Comparison of 1-day versus 3-day intravenous terlipressin in cirrhosis patients with variceal bleeding: A pilot randomised controlled trial

BACKGROUND

In cirrhosis patients with acute variceal bleeding (AVB), the optimal duration of vasoconstrictor therapy after endoscopic haemostasis is unclear.

AIMS

We aimed to compare efficacy of 1-day versus 3-day terlipressin therapy in cirrhosis patients with AVB post-endoscopic intervention. The primary objective was to compare rebleeding at 5 days between the two arms. Secondary objectives included rebleeding and mortality rates at 6 weeks.

METHODS

In this open-label, randomised controlled trial, cirrhosis patients with AVB were randomised to either 1-day or 3-day terlipressin therapy.

RESULTS

A total of 150 cirrhosis patients with AVB were recruited to receive either 1 day (n = 75) or 3 days (n = 75) of terlipressin therapy. One patient from 1-day arm was excluded. Modified intention-to-treat analysis included 149 patients. Baseline characteristics were comparable between the two groups. Rebleeding at 5 days: 3 (4.1%; 95% confidence interval [CI]: 0.4-9.0) versus 4 (5.3%; 95% CI: 2.0-10.0), risk difference (RD) p = 0.726 and 5-day mortality rates: 1 (1.4%; 95% CI: 0-7.3) versus 1 (1.3%; 95% CI: 0.2-7.0), RD p = 0.960 were similar. Rebleeding at 42 days: 9 (12.2%; 95% CI: 7.0-20.0) versus 10 (13.3%; 95% CI: 7.0-20.0), RD p = 0.842 and mortality at 42 days: 5 (6.8%; 95% CI: 3.0-10.0) versus 4 (5.3%; 95% CI: 2.0-10.0), RD p = 0.704 were also similar. Patients in the 1-day terlipressin therapy arm experienced significantly fewer adverse effects compared with those receiving 3 days of terlipressin therapy: 28 (37.8%) versus 42 (56%), p = 0.026.

CONCLUSIONS

Our results suggest that 1 day of terlipressin therapy is associated with similar 5-day and 42-day rebleeding rates, 42-day mortality and an overall superior safety profile compared with 3-day of terlipressin therapy. These findings require to be validated in double-blinded, larger, multiethnic and multicentre studies across the various stages of cirrhosis (CTRI/2019/10/021771).

Patient Portal Use and Risk of Readmissions in Decompensated Cirrhosis: Retrospective Study

BACKGROUND

Patient portals are a common electronic medical record tool that allow for the asynchronous exchange of health information between patients and their health care teams. Patients can leverage patient portals to perform tasks such as viewing test results, reviewing clinical notes, and messaging their health care team. The impact of patient portal use on clinical outcomes in cirrhosis is unknown.

OBJECTIVE

In this study, we evaluated the relationship between patient portal use patterns and readmissions in cirrhosis.

METHODS

We identified 131 patients with decompensated cirrhosis with an index cirrhosis-related admission between May 1, 2018, and May 1, 2019. We then examined patient portal enrollment and use data during the 6-month period preceding the study period. Portal functions evaluated included sending a message, reading a message, and reading a test result. Use was categorized as active (sending a message) and passive (reading a message or test result) and was further stratified as no, moderate, or frequent use based on the frequency of portal function use compared to the mean. The primary outcomes were 90-day and overall readmissions, adjusted for age, model for end-stage liver disease-sodium, alcohol-related cirrhosis etiology, ascites, and hepatic encephalopathy. Portal functions assessed included sending a message, reading a message, and reading a result; the total number of times a portal function was performed was divided by the number of months the patient was enrolled in the patient portal during the 6-month period.

RESULTS

The study population was 50.4% (66/131) female, with a mean age of 58 years. Enrollment in the patient portal was 63.4% (83/131), and there was no significant difference in enrollment based on clinical or demographic characteristics. For the entire cohort, 14.5% (19/131) and 22.1% (29/131) of patients were moderate and frequent active users, respectively. Of those enrolled in the patient portal, 97.6% (81/83) of patients were moderate or frequent passive users for both reading a message and reading a test result. Moderate active users had less 90-day readmissions (odds ratio 0.77, 95% CI 0.60-1.00) and overall readmissions (subdistribution hazard ratio 0.42, 95% CI 0.21-0.84), compared to nonactive users. There was no relationship between readmissions and passive use.

