoms are gas, bloating, indigestion, fatigue, and headaches. This disease is diagnosed by a blood test.

Related:

Celiac disease confers a 1.6-fold increased risk of asthma, JACI 2011, http://goo.gl/dhxKX

Celiac Disease: Small bowel biopsy remains the gold standard for diagnosis, gluten-free diet the only treatment option. Medscape, 2011.

LRG urine test may help diagnose appendicitis

From Reuters:

Appendicitis is the most common emergency in childhood, yet 3-30% of appendectomies may be unnecessary. Urine test for leucine-rich alpha-2-glycoprotein (LRG) may help diagnose appendicitis in children.


Inflamed appendix removal by open surgery. Image source: Wikipedia, Dr Vgaikwad, Creative Commons Attribution 3.0 Unported License.


An example of a leucine-rich repeat protein, a porcine ribonuclease inhibitor. Image source: Wikipedia, GNU Free Documentation License.

Twitter comments:

hjluks better to remove a few normals than miss an appy that perforates. about 6 hours ago from Tweetie in reply to AllergyNotes