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Fevipiprant - new oral med for allergic asthm 08-Aug-2016

Recent article from Lancet showed Fevipiprant - works well for allergic asthma.  It is a prostaglandin  D2 receptor 2 antagonist.  Novel mode of action

Volixibat - for NASH ? It is on FDA fast tract 08-Aug-2016

Volixibat is a novel drug possibly for NASH.  It is once-daily, orally-administered inhibitor of the apical sodium dependent bile acid transporter, a protein primarily responsible for recycling bile acids from the intestine to the liver.

Two types of LVEF ? 08-Jul-2016

New study suggests two types of LVEF. LVrecEF Where the LV recovers to more than 40% over time versus LVrEF which is LV reduced EF PERMANENT.  
Mortality benefit reduction of LVrecEF is 16 % in favor versus 4% in LVrEF

NGAL elevation correlates with ACLF 07-Jul-2016

NGAL has been used by nephrologists for differentiating new onset RF versus chronic.  It can also help identify acute on chronic liver failure - an elevated level correlates with ACLF

Rikkunshito for resistant GERD ? 04-Jul-2016

Rikkunshito a Japanese herb for resistant GERD is part of the guidelines in Rx in Japan 

It works for anorexia also. It increases gherlin and improves sensitivity to ghrelin

Digoxin in AF associated with higher mortality 19-Jun-2016

AF is associated with a higher mortality - both sudden cardiac death and non sudden cardiac death.  Contributing factors include
1. Digoxin increases mortality with or without CHF.  Perhaps there is a selection bias since these patients are difficult to treat
2. Sustained AF is associated with a higher mortality
3. CHF is a RF for AF for a higher mortality.

New Diabetes Rx - endoscopic laser 17-Jun-2016

DMR- duodenal mucosal resurfacing changes insulin resistance and improves weight, blood sugar, Hb A1 c and liver panel.  This is a study from Fractal. 2014 there were studies from Europe also

CHF : vent. Asst. Devices : impella & tandem 13-Jun-2016

A few months ago 2 new VAD were approved  They are portable

*Impella* was approved for *pVAD   Tandem* is another one.  Both are used for CHF  

H pylori 2016 Rx update 13-Jun-2016


  1. Needs 14 day treatment regimen.10 days had a high failure rate

  2. Quadruple treatment is first line.

    1. PPI + Amoxicillin + Metronidazole + clarithromycin (PAMC)

    2. PPI + Bismuth + Metrnoidazole + Tetracycline (PBMT)

  3. PPI + clarithromycin + amoxicillin / flagyl) is restricted to places with knownlow resistance to clarithromycin less than 15%

  4. Rescue therapies include PBMT and levofloxacin containing regimen ( PPI + amoxicillin + levofloxacin)USE ONLY IF they have FAILED 3 prior options as above

  5. If previous regimen with levofloxacin or clarithromycin has failed, do not use them again

  6. Recommend use of probiotics to reduce adverse reactions and increase eradication rate.

Zinplava from Merck - one infusion Rx for C diff 10-Jun-2016

 A single, one-time infusion of the antitoxin bezlotoxumab given with standard of care C. difficile antibiotic treatment significantly reduced the recurrence of C. difficile infection compared to standard of care alone, and demonstrated this benefit over a 12-week period,” said Dr. Mark Wilcox, Leeds Teaching Hospitals and University of Leeds, U.K., and a lead investigator for the studies. “These results were also demonstrated in patient subgroups known to be at high risk for C. difficile recurrence.”

Contrast enhanced US for liver lesion and Crohns 09-Jun-2016

Lumason was approved for CEUS to enhance diagnosis of liver lesions without exposing patients to radiation.  Contrast enhanced US can be used for crohns also.

Statins beneficial in Hep B - Taiwan data 09-Jun-2016

“This large population-based study in a hepatitis B virus endemic country suggested that statins independently protect [chronic hepatitis B] patients from the development of cirrhosis, its complications and its decompensation according to a dose–response relationship,” Yi-Wen Huang, MD, PhD, of the Liver Center, Cathay General Hospital Medical Center, Taiwan, and colleagues wrote.

IV Tigecycline for C diff Rx - 76% effective. 08-Jun-2016

 C diff Rx Tigecycline effected a 76% clinical cure rate, compared with 53% for the combination regimen of intravenous metronidazole and oral vancomycin.  This trial is from Europe

Immodium causes torsades 07-Jun-2016

Immodium has been associated with torsades. Max dose recommended is 8 mg/day
More likely to happen if zantac / rantidine is used.

Highly sensitive troponin I 04-Jun-2016

Myocardial infarction


The second study released alongside in JAMA Cardiology affirmed that serial use of the high-sensitivity test at presentation and at 1 hour was "comparable" in performance to a 3-hour protocol, as had been initially reported at the European Society of Cardiology meeting.


