10 PRACTICE GEH CHANGES IN 2013:
Kurdistan GEH Board journal club:
1.Adalimumab Is More Effective in Crohn's
 Adalimumab Is More Effective Than Azathioprine and
Mesalamine at Preventing Po...
2. Diagnostic Delay in Crohn's Disease Is Associated With a Complicated Disease Course and
Increased Operation Rate
Schoep...
3. Vedolizumab as Induction and Maintenance Therapy for Ulcerative Colitis
Feagan BG, Rutgeerts P, Sands BE, et al
N Engl ...
4.Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Surawicz CM, Brandt LJ, Binion D...
Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Surawicz CM, Brandt LJ, Binion DG,...
5.Peroral Endoscopic Myotomy for Treatment of Achalasia: From
Bench to Bedside (With Video)
Chiu PW, Wu JC, Teoh AY, et al...
6.Outcomes of Treatment for Achalasia Depend on Manometric Subtype
Rohof WO Gastroenterology. 2013;144:718-725
 This stud...
7.Sofosbuvir and Ledipasvir Fixed-Dose Combination With and Without Ribavirin in
Treatment-Naive and Previously Treated Pa...
8.Muscle Cramps in Liver Disease
Mehta SS, Fallon MB Clin Gastroenterol Hepatol. 2013;11:1385-1391
 Mehta and Fallon prov...
9.Coagulation in Liver Disease: A Guide for the Clinician
Northup PG, Caldwell SH Clin Gastroenterol Hepatol. 2013;11:1064...
10.Impact of Endoscopic Surveillance on Mortality From Barrett's Esophagus-Associated
Esophageal Adenocarcinomas
Corley DA...
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Git j club geh practise changes 2013.

  1. 1. 10 PRACTICE GEH CHANGES IN 2013: Kurdistan GEH Board journal club:
  2. 2. 1.Adalimumab Is More Effective in Crohn's  Adalimumab Is More Effective Than Azathioprine and Mesalamine at Preventing Postoperative Recurrence of Crohn's Disease: A Randomized Controlled Trial  Savarino E, Bodini G, Dulbecco P, et al Am J Gastroenterol. 2013;108:1731-42
  3. 3. 2. Diagnostic Delay in Crohn's Disease Is Associated With a Complicated Disease Course and Increased Operation Rate Schoepfer AM, Dehlavi MA, Fournier N, et al Am J Gastroenterol. 2013;108:1744-1753  Clearly, multiple factors can lead to a delay in diagnosis of Crohn disease and the appropriate initiation of therapies. The importance of avoiding a delay in diagnosis to prevent complications is underscored by the results of this study.
  4. 4. 3. Vedolizumab as Induction and Maintenance Therapy for Ulcerative Colitis Feagan BG, Rutgeerts P, Sands BE, et al N Engl J Med. 2013;369:699-710  Vedolizumab is a new, effective option for induction and maintenance therapy for patients with IBD. It is anticipated that this will receive US Food and Drug Administration (FDA) approval and be available in 2014. The gut-specific effects and the lack of risk for potentially devastating PML will make this an attractive therapeutic option for appropriate patients.
  5. 5. 4.Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections Surawicz CM, Brandt LJ, Binion DG, et al Am J Gastroenterol. 2013;108:478-498  This American College of Gastroenterology guideline provides a comprehensive review of current diagnosis and treatment. Notable strong recommendations include:  Only patients with diarrhea (a stool that takes the shape of the container) should be tested for CDI.  Initial testing should be done with glutamate dehydrogenase or nucleic acid amplification test for CDI, without repeat testing unless suspicion for infection is high and initial GDH testing is done.  Patients with resolution of diarrhea should not be tested to document cure of CDI.  Initial antibiotic treatment for patients with mild to moderate CDI infection should be metronidazole 500 mg 3 times daily orally (provided there is no drug allergy contraindication).  Initial treatment for severe CDI or failure to respond to 5-7 days of metronidazole should be vancomycin 125 mg 4 times daily orally. If severe or complicated CDI, intravenous metronidazole 500 mg 3 times daily should be added.  In patients with severe ileus or complicated CDI, the best antibiotic plan is intravenous metronidazole 500 mg 3 times daily plus oral vancomycin 500 mg 4 times daily with vancomycin 500 mg in 500 cc fluid 4 times daily (given rectally by retention enema).
  6. 6. Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections Surawicz CM, Brandt LJ, Binion DG, et al Am J Gastroenterol. 2013;108:478-498  First recurrence of CDI can be treated with the initial regimen if it induced an appropriate clinical response.  Second recurrence of CDI should be treated with pulsed vancomycin.  If third recurrence or unresponsive severe CDI, FMT should be considered.  Current data suggest limited, if any, value of probiotics for CDI treatment or prevention of relapse.  High-level disinfection (sporicidal label claim or 5000 ppm chlorine-containing cleaning agents) of environmental surfaces in bathrooms; if inpatient, disinfection of contact surfaces is recommended.  Contact precautions should be continued at least until resolution of the patient's diarrhea.
  7. 7. 5.Peroral Endoscopic Myotomy for Treatment of Achalasia: From Bench to Bedside (With Video) Chiu PW, Wu JC, Teoh AY, et al Gastrointest Endosc. 2013;77:29-38  The cumulative 5-year remission rate of pneumatic dilation for achalasia has been reported at 50%-70%, LHM has a failure rate of 10%-15%, and gastroesophageal reflux disease is reported in 30%.  Data on POEM show impressive results without major complications. Clearly, this procedure should be performed in centers of excellence with advanced therapeutic experience in this technique. Because the myotomy for POEM is targeted for 15-17 cm vs 6-8 cm with LHM, this may be more effective in the Chicago classification type III patient with vigorous achalasia. The failure rate for these patients to date has been the ineffective control of associated chest pain, which may be much more adequately treated with this longer myotomy. Although not yet ready for prime time as a preferred treatment, it is a promising alternative (if only in selected patients).
  8. 8. 6.Outcomes of Treatment for Achalasia Depend on Manometric Subtype Rohof WO Gastroenterology. 2013;144:718-725  This study provides the best evidence to date that manometric subtype of achalasia using Chicago classification is important in predicting treatment success for different interventions. The relative lack of treatment success with both PD and LHM in patients with type III achalasia is probably attributable to the extended myotomy. The extended myotomy achieved with peroral endoscopic myotomy (POEM) may be more effective in these patients but needs to be studied. Clearly, longer-term follow-up is needed, but these findings should help clinicians avoid arbitrary selection of interventions for achalasia.
  9. 9. 7.Sofosbuvir and Ledipasvir Fixed-Dose Combination With and Without Ribavirin in Treatment-Naive and Previously Treated Patients With Genotype 1 Hepatitis C Virus Infection (LONESTAR): An Open-Label, Randomised, Phase 2 Trial Lawitz E, Poordad FF, Pang PS, et al Lancet. 2013 Nov 1.  The results of this small phase 2 study are impressive and set the stage, in the very near future, for having nearly universally effective, safe, and well-tolerated short-term therapies for HCV infection. The treatment paradigm will be shifting rapidly.
  10. 10. 8.Muscle Cramps in Liver Disease Mehta SS, Fallon MB Clin Gastroenterol Hepatol. 2013;11:1385-1391  Mehta and Fallon provide an excellent algorithm for the approach and diagnostic workup of these patients, as well as specific treatments for different clinical pathways. It's a must-read for all who take care of cirrhotic patients.
  11. 11. 9.Coagulation in Liver Disease: A Guide for the Clinician Northup PG, Caldwell SH Clin Gastroenterol Hepatol. 2013;11:1064-1074  This excellent review makes specific recommendations to guide clinical management.  Bleeding varices. Transfuse platelets to a target level of ≥ 56,000/mm3. Aggressive transfusion is to be avoided because higher volumes increase the intravascular pressures and risk for ongoing or recurrent variceal bleeding. Transfusions should target a hemoglobin of 7 g/dL. The empiric use of fresh frozen plasma (FFP) should be avoided. A fibrinogen level should be checked and maintained with a target of > 100 mg/dL (which is lower than the 150 mg/dL target recommended for disseminated intravascular coagulation). This is best achieved by infusing cryoprecipitate that contains factor VIII, fibrinogen, fibronectin, and factor XIII.  Before invasive procedures. Prophylactic platelets should be infused to a target of 50,000-60,000/mm3 (or > 100,000/mm3 for extremely high-risk procedures). Prophylactic FFP should be avoided. The use of prophylactic intranasal desmopressin acetate (DDAVP) for dental extraction improves platelet function.  Peripheral venous thrombosis. For patients with acute or subacute (but not chronic) peripheral venous thrombosis or cavernous transformation of the portal vein, therapeutic anticoagulation with low-molecular-weight heparin is recommended.  Bedridden patients. In all hospitalized or extended bed-restricted patients with cirrhosis, standard medical prophylaxis against deep venous thrombosis or pulmonary embolus should be considered as it would be for patients who do not have cirrhosis.
  12. 12. 10.Impact of Endoscopic Surveillance on Mortality From Barrett's Esophagus-Associated Esophageal Adenocarcinomas Corley DA Gastroenterology. 2013;145:312-319.e1  Several studies have documented the development of incurable malignancies in some patients despite adherence to endoscopic surveillance programs.  A previous report[1] estimated that the annual incidence of EAC would have to be > 1.9% for surveillance of nondysplastic BE at 5-year intervals to be cost- effective.  The most recent annual incidence estimates for high-grade dysplasia or EAC are 0.1% to 0.2%. The time has come to question the standard practice of routine endoscopic surveillance -- much less screening -- for patients with nondysplastic BE. A risk-stratification paradigm improvement is clearly needed.

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