CONCLUSIONS

Passive use of the patient portal is very high but is not associated with the risk of readmissions in people with decompensated cirrhosis. However, moderately active use of the patient portal is associated with a reduced risk of readmissions. Further work is needed to identify possible confounders and refine key use behaviors that may be protective with regard to the risk of readmission in this population.

Advances in endobariatrics: past, present, and future

The obesity epidemic in the USA and worldwide is well documented and continues to grow. Endoscopic metabolic and bariatric therapies may offer a less invasive approach than surgical intervention. This article will review advances in endobariatrics over the last several decades, addressing the past and current state of bariatric and metabolic endoscopy. Food and Drug Administration-cleared devices and interventions currently under investigation are described including gastric devices, gastric remodeling procedures, small-bowel devices, duodenal ablation, as well as procedures to address weight regain after bariatric surgery. Future studies evaluating gastric and duodenal combination therapy, adjunctive pharmacotherapy, as well as individualized precision-health algorithms are underway.

A case of nocardiosis in a patient with ulcerative colitis on chronic corticosteroids, infliximab, and upadacitinib

Key Clinical Message

Immunosuppression, malnutrition, and underlying infection can unmask obscure infections which can be challenging to identify. Early diagnosis and treatment of infections in immunosuppressed patients are essential due to high morbidity and mortality.

Abstract

The immunosuppressive effects of treatment for ulcerative colitis (UC), including chronic corticosteroids, anti-TNF agents, and JAK inhibitors, can impact the spread of latent or obscure infections. Clinicians should have a low threshold for pursuing aggressive diagnostic and therapeutic intervention in patients who show signs of clinical deterioration while on immunosuppressing medications. Our unique case highlights an immunosuppressed patient with UC who developed Nocardiosis after initiation of upadacitinib while hospitalized for concurrent UC flare and Clostridium difficile infection.

Viscoelastic Testing Prior to Non-surgical Procedures Reduces Blood Product Use Without Increasing Bleeding Risk in Cirrhosis

BACKGROUND/AIMS

Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) analyze hemostatic function in patients with coagulopathy. We sought to quantify the impact of TEG and ROTEM-guided transfusion algorithms on blood product utilization in patients with cirrhosis undergoing non-surgical procedures.

METHODS

We performed a systematic review and meta-analysis on the utility of viscoelastic testing prior to non-surgical procedures to determine their impact on pre-procedural blood product use and post-procedural bleeding events. Studies comparing TEG or ROTEM-guided transfusions with standard-of-care (SOC) prior to non-surgical procedures in adult patients with cirrhosis were included. Primary outcomes were fresh frozen plasma (FFP) and platelet transfusion and secondary outcomes of post-procedure bleeding, transfusion-related complications, and mortality; and were reported as standardized mean differences (SMD) and risk ratios (RR).

RESULTS

Six studies (five randomized controlled trials and one cohort study) involving 367 patients met inclusion criteria. Compared with SOC, TEG/ROTEM-guided transfusions led to an overall decreased number of patients who received FFP transfusions (SMD = -0.93, 95% CI [-1.54, -0.33], p < 0.001) and platelets transfusions (SMD = -1.50, CI [-1.85, -1.15], p < 0.001). Total amount of FFP (SMD-0.86, p < 0.001) and platelet (SMD = -0.99, p < 0.001) transfused in the TEG/ROTEM group were also lower. Decreased pre-procedure transfusion in the TEG/ROTEM group did not result in increased post-procedure bleeding (RR = 0.61, p = 0.09) or in mortality (RR = 0.91, p = 0.93).

CONCLUSION

In patients with cirrhosis, TEG or ROTEM significantly reduces blood product utilization prior to non-surgical procedures, with no increase in post-procedure bleeding or mortality. TEG and ROTEM utilization can promote high-value care and improve transfusion stewardship in this population.

P11.45.B Improved overall survival following Stereotactic Radiosurgery for brain metastases - a single institution experience

Background

Brain metastases are increasingly common due to longer survival associated with advancements in treatment. Approximately 40% of cancer patients are diagnosed with brain metastases at some point during their disease. Stereotactic radiosurgery (SRS) avoids the neuro-cognitive toxicity associated with whole brain radiotherapy and has been increasingly offered as a treatment alternative for brain metastases. Combined with developments in systemic treatments, this approach has resulted in improved overall survival (OS). This study reviewed patients treated with single fraction SRS at our institution with a primary endpoint of overall survival.

Material and Methods

A retrospective review determined overall survival for 237 patients who received single fraction SRS for 451 brain metastases from solid tumours between 1st January 2017 and 31st December 2021. Primary tumour sites were classified as breast, kidney, colorectal, melanoma, lung or other. SPSS v.27 was used for Kaplan Meier OS determination. The median follow up was 10.3 months. Cox regression analysis assessed the association between Gross Tumour Volume (GTV) and OS.

Results

In this patient cohort, 60% (N=142) were female and 40% (N=95) were male, with a median age of 63 [32-85]. 63.7% (N = 151) had a solitary metastasis. Patients received a single fraction of 15, 17.5 or 20 Gy (prescribed to 80% isodose) dependent on the planning target volume (PTV) size and whether it was initial treatment or re-treatment. 71% of all patients were alive at 6 months with median OS of 12.0 months [10.6-13.4]. Primary tumour site significantly affected OS (Log rank, Chi squared 15.656, p0.008) with breast cancer patients (N=58) surviving longest with a median OS 16.0 months [13.6-18.4] followed by melanoma median OS 15.0 months [7.6-22.4], kidney cancer patients (N = 24) median OS 12.0 months [8.3-15.7] and lung patients (N=87) median OS 10.0 months [8.9-11.3]. The lowest median OS was for colorectal patients at 7.0 months [1.4-12.6]. However, considering the small sample size, N = 15, more data is needed to confirm the significance. The larger the GTV volume the lower the survival time (Chi squared 8.692, p 0.003).

Conclusion

71% of patients had an OS of 6.0 months or more with a median of 12.0 months. As expected, primary tumour site has a significant impact on OS, with breast cancer patients living longest. In addition, increasing GTV size is associated with significantly worse survival. Given the improved survival for these patients, the avoidance of neuro cognitive decline remains of paramount importance and outcomes for these patients need to be reported in future work.

Cryoballoon Ablation for the Treatment of Atrial Fibrillation: A Meta-analysis

BACKGROUND

Ablation therapy is the treatment of choice in antiarrhythmic drugrefractory atrial fibrillation (AF). It is performed by either cryoballoon ablation (CBA) or radiofrequency ablation. CBA is gaining popularity due to simplicity with similar efficacy and complication rate compared with RFA. In this meta-analysis, we compare the recurrence rate of AF and the complications from CBA versus RFA for the treatment of AF.

METHODS

We systematically searched PubMed for the articles that compared the outcome of interest. The primary outcome was to compare the recurrence rate of AF between CBA and RFA. We also included subgroup analysis with complications of pericardial effusion, phrenic nerve palsy and cerebral microemboli following ablation therapy.

RESULTS

A total of 24 studies with 3527 patients met our predefined inclusion criteria. Recurrence of AF after CBA or RFA was similar in both groups (RR: 0.84; 95% CI: 0.65, 1.07; I2=48%, Cochrane p=0.16). In subgroup analysis, heterogeneity was less in paroxysmal AF (I2=0%, Cochrane p=0.46) compared to mixed AF (I2=72%, Cochrane p=0.003). Procedure and fluoroscopy time was less by 26.37 and 5.94 minutes respectively in CBA compared to RFA. Complications, pericardial effusion, and silent cerebral microemboli, were not different between the two groups, however, phrenic nerve palsy was exclusively present only in CBA group.

CONCLUSION

This study confirms that the effectiveness of CBA is similar to RFA in the treatment of AF with the added advantages of shorter procedure and fluoroscopy times.

785. Treatment of Mycobacterium immunogenum Skin and Soft-Tissue Infections: A Case in a Peritoneal Dialysis Patient

Background

Mycobacterium immunogenum is a somewhat recently identified species of rapidly growing nontuberculous mycobacteria, genetically related to M. abscessus and M. chelonae. Resistance patterns of rapidly growing nontuberculous mycobacterium species can make them difficult to treat. This is particularly true of M. immunogenum, in part due to the infrequency of reported cases of human infection and limited data to guide therapy.

Methods

We present here a case of M. immunogenum skin and soft-tissue infection at the site of insertion of a peritoneal dialysis catheter in a patient with end-stage renal disease. He initially presented with nodular subcutaneous lesions around his catheter site that progressed through oral antibiotics. This led to sampling which confirmed the diagnosis of M. immunogenum. We conducted a review of the literature to identify previously reported cases of M. immunogenum, including skin and soft-tissue infections, and used these data to guide management.