"With application of a low troponin I cutoff value of 6 ng/L, the rule-out algorithm showed a high negative predictive value of 99.8% (95% CI, 98.6%-100.0%) after 1 hour for non-ST-segment elevation MI type 1," Dirk Westermann, MD, PhD, of the University Heart Center Hamburg, Germany, and colleagues reported. "Similarly, a rule-in algorithm based on troponin I levels provided a high positive predictive value with 82.8% (95% CI 73.2%-90.0%)."


Again, a lower cutoff appeared better, the researchers wrote, as "application of the cutoff of 6 ng/L resulted in lower follow-up mortality (1.0%) compared with the routinely used 99th percentile (3.7%) for this assay."


Their prospective Biomarkers in Acute Cardiac Care (BACC) study included 1,040 patients presenting to the emergency department with acute chest pain from July 19, 2013, to Dec. 31, 2014, along with two independent cohorts totalling 4,009 patients.


High-sensitivity troponin tests are used routinely in many regions of the world but haven't yet become available in the U.S., David A. Morrow, MD, MPH, of Brigham and Women's Hospital in Boston, noted in an accompanying editorial.

FMT in IBD 30-May-2016

A total of 27% of patients given the active treatment met the study's primary outcome of clinical remission plus endoscopic response or remission after 8 weeks compared with 8% of those who received placebo (<=0.02), reported Sudarshan Paramsothy, MD, of the University of New South Wales in Australia.


In addition, at week 8, steroid-free clinical remission and clinical response rates compared with placebo were 44% versus 20% (P=0.02) and 54% versus 23% (P<<0.01), he said at the annual Digestive Disease Week.


"In recent years, researchers have gained a better understanding of the gut microbiota and the critical role it plays in health and disease, including conditions like ulcerative colitis," Paramsothy said during a press briefing. The estimated prevalence of ulcerative colitis is 200/100,000 adults, according to the CDC.


"The FDA has approved FMT for recurrent Clostridium difficile  infection, but questions remain as to whether FMTs could be useful for other types of digestive disorders," said Beth McCormick, PhD, of the University of Massachusetts Center for Microbiome Research in Worcester, who was not involved in the study. "This randomized, placebo-controlled trial demonstrated promising results for ulcerative colitis, a treatment that hasn't received FDA approval specifically for this indication, but there's potential for future progress here," she said in a press briefing.


"FMT has a lot of promise in ulcerative colitis," Paramsothy told MedPage Today.


And while the gut microbiota is the antigenic driver in ulcerative colitis, the efficacy of microbial manipulation has not been established, although preliminary low-dose studies suggested potential benefit.


To test FMT in a population of treatment-resistant patients, the authors enrolled 81 patients with active disease, in that Mayo scores were 4 to 10. They were given FMT via a colonoscopic infusion on day 1 and then self-administered FMT enemas 5 days per week for 8 weeks.


"This population is accustomed to using enemas as part of their treatment, so our approach would not be unusual to them," he said.


The enemas consisted of stool from at least three different donors, to avoid potential "donor effect," in which the microbial characteristics of a single patients could be unduly influential. Donors are screened to ensure safety of the stool.


Patients were allowed to continue taking immunomodulators such as 5-aminosalicylate and and steroids in doses no higher than 20 mg/day, but had to have stopped previous biologics at least 12 weeks earlier. They also had to stop using any other enema treatments.


The primary endpoint required a Mayo score of 2 or less with subscores of 1 or less for rectal bleeding, stool frequency, and endoscopic appearance, as well as a 1-point or more reduction from baseline on the endoscopy subscore. Clinical remission required a combined total score of 1 or less for the rectal bleeding and stool frequency subscores.


Steroid-free endoscopic remission scores for the FMT and placebo groups were 17% versus 8% at week 8 (P=0.19), while endoscopic response rates were 37% versus 10% (P<0.01).


After the initial 8-week phase, 37 of 40 patients who had been randomized to placebo and went on to receive the active FMT for an additional 8 weeks. Of these, 27% met the primary endpoint, 46% were in clinical remission, and 24% had endoscopic remission.


There were three serious adverse events of worsening of colitis. Two of these were in the active treatment group, with one requiring colectomy, and one in the placebo group.


"We were able to show definitively that fecal microbiota transplantation is an effective treatment for ulcerative colitis. This is important because there are millions of people worldwide seeking alternative treatments for this condition," Paramsothy said.


The long-term effects of the treatment have yet to be established, he cautioned.

Vitamin E warning and Efficacy of Selenium? 12-Oct-2011

A new study that came out in JAMA suggested that patients taking high dose Vitamin E had a higher chance of developing prosate cancer. We still await more studies for the same. The study did not show any benefit with using Selenium.

New warnings! 05-Oct-2011

New FDA warnings were issued today about TNF antagonists (Remicaide, Cimzia and Humira) Fatal infections have occured with Legionella and Listeria. This is especially true with patients on TNF plus another immunusuppresant. Simvastatin has drug warnings with interactions with amidarone, diltiazem, verapamil, antifungals including diflucan and other drugs. Dose reduction or NOT using them at the same time is strongly recommended. Also dose of 80 mg is associated with a higher drug toxicity. Talk with your cardiologist or primary care for the same.

Sniff it out 28-Apr-2011

Dogs have been known to sniff humans and indicate the person has colon or rectal cancer. However, they get olfactory fatigue (tired of smelling). In an article published in Gut and Irish Medical times, they have made a device which can "smell" and detect colorectal cancer.

Constipation associated with CKD 11-Nov-2016

10% of patients with constipation can develop chronic kidney disease

Non gluten sensitivity 17-Oct-2016

A newly discovered protein called amylase trypsin inhibitor may be responsible for NCGS symptoms 

HCV assoc.with nasopharyngeal and oropharynx cance 06-Jul-2016

Risk association with HCV cancer includes liver cancer, non hodgkins Lymphoma, nasopharyngeal cancer and oropharyngeal cancer (MD anderson study)

Risk of alkaseltzer - GI bleed 01-Jul-2016

Risk of bleeding is higher in alkaseltzer seltzer Risk factors include: Age 60 or older A history of stomach ulcers or bleeding problems Taking a blood thinner or steroid medication Taking an NSAID Drinking three or more alcoholic beverages a day

Epclusa aporoved for hepatitis C 30-Jun-2016

this is the first pan genotypic medication for HCV.  EPCLUSA

MS : fatigue assoc with sluggish bowel 16-Jun-2016

A small study based on 3 different types of questionaire found that multiple sclerosis patients had a higher incidence of fatigue if they had sluggish bowel habits

Ulcer prevention on ASA-PPI , H2 block no effect 15-Jun-2016

Ulcer prevention on ASA - H2 blocker 12% effective versus PPI 8% effective and neither was statistically different.

Normal BMI for asians is 2.5% less ! 14-Jun-2016

This is true for all aspects of obesity.

Obesity table
  Others Asians
Normal 19-24.9 18-23
Overweight 25-29.9 23-27.5
Obese 30-39.9 28-37.5
Morbidly Obese More than 40 More than 37.5

Sleep apnea 01-Jun-2016

Sleep apnea. One third of patients with insomnia have obstructive sleep apnea (OSA),[8] which is caused by upper-airway collapse during sleep that leads to repeated breathing stoppages throughout the night. If a patient has OSA, their insomnia may be refractory to both nonmedication and medication treatment options. Once OSA is formally diagnosed with polysomnography and treated, the associated insomnia symptoms often completely resolve.

In addition to insomnia, there are also long-term risks associated with untreated OSA. These include an association with long-term cardiovascular and cerebrovascular disease.[5]

The STOP BANG Inventory[9] can help you quickly establish whether your patient is at high risk for OSA and would benefit from polysomnography. If they have five or more of the following factors, they are considered at high risk:


  • Snoring
  • Tiredness
  • Observed that you stop breathing
  • History of high blood pressure


  • Body mass index > 35 kg/m2
  • Age older than 50 years
  • Neck circumference > 40 cm (15.75 in)
  • Gender: male

Although polysomnography is not part of the standard workup of insomnia, it is warranted in specific cases, such as when sleep apnea or another sleep disorder is suspected or if the insomnia remains refractory to treatment.[2]

Insomnia 01-Jun-2016

Common medications than can cause insomnia include anticonvulsants, beta-blockers, antipsychotics, antidepressants, and nonsteroidal anti-inflammatory drugs.[12] A timeline may be useful to determine whether the initiation of a new medication, or a change in dose, correlates with worsening of insomnia.

Qnexa - Is there hope? 12-Apr-2011

Qnexa, an investigational drug, for weight loss showed promise. In one study published in Lancet, it helped patients lose 22 pounds, lowered their blood pressure and cholesterol. The drug was denied by FDA in October 2010 - they asked for additional studies.

C Diff 06-Apr-2011

C diff is an infection that occurs when the normal bowel bacteria is killed. This gives an opportunity to other toxic bacteria like C diff to grow. Currently we use flagyl (metronidazole) or vancomycin or Rifaximin. However, there is a relapse meaning repeated infection of C diff because those antibiotics stil kill the normal flora. A new medication will hopefully come out soon - it is called Fidaxomicin (Dificid) which is better in preventing relapses and works better

NEW PPI WARNING! 03-Mar-2011

The latest update on PPI (Protonix, Nexium, Aciphex, Prilosec, Prevacid, Dexalant) is that long term use (defined as more than 1 year use) is associated with low Magnesium level. This low magnesium level can be associated with a higher chance of cardiac rhythym problems. All patients on long term PPI use, especially if they take a diuretic or digoxin should get their Magnesium level checked. Please call my office or your primary care

Capsule Crawler 30-Oct-2010

In the United Kingdom, they are working on a capsule endoscopy that has "legs" and can be controlled with a remote!