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Background: Capsule endoscopy (CE) is an emerging tool in the diagnosis and management of occult bleeding and overt obscure gastrointestinal bleeding (OOGIB). Maximizing efficiency of CE can lead to rapid bleeding localization and shorter time to therapy. We investigated whether a trained registered nurse (RN) can accurately interpret bleeding by CE in real time by measuring inter-observer agreement between RN and physician interpretation. Methods: We conducted a prospective study of patients admitted for OOGIB who underwent live-view capsule endoscopy (LVCE) between 12/2016 and 11/2017. A match control group who underwent standard CE was obtained through retrospective review. An RN received a 2-day training program for CE interpretation. RN bedside interpretation for bleeding was followed by interpretation by 2 GI physicians blinded to LVCE findings. Outcomes were compared between groups using t-tests and chi-square tests. Cohen’s kappa measured agreement between physician and RN. Results: Ten subjects were in the LVCE group, and 12 subjects were in the standard of care group. The agreement between the physicians and RNs was 9/10 (90%) with a kappa of 0.73 (95% CI: 0.26-1.00; p=0.016). Patients in the LVCE group had shorter duration to physician interpretation (0.6 vs 0.7 days (p=0.50), duration to endoscopy (1.8 days vs 3 days (p=0.240) and length of stay (8.1 vs. 11.4 days (p=0.26) compared to the standard of care group. Conclusion: This study utilizing an RN for LVCE interpretation found interobserver agreement between RN and physician findings. Larger studies are needed to assess whether this RN-physician team approach can translate to improved outcomes.

The effect of octreotide on sphincter of Oddimotility was investigated in six liver transplantpatients, employing percutaneous (through the T-tubetract) manometry. Continuous and simultaneous sphincter of Oddi and duodenal motor activities wererecorded before and for 60 min after the administrationof octreotide (100 μg subcutaneously) and after theinjection of cholecystokinin (0.02 μg/kgintravenously). With octreotide, contraction frequency andbasal pressure significantly increased (P < 0.05).This effect lasted more than 60 min, long afteroctreotide-induced duodenal migrating motor complexphase III activity had ceased. Sphincter of Oddicontraction amplitude and duration were unaffected byoctreotide. Subsequent cholecystokinin administrationtransiently reduced sphincter of Oddi basal pressure and contraction frequency. We conclude thatoctreotide significantly increases sphincter of Oddibasal pressure and contraction frequency. This effect isdistinct from octreotide induction of migrating motor complex phase III activity, persists for aprolonged period, and is inhibited bycholecystokinin.

Question: A 60-year-old man with acute myelogenous leukemia (AML) in remission relapsed and was admitted for salvage chemotherapy. He received induction with methotrexate, epirubicin and cisplatin. During the course of treatment, he became hypotensive and tachycardic, prompting transfer to the intensive care unit. Septic shock was empirically treated with broad-spectrum antibiotics. His course was further complicated by persistent pancytopenia, atrial fibrillation with rapid ventricular response, disseminated intravascular coagulation and respiratory failure requiring mechanical ventilation. He developed abdominal distension, proximal small bowel dilation, and mesenteric edema by computed tomography without pneumoperitoneum. Subsequent radiographic studies over several days revealed no interval changes; conservative therapy with nasogastric tube suction and methylnaltrexone was given. Five days later, he had an episode of melena accompanied by passage rectally of a 15-cm tubular structure (Figure A). Within hours of this event, he developed multisystem organ failure and hypotension followed by asystolic cardiac

A 66-year-old man with squamous cell carcinoma of the tongue and vallecula had massive lower gastrointestinal hemorrhage. Colonoscopy examination results were normal, but angiography revealed a 3 x 6-cm hypervascular mass in the right lower quadrant. Persistent bleeding required resection of a large ileal ulcer, which proved to be an isolated ulcer containing cells with cytomegalovirus (CMV) inclusion bodies. Massive gastrointestinal hemorrhage due to an isolated CMV ileal ulcer in adults without acquired immunodeficiency syndrome has not been previously reported. This case illustrates that hemorrhage due to CMV infection of the ileum may occur in the absence of endoscopic evidence of colonic involvement.

Deficiency of any of the 5 enzymes in the urea cycle results in the accumulation of ammonia, leading to encephalopathy; which if untreated, can be lethal and produce devastating neurologic sequelae in long-term survivors. We hereby present an interesting case that presented with hyperammonemia and encephalopathy; later found to have an urea cycle defect.

Spirochetes from a variety of salt marsh sediments were enumerated and isolated directly by using a prereduced complex medium containing rifampin as a selective agent. Based on cell morphology, the spirochetal strains isolated were divided into two groups, a group consisting of “tightly coiled” spirochetes and a group consisting of “loosely coiled” spirochetes. Generally, spirochete colony-forming units ranged between 104 and 106 per gram wet weight of the top 1 cm of sediment. Spirochete colony-forming units were in greater abundance in the uppermost 1–2 cm of sediment than in sediment taken from depths of 3–5 cm. Apparently, the top 1 or 2 cm of salt marsh sediment can provide a favorable habitat for certain spirochetal species.

This paper reports a patient with a pure Candida albicans vascular graft infection. Presentation was notable for the absence of systemic signs and symp toms of infection, minimal local tissue reaction, and a paucity of organisms in the initial pathologic specimen. The clinical course with multiple episodes of bleeding, the associated pathologic finding of vein necrosis, plus the repeated finding of yeast in tissue sections and in culture implicate the fungus as the cause of local pathology. This paper presents the patient, describes risk factors and possible mechanisms for infection, speculates on the reasons for the rarity of documented candida graft infections, and discusses the implications for patient management.

The addition of carbaryl (100μg/ml) to a model estuarine ecosystem did not affect the number of bacteria in the sediment, but reduced the diversity (as measured by the rarefaction technique) of the microbial community as compared with a control model ecosystem. Two carbaryltolerant strains of bacteria were isolated from the carbaryl-treated system, but none were isolated from the control system. Bacterial growth and filter paper decomposition in mixed cultures was prevented by 100μg/ml carbaryl, but this amount had no effect on the extracellular cellulase of an estuarine isolate. Increasing the amount of organic matter in the medium attenuated the toxicity of carbaryl to pure cultures of an estuarine isolate. The addition of 1, 10, or 100μg/ml carbaryl to field plots had no effect on bacterial numbers, diversity, or filter paper decomposition. The amount of carbaryl in sediments exposed to 100μg/ml fell below the limit of detection by thin-layer chromatography within 12 hours. In sterile and nonsterile model systems, carbaryl rapidly adsorbed to sediment, and hydrolyzed to 1-naphthol in both sediment and water. Although carbaryl may be toxic to bacteria under some conditions, the amounts that might enter and persist in an estuary are insufficient to have a significant impact on the sediment microbial community.

A 21-year-old man presented in shock after ingesting 2 g of arsenic trioxide. He died within 37 hours despite intensive treatment that included intramuscular dimercaprol and hemodialysis. Hemodynamic and laboratory data are presented illustrating the multisystem toxicities of inorganic arsenic. Hemodialysis, previously described as an effective therapeutic adjunct, was shown to be ineffective in this case.