Results

We reviewed 11 reports (cases and case series) of Mycobacterium immunogenum in the literature. Susceptibilities often take weeks to return, and so empiric therapy is based on case series, and then later adjusted based on susceptibilities. Patients received combined antimicrobial regimens with durations of 2 weeks to 12 months, with variable outcomes. Several required surgical debridement, as was the case with our patient. His PD catheter was removed and he was treated empirically with amikacin, azithromycin, and tigecycline intravenous induction. His ultimate long-term regimen was later switched to azithromycin, clofazimine, and tedizolid due to side effects and the eventually available susceptibility profile.

Conclusion

The treatment of M. immunogenum remains a challenge due to the relative scarcity of data to guide treatment, and consequent lack of systemic approach to therapy. Most reported cases involve the use of a macrolide, often in combination with an aminoglycoside or a fluoroquinolone. Several started with intravenous induction, followed by transition to oral therapy on the order of weeks to months. Others also require surgical debridement. More data are required to develop a standardized approach to the treatment of M. immunogenum.

Disclosures

All authors: No reported disclosures.

Management of a Mycobacterium immunogenum infection of a peritoneal dialysis catheter site

Mycobacterium immunogenum is a member of the rapidly growing non-tuberculous mycobacteria and is a relatively new species identified within this group. An 81-year-old immune-competent male was diagnosed with M. immunogenum infection of his peritoneal dialysis catheter exit site and surrounding soft tissue. To our knowledge, this is the first reported case of M. immunogenum infection of a peritoneal catheter. Treatment included catheter removal, local surgical debridement, and combination antimicrobial therapy. Herein, we review literature describing antibiotic management of M. immunogenum, an organism for which optimal therapy is not defined.

Obesity paradox in patients undergoing coronary intervention: A review

There is strong relationship between obesity and cardiovascular disease including coronary artery disease (CAD). However, the literature has shown better outcomes in higher obese patients who undergo percutaneous cardiovascular interventions for CAD, a phenomenon known as the obesity paradox (OX). In this review, we performed extensive search for OX in patients undergoing percutaneous coronary intervention. We also discussed possible mechanism OX and disparities in different race and sex.

Obstructive sleep apnea and arrhythmia: A systemic review

There is a growing consensus in the scientific community that suggests a strong association between obstructive sleep apnea (OSA) and cardiovascular (CVD) conditions and events, including coronary artery disease, hypertension, arrhythmia, heart failure, and sudden cardiac death. We reviewed evidence on the relationship between OSA and arrhythmia. Our conclusion, based on our review of the literature, is that the evidence supports a strong link between OSA and cardiovascular mortality, which warrants treating OSA. Continuous positive airway pressure (CPAP) appears to reduce the CVD consequences of OSA. Future research is expected to clarify the benefits and optimal application of these treatment approaches.

Early Liver Transplantation for Severe Alcoholic Hepatitis in the United States--A Single-Center Experience

Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.

Insights into the pathophysiology of catch-up compared with non-catch-up growth in children born small for gestational age: an integrated analysis of metabolic and transcriptomic data

Small for gestational age (SGA) children exhibiting catch-up (CU) growth have a greater risk of cardiometabolic diseases in later life compared with non-catch-up (NCU) SGA children. The aim of this study was to establish differences in metabolism and gene expression profiles between CU and NCU at age 4-9 years. CU children (n=22) had greater height, weight and body mass index standard deviation scores along with insulin-like growth factor-I (IGF-I) and fasting glucose levels but lower adiponectin values than NCU children (n=11; all P<0.05). Metabolic profiling demonstrated a fourfold decrease of urine myo-inositol in CU compared with NCU (P<0.05). There were 1558 genes differentially expressed in peripheral blood mononuclear cells between the groups (P<0.05). Integrated analysis of data identified myo-inositol related to gene clusters associated with an increase in insulin, growth factor and IGF-I signalling in CU children (P<0.05). Metabolic and transcriptomic profiles in CU SGA children showed changes that may relate to cardiometabolic risk.

Clinical applications of imaging biomarkers. Part 3. The neuro-oncologist's perspective

Radiation therapy is an important treatment modality in the management of brain tumours. Imaging biomarkers continue to be a focus of active investigation and there is increasing evidence of the utility of biomarkers in refining the overall management plan. This article briefly reviews the literature and outlines the possible clinical applications of imaging biomarkers in neuro-oncology.

Intradiploic frontal bone aneurysmal bone cyst in a child: a case report

This report presents the imaging appearances of an uncommon case of intradiploic frontal bone aneurysmal bone cyst (ABC) in a 10-year-old girl. ABCs are rare in the calvarium. The radiological and aetiopathological differences between the more commonly occurring ABCs of the long bones and vertebrae, and their rarer counterparts in the calvarium and facial bones, have been discussed. Unique also to this case is the reconstruction performed using the outer table of the bone flap after excising the tumour.

A phase IIb 4-arm open-label randomized study to assess the safety and efficacy of h-R3 monoclonal antibody against EGFR in combination with chemoradiation therapy or radiation therapy in patients with advanced (stage III or IVA) inoperable head and neck cancer

6041

Background: Patients (pt) with advanced inoperable squamous cell carcinoma of the head and neck (SCCHN) have poor radiotherapy alone (RT) outcome. EGFR is over-expressed in >90% SCCHN. h-R3mAb (BIOMAb/nimotuzumab/TheraCIM) is a humanized monoclonal antibody, a validated oncotherapeutic-targeting EGFR. Objective: To investigate the safety and efficacy of concurrent h-R3mAb in combination with chemoradiotherapy of SCCHN. Methods: September 2004–2005, pt 18–70 yrs, SCCHN stageIII-IVA, 113 screened, 92 enrolled and randomly asssigned to, Group A: radical radiotherapy (pt) and Group B: chemoradiotherapy (pt). Randomization within Group A: [RT]v/s[RT+h-R3mAb] and within Group B: [RT+CT]v/s[RT+CT+ h-R3mAb] (n = 23 in each arm). Protocol: Radiotherapy: TD: 66 Gy,2Gy/Fr,5Fr/w,6.5wks. Radiation sensitizer (chemotherapy): CDDP-50mg/wk x 6wks. Study Drug (h-R3mAb): 200 mg/wk I.V.60min x 6weeks. Results: Evaluable (n = 76) in Group A-36 and Group B-40. F/u Analysis at 30 months after end of RT. Survival rate ITT: Group B: CT+RT+hR3- 69.5% v/s CT+RT-21.7% (p - 0.0011), Group A: RT alone - 21.7% v/s RT+ hR3–39.1% (ns). Progression-free survival: RT alone - 3(13.04 %) v/s RT+hR3mAb-8 (34.78 %), RT+CT-5 (21.74 %) v/s RT+CT+hR3mAb-13 (56.52%). Median overall survival (OS): CT+RT+hR3 - NR* v/s CT+RT- 21.96 months (hazard ratio [HR]-0.337, p - 0.0018) and RT alone - 25.02 v/s RT+hR3 - NR*(HR-0.678, p - 0.39). Disease-free survival: CT+RT+hR3- NR*v/sCT+RT-21.30 mths (HR-0.344, p - 0.0052) and RT alone-25.02 v/s RT+hR3- NA* (HR-0.599, p - 0.32). (NR*- median OS is yet to be reached). Safety: few grade - 1/2AE, no HAMA observed. OS per protocol - adding h-R3mAb to chemoradiation resulted in a reduction in risk of death (rrd) by 85% (HR 0.15, p - 0.0006) and to RT a 36 % rrd (HR0.64, p - 0.33). Conclusions: Concurrent use of h-R3mAb with RT or RT+CT is safe and efficacious. It enhances radiation and chemotherapy responses. Concurrent use of h-R3mAb with chemoradiotherapy enhances long-term loco-regional control and survival. Adding biological agents to physically targeted modality improves long-term therapeutic outcome of SCCHN.

No significant financial relationships to disclose.

Primary gastrointestinal mucormycosis in an immunocompetent person

In the past decade, mucormycosis has emerged as an important lethal infection in diabetics and other immunocompromised hosts. Rhinosinusitis, pansinusitis, rhino-orbital and rhinocerebral are the common classical manifestations of mucormycosis. However, primary gastrointestinal (GI) mucormycosis is an uncommon disease associated with a high mortality rate. Stomach is the most common site involved in GI mucormycosis. Reported cases of GI mucormycosis in an immunocompetent host are very few in the literature. Here we present a case of a young male with fungal sepsis secondary to GI mucormycosis in an immunocompetent person.