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The increasing use of complementary and alternative medicines (CAMs) has been associated with a rising incidence of CAM-induced drug-induced liver injury (DILI). The aim of this study was to examine the clinical features and outcomes among patients with acute liver failure (ALF) and acute liver injury (ALI) enrolled in the Acute Liver Failure Study Group database, comparing CAM-induced with prescription medicine (PM)-induced DILI. A total of 2,626 hospitalized patients with ALF/ALI of any etiology were prospectively enrolled between 1998 and 2015 from 32 academic transplant centers. Only those with CAM or PM-induced ALI/ALF were selected for analysis. A total of 253 (9.6%) subjects were found to have idiosyncratic DILI, of which 41 (16.3%) were from CAM and 210 (83.7%) were due to PM. The fraction of DILI-ALF/ALI cases due to CAM increased from 1998-2007 to 2007-2015 (12.4 vs. 21.1%, P=0.047). There was no difference in the type of liver injury-hepatocellular, cholestatic, or mixed-between groups as determined by R score (P=0.26). PM-induced DILI showed higher serum alkaline phosphatase levels compared with the CAM group (median IU/L, 171 vs. 125, P=0.003). The CAM population had fewer comorbid conditions (1.0 vs. 2.0, P<0.005), higher transplantation rates (56 vs. 32%, P<0.005), and a lower ALF-specific 21-day transplant-free survival (17 vs. 34%, P=0.044). CAM-induced DILI is at least as severe in presentation as that observed due to PM with higher rates of transplantation and lower transplant-free survival in those who progress to ALF. This study highlights the increasing incidence of CAM-induced liver injury and emphasizes the importance of early referral and evaluation for liver transplantation when CAM-induced liver injury is suspected.

The following project analyzes religious life through the lens of religious language. Motivated by ideas of Wittgenstein and Wittgensteinians, religious language is shown to be nonsensical, and yet significant. Wittgenstein connects how we understand language with how we understand life, and this connection extends to religious life. This project offers an answer to how religious language is unique by comparing religious language to riddles and the process of answering riddles. In addition, religious language becomes understandable with imagination, a relationship with the transcendent, and an understanding of the kinds of language present in religious discourse. These ideas are solidified with the study of Kierkegaard’s Abraham. Above all, grasping the religious form of life is necessary to understanding religious language.

BackgroundPatients with inflammatory bowel disease (IBD) on anti-tumor necrosis factor alpha (TNF) agents may have lower immune response to the influenza vaccine. We aimed to evaluate the immunogenicity of the high dose (HD) vs standard dose (SD) influenza vaccine in patients with IBD on anti-TNF monotherapy.MethodsWe performed a randomized clinical trial at a single academic center evaluating the immunogenicity of the HD vs SD influenza vaccine in patients with IBD on anti-TNF monotherapy. Influenza antibody concentration was measured at immunization, at 2 to 4 weeks postimmunization, and at 6 months.ResultsSixty-nine patients with IBD were recruited into the study, 40 on anti-TNF monotherapy, and 19 on vedolizumab, along with 20 healthy controls (HC). Patients with IBD receiving the HD influenza vaccine had significantly higher H3N2 postimmunization antibodies compared with those who received the SD influenza vaccine (160 [interquartile range 80 to 320] vs 80 [interquartile range 40 to 160]; P = 0.003). The H1N1 postimmunization levels were not significantly higher in the HD influenza vaccine (320 [interquartile range 150 to 320] vs 160 [interquartile range 80 to 320]; P = 0.18). Patients with IBD receiving the HD influenza vaccine and those on vedolizumab who received SD had equivalent antibody concentrations to HC (H1N1 P = 0.85; H3N2 P = 0.23; B/Victoria P = 0.20 and H1N1 P = 0.46; H3N2 P = 0.21; B/Victoria P = 1.00, respectively).ConclusionsPatients with IBD on anti-TNF monotherapy receiving the HD influenza vaccine had significantly higher postimmunization antibody levels compared with SD vaccine. Clinicaltrials.gov (#NCT02461758).High-dose influenza vaccine improves immunogenicity compared with standard-dose vaccine in patients with IBD on anti-TNF therapy and may provide better protection against infection. Vedolizumab does not impact immune response to influenza vaccine in patients with IBD.Video Abstract 10.1093/ibd/izz164_video1Video Abstractizz164_video16076481126001

