Bleeding Meckel’s Diverticulum in a 33-Year-Old Female Diagnosed with Video Capsule Endoscopy and a Technetium-99 m Pertechnetate Scan with a Favorable Response to H2 Blocker and PPI

Meckel’s diverticulum is a true diverticulum consisting of all three layers of the small intestine resulting from incomplete regression of the vitelline duct. While it is often benign, it can present with serious complications such as intussusception, ulceration, torsion, hemorrhage, obstruction, inflammation, and fistula formation. Although it typically presents in infancy and early childhood, it can also manifest much later into adulthood. We report a case of Meckel’s diverticulum complicated by significant bleeding in a 33-year-old female patient. Diagnosis was accomplished with video capsule endoscopy and a technetium-99 m pertechnetate scan. The patient responded well to acid suppression, initially with an H2 blocker and later with a PPI (proton pump inhibitor), and remained asymptomatic for nearly four months in the interim to definitive surgical treatment. Microscopic examination of the resected diverticulum confirmed the presence of ectopic gastric mucosa. A PubMed literature search revealed several similar cases of Meckel’s diverticulum complicated by hemorrhage with a favorable response to H2 blockers and PPIs. While surgical resection remains the mainstay of definitive treatment, medications aimed at acid suppression can delay the need for urgent surgery, allow for diagnostic assessment, and optimize conditions for elective surgical treatment.

Role of calcium channel blocker in excessive mast cell degranulation

Background:I present a case of a female patient, age 45 years, for whom the uncontrolled mast cell degranulation created many issues related to allergy like, skin rash, itching, breathing discomfort, frequent throat infection, GERD, migraine, fibromyalgia, peripheral neuropathy, depression, anxiety disorder, constipation etc. For the patient, it was observed that calcium channel blockers seem to control the unnecessary and uncontrolled mast cell degranulation. CCB seemed to have a role to play in mast cell degranulation.Case presentation:When the patient is taking either Flunarizine or Pregabalin or both together, the need for antihistamine and montelukast are very low. The patient suffers less throat infection while Flunarizine or Pregabalin are being taken. More the dose of Pregabalin less the occurrence of any type of allergy (food, pollen, dust etc.). The requirement of corticosteroid inhaler for breathing discomfort is also less. Frequency of body pain, migraine is minimal. Occurrence of stomach acid or GERD or digestion disorder is also very less. In terms of mood or anxiety, body is stable too. So, per day when 3 Pregabalin (75mg) were taken with 1 Amitriptyline (50mg) and 1 Duloxetine (60mg) health is completely stable with no need for H1 Blocker, H2 Blocker, Montelukast and Corticosteroid inhaler. Conclusion:CCB, specifically L-type CCB must have role in controlling the degranulation of mast cells, thus reducing all problem together at the root. But there are disadvantages like aggravated IBS (lazy gut), aggravated RLS and fluid retention (swelling of palm).We must check the use of Gabapentin and Sodium cromoglycate too. They should also control the unnecessary mast cell degranulation. Thus, fixing the problem at the root.

Awareness about FDA announcement on voluntary recall of ranitidine among physicians and pharmacists in and around Chennai, India: a cross-sectional study

Background Ranitidine is a histamine-2 (H2) blocker, which decreases the amount of acid created by the stomach. In September 2019, the drug was recalled due to impurities N-nitrosodimethylamine (NDMA) by the Food and Drug Administration (FDA), European Medicines Agency (EMA), and Health Canada. NDMA is a carcinogen based on results from laboratory tests. The objective of the study is to assess the awareness among the physicians and pharmacists in and around Chennai about the ranitidine recall notification and its related issues. A descriptive, cross-sectional study was carried out where a questionnaire was administered on 198 physicians and 113 pharmacists who were enrolled in the study. Awareness, knowledge, and issues related to recall notification were recorded from the participants. Results Results showed that only 75% of the study participants were aware of the notification and the issues related, with significantly more participants from the urban area compared with the rural area. When the notification was known by many, the reasons pertaining to the notification were not known. Conclusion Overall, the awareness assessed among physicians and pharmacists was not satisfactory. Physicians and pharmacists are the most responsible healthcare providers and to be updated with every notification on medication published by regulatory bodies.

Gambaran Pasien yang Menggunakan Suplemen Kalsium di Poliklinik Sub Spesialis Bedah Onkologi RSUD Ulin Banjarmasin

Suplemen kalsium banyak digunakan oleh pasien yang menderita kanker dengan terapi hormonal di poliklinik sub spesialis bedah onkologi RSUD Ulin Banjarmasin. Penelitian ini bertujuan mendeskripsikan karakteristik berupa umur dan jenis kelamin pasien yang menerima suplemen kalsium, jenis kanker, obat lain yang diberikan bersama pemberian kalsium, jenis suplemen kalsium, frekuensi pemberian kalsium, lama pemberian kalsium dan penggunaan suplemen kalsium dari lama pemberian kalsium dan obat terapi hormonal yang digunakan di poliklinik sub spesialis bedah onkologi RSUD Ulin Banjarmasin. eksperimental deskriptif adalah jenis penelitiannya serta pengambilan datanya dengan retrospektif menggunakan sumber cacatan medik pada tahun 2018. Data Populasi digunakan dengan kriteria inklusi adalah pasien kanker usia >18 tahun, menerima suplemen kalsium dan kriteria eksklusi yaitu penderita kanker dengan informasi catatan medik yang kurang lengkap/tak ditemukan. Total jumlah populasi yang digunakan adalah 55 pasien. Hasil dan kesimpulan penelitian didapatkan karakteristik berdasarkan usia pada rentang 26-35 tahun (1,81%), 36-45 tahun (10,91%), 46-65 tahun (43,64%), 56-65 tahun (40,00%) dan >65 tahun (3,64%); jenis kelamin perempuan (100%); jenis kanker berupa kanker payudara (98,18%) dan kanker tiroid (1,82%); obat lain yang diberikan bersama pemberian kalsium adalah obat golongan hormonal, kemoterapi sitotoksik, analgesik, H2 Blocker, ACE Inhibitor, Antihistamin, Bifosfonat, Analog vitamin D serta multivitamin lainnya; jenis suplemen kalsium yang didapat yaitu kalsium karbonat (100%); frekuensi pemberian kalsium 1x sehari 500 mg (100%); lama pemberian kalsium selama 7 hari (1,82%), 15 hari (1,82%), 20 hari (1,82%), 21 hari (1,82%), 30 hari (92,72%) dan penggunaan suplemen kalsium dari lama pemberian kalsium dan obat terapi hormonal yang digunakan adalah 7, 15, 20 dan 21 hari dengan jumlah pasien masing-masing 1 pasien terapi hormonal yang digunakan yaitu letrozole dan 30 hari dengan jumlah pasien 51 terapi hormonal yang digunakan yaitu letrozole, anasrozole, tamoxifen, goserelin acetate, megestrol acetate, dan levothyroxine. Kata Kunci: Suplemen, Kalsium, Onkologi, Hormonal, Kanker Calcium supplements are widely used by patients who suffer cancer with hormonal therapy at oncology surgery sub specialist polyclinic at Ulin Regional Public Hospital Banjarmasin. The research aims to describe the characteristics of the age and gender of patiens who receive calcium supplements, types of cancer, other drugs given with calcium, types of calcium supplements, frequency of calcium administration, duration of calcium administration and the use of calcium supplements from the duration of calcium administration and hormonal therapy drugs used at oncology surgery sub specialist polyclinic at Ulin Regional Public Hospital Banjarmasin. The research type is non-experimental descriptive and the data retrieval is taken restropective by using medical record as the source in 2018. The population data used with inclusion criteria are patients who suffer cancer with the age of > 18 years old, consumed calcium supplements and the exclusion criteria are patients with incomplete / not found medical record. The total population used are 55 patients. The research result and conclusion shows that the characteristics based on age is between 26-35 years old (1,81%), 36-45 years old (10,91%), 46-65 years old (43,64%), 56-65 years old (40,00%) and > 65 years old (3,64%); female (100%); types of cancer in the form of breast cancer (98,18%) and thyroid cancer (1,82%); other drugs given with calcium are hormonal medicine groups, cytotoxic chemotherapy, analgesic, H2 Blocker, ACE Inhibitor, Antihistamine, Bisphosphonates, Vitamin analogues D and other multivitamins; types of calcium supplements obtained is calcium carbonate (100%); frequency of calcium administration is 1 x 500 mg (100%) each day and duration of calcium administration is 7 days (1,82%), 15 days (1,82%), 20 days (1,82%), 21 days (1,82%), 30 days (92,72%) and the use of calcium supplements from the duration of calcium administration and hormonal therapy drugs used were 7,15,20 and 21 days with 1 patient each of hormonal therapy used letrozole and 30 days with 51 patients using hormonal therapy letrozole, anasrozole, tamoxifen, goserelin acetate, megestrol acetate, dan levothyroxine.

Anti-Acid Drug Treatment Induces Changes in the Gut Microbiome Composition of Hemodialysis Patients

Anti-acid drugs, proton pump inhibitor (PPI) and histamine-2 blocker (H2-blocker), are commonly prescribed to treat gastrointestinal disorders. These anti-acid drugs alter gut microbiota in the general population, but their effects are not known in hemodialysis patients. Hence, we investigated the microbiota composition in hemodialysis patients treated with PPIs or H2-blocker. Among 193 hemodialysis patients, we identified 32 H2-blocker users, 23 PPI users, and 138 no anti-acid drug subjects. Fecal samples were obtained to analyze the gut microbiome using 16S RNA amplicon sequencing. Differences in the microbial composition of the H2-blocker users, PPI users, and controls were assessed using linear discriminant analysis effect size and the random forest algorithm. The species richness or evenness (α-diversity) was similar among the three groups, whereas the inter-individual diversity (β-diversity) was different between H2-blocker users, PPI users, and controls. Hemodialysis patients treated with H2-blocker and PPIs had a higher microbial dysbiosis index than the controls, with a significant increase in the genera Provetella 2, Phascolarctobacterium, Christensenellaceae R-7 group, and Eubacterium oxidoreducens group in H2-blocker users, and Streptococcus and Veillonella in PPI users. In addition, compared to the H2-blocker users, there was a significant enrichment of the genera Streptococcus in PPI users, as confirmed by the random forest analysis and the confounder-adjusted regression model. In conclusion, PPIs significantly changed the gut microbiota composition in hemodialysis patients compared to H2-blocker users or controls. Importantly, the Streptococcus genus was significantly increased in PPI treatment. These findings caution against the overuse of PPIs.

Genotoxic Impurities in Ranitidine Containing Products: An Overview

Ranitidine is a well known H2 blocker antihistaminic drug used for symptomatic relief of heartburn, indigestion, acid indigestion, peptic ulcer and hyperacidity. However, On 13th September 2019, the United States Food and Drug Administration (USFDA) has given an alerting statement regarding the presence of nitrosamine impurity called N-nitrosodimethylamine (NDMA) in ranitidine containing products. Recently, some pharmaceutical companies have also recalled their ranitidine containing products from the market. Thus, there is a need to understand about these impurities in ranitidine containing products. The first part of this article highlights the mechanism of action of ranitidine in established therapeutic indications along with its adverse drug reactions and contraindications. Further, the introduction of genotoxic impurities in pharmaceutical products along with its types and mechanism of toxicity of ranitidine containing genotoxic impurity have been discussed.

The clinical impact of delirium in the patients with acute decompensated heart failure

Background Delirium is frequent in-hospital complication in patients with illness. However, the clinical impact of delirium on cardiovascular mortality has not been fully addressed in patients with acute decompensated heart failure (ADHF). Methods Between April 2016 and May 2019, 474 consecutive patients with ADHF admitted to our institution were enrolled and followed for 6 months after discharge. Delirium was defined according to the Intensive Care Delirium Checklist. To compare the clinical outcome, we divided study patients into 3 groups according to the presence or absence of delirium: non-delirium (ND) (n=349), improved-delirium during hospitalization (ID) (n=68), and prolonged delirium (PD) (n=57). Results One hundred twenty-five (26.4%) patients developed delirium. During hospitalization, PD had higher incidence of all-cause death, cardiovascular death, and worsening heart failure compared with ND and ID (20.0% vs. 3.7% and 2.9%, 10.9% vs. 2.5% and 1.4%, 21.8% vs. 2.5% and 4.3%, p<0.001, respectively). Multivariable analysis identified the presence of frailty (OR: 8.56, 95% CI: 3.46–23.7) and dementia (OR: 7.34, 95% CI: 3.52–15.9), use of H2-blocker (OR: 3.41, 95% CI: 1.08–10.9) and plasma level of CRP (OR: 1.30, 95% CI: 1.06–1.61) as significant independent determinants of delirium. Also, in multivariable analysis, the development of frailty (OR: 5.51, 95% CI: 2.80–11.5), delirium (OR: 4.59, 95% CI: 2.23–9.66) and age (OR: 1.06, 95% CI: 1.03–1.11) were the independent determinants of composite endpoint with in-hospital death and discharge to other than home. Early treatment of delirium performed significantly higher in ID than PD (55.7% vs. 29.1%, p=0.003). Conclusion This study suggested that PD contributed to increasing in-hospital events in the patients with ADHF and significance of early screening and treatment for delirium. Figure 1. Outcomes during hospitalization Funding Acknowledgement Type of funding source: None