Research Spotlight

Posted May 15th 2018

Uncoiling the Coil: Coil Extrusion After Coil Assisted Retrograde Transvenous Obliteration for Gastric Variceal Bleeding.

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Soape, M. P., A. Lichliter and S. K. Asrani (2018). “Uncoiling the Coil: Coil Extrusion After Coil Assisted Retrograde Transvenous Obliteration for Gastric Variceal Bleeding.” Clin Gastroenterol Hepatol 16(5): e59.

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An 83-year-old woman with cryptogenic cirrhosis (Model for End-stage Liver Disease score, 7) presented with melena 7 months after successful coil-assisted retrograde transvenous obliteration treatment of hemodynamically unstable bleeding gastric varices. Previously, embolization of the gastrorenal shunt and bleeding gastric varices was successful with 3% sotradecol, lipiodol, and terlock-35 fibered detachable coils (Boston Scientific, Marlborough, MA) and Azur detachable coils (Terumo, Tokyo, Japan). During her current hospitalization, she underwent standard medical management for suspected variceal bleeding. Endoscopy showed an embolization coil extruding through a decompressed gastric varix with mild intermittent oozing. Computed tomography of the abdomen confirmed migration of a coil into the stomach. The intraluminal coil was not removed given concerns for worsening of the bleed. The patient was managed conservatively for 72 hours. She was discharged home and seen 1 month later as an outpatient in good health with no reported melena. The complication rate of balloon-occluded retrograde transvenous obliteration is less than 5% and primarily includes thromboembolic events with complications relatively unknown with its modified version of coil-assisted retrograde transvenous obliteration. This endoscopic finding likely will increase in prevalence with the expansive use of coiling for acute gastric variceal hemorrhage given fewer contraindications compared with transjugular intrahepatic portosystemic shunt creation. (Excerpt from text, p. e59; no abstract available.)


Posted May 15th 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 1-Background, Design Considerations, and Model Development.

James R. Edgerton M.D.

James R. Edgerton M.D.

Shahian, D. M., J. P. Jacobs, V. Badhwar, P. A. Kurlansky, A. P. Furnary, J. C. Cleveland, Jr., K. W. Lobdell, C. Vassileva, M. C. Wyler von Ballmoos, V. H. Thourani, J. S. Rankin, J. R. Edgerton, R. S. D’Agostino, N. D. Desai, L. Feng, X. He and S. M. O’Brien (2018). “The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 1-Background, Design Considerations, and Model Development.” Ann Thorac Surg 105(5): 1411-1418.

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BACKGROUND: The last published version of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) risk models were developed in 2008 based on patient data from 2002 to 2006 and have been periodically recalibrated. In response to evolving changes in patient characteristics, risk profiles, surgical practice, and outcomes, the STS has now developed a set of entirely new risk models for adult cardiac surgery. METHODS: New models were estimated for isolated coronary artery bypass grafting surgery (CABG [n = 439,092]), isolated aortic or mitral valve surgery (n = 150,150), and combined valve plus CABG procedures (n = 81,588). The development set was based on July 2011 to June 2014 STS ACSD data; validation was performed using July 2014 to December 2016 data. Separate models were developed for operative mortality, stroke, renal failure, prolonged ventilation, reoperation, composite major morbidity or mortality, and prolonged or short postoperative length of stay. Because of its low occurrence rate, a combined model incorporating all operative types was developed for deep sternal wound infection/mediastinitis. RESULTS: Calibration was excellent except for the deep sternal wound infection/mediastinitis model, which slightly underestimated risk because of higher rates of this endpoint in the more recent validation data; this will be recalibrated in each feedback report. Discrimination (c-index) of all models was superior to that of 2008 models except for the stroke model for valve patients. CONCLUSIONS: Completely new STS ACSD risk models have been developed based on contemporary patient data; their performance is superior to that of previous STS ACSD models.


Posted May 15th 2018

Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine.

Lawrence R. Schiller M.D.

Lawrence R. Schiller M.D.

Schiller, L. R. (2018). “Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine.” Am J Gastroenterol. May 1. [Epub ahead of print].

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Chronic diarrhea is a common clinical problem, affecting roughly 5% of the population in any given year. Evaluation and management of these patients can be difficult due to the extensive differential diagnosis of this symptom. Many patients with chronic diarrhea have structural problems, such as inflammatory bowel disease or celiac disease, that can be readily identified. Others do not, and often are given a diagnosis of irritable bowel syndrome with diarrhea (IBS-D). When based on generally accepted clinical criteria, a diagnosis of IBS-D identifies a group of patients who are unlikely to have disorders producing anatomical changes in the gut. It is less clear that a diagnosis of IBS-D identifies a specific pathophysiology or leads to better management of symptoms. Disorders such as small intestinal bacterial overgrowth, bile acid malabsorption, food intolerance, and motility disorders may account for symptoms in patients with IBS-D. More effective tests are being developed to identify the clinical problems underlying IBS-D and may lead to more specific diagnoses that may improve the results of therapy. Application of the principles of precision medicine (identifying a specific mechanism for disease and applying treatments that work on that mechanism) should lead to more expeditious diagnosis and treatment for patients with chronic diarrhea including IBS-D, but currently is limited by the availability of sufficiently sensitive and specific tests for underlying mechanisms that can predict response to treatment.


Posted May 15th 2018

Migalastat improves diarrhea in patients with Fabry disease: clinical-biomarker correlations from the phase 3 FACETS trial.

Raphael Schiffmann M.D.

Raphael Schiffmann M.D.

Schiffmann, R., D. G. Bichet, A. Jovanovic, D. A. Hughes, R. Giugliani, U. Feldt-Rasmussen, S. P. Shankar, L. Barisoni, R. B. Colvin, J. C. Jennette, F. Holdbrook, A. Mulberg, J. P. Castelli, N. Skuban, J. A. Barth and K. Nicholls (2018). “Migalastat improves diarrhea in patients with Fabry disease: clinical-biomarker correlations from the phase 3 FACETS trial.” Orphanet J Rare Dis 13(1): 68.

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BACKGROUND: Fabry disease is frequently characterized by gastrointestinal symptoms, including diarrhea. Migalastat is an orally-administered small molecule approved to treat the symptoms of Fabry disease in patients with amenable mutations. METHODS: We evaluated minimal clinically important differences (MCID) in diarrhea based on the corresponding domain of the patient-reported Gastrointestinal Symptom Rating Scale (GSRS) in patients with Fabry disease and amenable mutations (N = 50) treated with migalastat 150 mg every other day or placebo during the phase 3 FACETS trial (NCT00925301). RESULTS: After 6 months, significantly more patients receiving migalastat versus placebo experienced improvement in diarrhea based on a MCID of 0.33 (43% vs 11%; p = .02), including the subset with baseline diarrhea (71% vs 20%; p = .02). A decline in kidney peritubular capillary globotriaosylceramide inclusions correlated with diarrhea improvement; patients with a reduction > 0.1 were 5.6 times more likely to have an improvement in diarrhea than those without (p = .031). CONCLUSIONS: Migalastat was associated with a clinically meaningful improvement in diarrhea in patients with Fabry disease and amenable mutations. Reductions in kidney globotriaosylceramide may be a useful surrogate endpoint to predict clinical benefit with migalastat in patients with Fabry disease. TRIAL REGISTRATION: NCT00925301


Posted May 15th 2018

Avoiding Cribari gridlock: The standardized triage assessment tool improves the accuracy of the Cribari matrix method in identifying potential overtriage and undertriage.

Michael L. Foreman M.D.

Michael L. Foreman M.D.

Roden-Foreman, J. W., N. R. Rapier, L. Yelverton and M. L. Foreman (2018). “Avoiding Cribari gridlock: The standardized triage assessment tool improves the accuracy of the Cribari matrix method in identifying potential overtriage and undertriage.” J Trauma Acute Care Surg 84(5): 718-726.

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BACKGROUND: The Cribari matrix method (CMM) is the standard to identify potential overtriage and undertriage but requires case reviews to correct for the fact that Injury Severity Score does not account for physiology or comorbidities, nor is it well correlated with resource consumption. Further, the secondary reviews introduce undesirable subjectivity. This study assessed if the Standardized Triage Assessment Tool (STAT)-a combination of the CMM and the Need For Trauma Intervention-could more accurately determine overtriage and undertriage than the CMM alone. METHODS: The registry of an American College of Surgeons verified Level I adult trauma center in Texas was queried for all new emergency department traumas 2013 to 2016 (n = 11,110). Binary logistic regressions were used to test the associations between the triage determinations of each metric against indicators of injury severity (risk factors, complications, and mortality) and resource consumption (number of procedures in 3 days and total length of stay). RESULTS: Both metrics were associated with the indicators of injury severity and resource consumption in the expected directions, but STAT had stronger or equivalent associations with all variables tested. Using the CMM, there was 50.4% overtriage and 9.1% undertriage. Using STAT, overtriage was reduced to 30.8% (relative reduction = 38.9%) and undertriage was reduced to 3.3% (relative reduction = 63.7%). CONCLUSION: Using the CMM with secondary case reviews makes valid multi-institutional triage rate comparisons impossible because of the subjective and unstandardized nature of these reviews. STAT’s out-of-box triage determinations (i.e., without manual case review) outperformed CMM in almost every tested variable for both over- and undertriage. STAT, an automatic, standardized method offers significant improvements compared to the current subjective system. Further, by accounting for both anatomic injury severity and resource consumption, STAT may allow trauma centers to better allocate resources and predict patient needs with fewer cases requiring manual review. LEVEL OF EVIDENCE: Prognostic, level III.