INTRODUCTION:Esophageal food impaction (EFI) is often the first presentation for patients with eosinophilic esophagitis (EoE). Management of EFI when EoE is suspected lacks evidence-based guidelines. The goals of this study are to evaluate the biopsy rates, medical management, follow-up and recurrence of EFI in patients with suspected EoE.METHODS:Adult patients presenting with EFI between 2007-2017 were identified by ICD-9 (935.1) and ICD-10 (T18.1) codes for foreign body in the esophagus. Inclusion criteria required endoscopic intervention with documentation of suspected EoE: defined as endoscopic features of rings, furrows, edema or exudate.RESULTS:We identified 471 cases of EFI requiring endoscopic intervention, with 171 suspected to have EoE. The biopsy rate at time of EFI for patients with suspected EoE was 46%. When patients were not biopsied at time of EFI (n = 93), the majority were initiated on empiric therapy without histologic diagnosis: PPI (90%) and topical steroids (1%). Follow-up endoscopy was recommended in 97% of patients not biopsied at time of EFI and 32% (n = 27) were lost to follow-up. Empiric therapy after EFI did not impact the diagnostic yield at time of follow-up endoscopy (median: 36 days) as rates of diagnostic biopsy (≥15 eos/hpf) were similar compared to those biopsied at time of EFI (66% vs 65%, P = 0.612). Time to follow-up endoscopy did not impact diagnostic yield (P = 0.21). While on therapy, 16% of patients (n = 9) had low level esophageal eosinophilia (5-14 per hpf) on follow-up EGD (median: 29 days). Over the 11 year period, recurrent EFI occurred in 16 patients (3.4%) with a median time to recurrence of 1.65 years.CONCLUSION:EFI presents a unique opportunity to diagnose, treat and establish care for patients with EoE. Our study identified low rates of esophageal biopsy and high rates of loss to follow-up. Empiric therapy did not impact diagnostic yield on subsequent endoscopy with early follow-up. Low level eosinophilia while on therapy should be interpreted cautiously as this may represent partially treated disease. Although uncommon, EFI and recurrence are a disease defining event that create significant patient discomfort and require costly intervention. Our study highlights the need for standardize practice at the time of EFI when EoE is suspected including a structured system to streamline outpatient care, avoid loss to follow up and ultimately, prevent long term complications from this chronic disease.

BackgroundThe aim of this study was to assess expert gastroenterologists’ opinion on treatment for distinct gastroesophageal reflux disease (GERD) profiles characterized by proton pump inhibitor (PPI) unresponsive symptoms.MethodsFourteen esophagologists applied the RAND/UCLA Appropriateness Method to hypothetical scenarios with previously demonstrated GERD (positive pH-metry or endoscopy) and persistent symptoms despite double-dose PPI therapy undergoing pH-impedance monitoring on therapy. A priori thresholds included: esophageal acid exposure (EAE) time >6.0%; symptom-reflux association: symptom index >50% and symptom association probability >95%; >80 reflux events; large hiatal hernia: >3 cm. Primary outcomes were appropriateness of four invasive procedures (laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication, radiofrequency energy delivery) and preference for pharmacologic/behavioral therapy.ResultsLaparoscopic fundoplication was deemed appropriate for elevated EAE, and moderately appropriate for positive symptom-reflux association for regurgitation and a large hiatal hernia with normal EAE. Magnetic sphincter augmentation was deemed moderately appropriate for elevated EAE without a large hiatal hernia. Transoral incisionless fundoplication and radiofrequency energy delivery were not judged appropriate in any scenario. Preference for non-invasive options was as follows: H2RA for elevated EAE, transient lower esophageal sphincter relaxation inhibitors for elevated reflux episodes, and neuromodulation/behavioral therapy for positive symptom-reflux association.ConclusionFor treatment of PPI unresponsive symptoms in proven GERD, expert esophagologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia. Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios.