Association of geographic and seasonal variation with diverticulitis admissions

Seasonal Variations and Factors that Influence Diverticular Bleeding in the United States of America

BACKGROUND

Seasonal variation in hospitalizations for diverticulitis has a sinusoidal pattern, peaking in summer. Little is known about seasonal, regional trends, and risk factors associated with hospital admissions regarding diverticular bleeding in the United States.

STUDY DESIGN

Cross-sectional population database review using the healthcare cost and utilization project's national inpatient sample.

METHODS

Patients that had diagnoses of diverticulitis with bleeding or diverticulosis with bleeding admitted from January 1, 2015, through December 31, 2017, were identified and stratified by month and season. Then, the potential effects of region, age, gender, race, and patient risk factors on seasonal admissions for diverticular bleeding were explored, and data were analyzed in SAS and presented in Excel using chi-square and Kruskal-Wallis for categorical and continuous variables, respectively.

RESULTS

Of the 54191 hospitalized cases for diverticular bleeding, the peak and the lowest seasons were spring and summer (25.5% vs. 24.2%, P<0.0001). A significant seasonal pattern in comorbidities was also identified, and those with diabetes (P<0.0001), hypertension (HTN) (P<0.0001), obesity (P<0.0001), and those on anticoagulants (P=0.016) all had more bleeding events in the spring. This was noted across US regions, gender, race, and age. Eventually, the southern region had the most admissions for diverticular bleeding at 40.9% (P<0.0001).

CONCLUSION

A better understanding of these seasonal and regional trends may provide a mechanism to identify a potential trigger for diverticular bleeding events. This helps identify individuals at greatest risk for hospitalization, as well as prepare hospitals to allocate supplies appropriately during the seasons.

Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists

   Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.

Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists

   Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.

Patients with Diverticular Disease Have Different Dietary Habits Compared to Control Subjects: Results from an Observational Italian Study

The role of dietary habits as risk factor for the development of diverticular complications has strongly emerged in the last years. We aimed to evaluate possible differences in dietary habits between patients with diverticular disease (DD) and matched controls without diverticula. Dietary habits were obtained from standardized food frequency questionnaires collected at entry to the Diverticular Disease Registry (REMAD). We compared controls (C) (n = 119) with asymptomatic diverticulosis (D) (n = 344), symptomatic uncomplicated diverticular disease (SUDD) (n = 154) and previous diverticulitis (PD) (n = 83) patients, in terms of daily calories, macro and micronutrients and dietary vitamins. Daily kcal intake and lipids, both saturated and unsaturated, were significantly lower in patients with DD than C. Total protein consumption was lower in PD than D, with differing consumption of unprocessed red meat, white meat and eggs between groups. Consumption of fibre, both soluble and insoluble, was lower in patients with PD compared to patients with SUDD, D and C, whereas dietary vitamins A, C, D and E and Oxygen Radical Adsorbance Capacity index were lower in all DD groups compared to C. This observational study showed that DD patients have different dietary habits, mainly in terms of caloric, fat, fibre and vitamin intake, compared to control subjects.

Seasonal variations in acute diverticular disease hospitalisations in New Zealand

PURPOSE

Seasonal variation of acute diverticular disease is variably reported in observational studies. This study aimed to describe seasonal variation of acute diverticular disease hospital admissions in New Zealand.

METHODS

A time series analysis of national diverticular disease hospitalisations from 2000 to 2015 was conducted among adults aged 30 years or over. Monthly counts of acute hospitalisations' primary diagnosis of diverticular disease were decomposed using Census X-11 times series methods. A combined test for the presence of identifiable seasonality was used to determine if overall seasonality was present; thereafter, annual seasonal amplitude was calculated. The mean seasonal amplitude of demographic groups was compared by analysis of variance.

RESULTS

Over the 16-year period, 35,582 hospital admissions with acute diverticular disease were included. Seasonality in monthly acute diverticular disease admissions was identified. The mean monthly seasonal component of acute diverticular disease admissions peaked in early-autumn (March) and troughed in early-spring (September). The mean annual seasonal amplitude was 23%, suggesting on average 23% higher acute diverticular disease hospitalisations during early-autumn (March) than in early-spring (September). The results were similar in sensitivity analyses that employed different definitions of diverticular disease. Seasonal variation was less pronounced in patients aged over 80 (p = 0.002). Seasonal variation was significantly greater among Māori than Europeans (p < 0.001) and in more southern regions (p < 0.001). However, seasonal variations were not significantly different by gender.

CONCLUSIONS

Acute diverticular disease admissions in New Zealand exhibit seasonal variation with a peak in Autumn (March) and a trough in Spring (September). Significant seasonal variations are associated with ethnicity, age, and region, but not with gender.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Effect of monthly vitamin D on diverticular disease hospitalization: Post-hoc analysis of a randomized controlled trial

BACKGROUND & AIMS

Some studies have linked low vitamin D status and high risk of diverticular disease, but the causal relationship between vitamin D and diverticular disease remains unclear; clinical trial data are warranted. The objective was to assess the efficacy of vitamin D₃ supplementation on diverticular disease hospitalization.

METHODS

Post-hoc analysis of a community-based randomized double-blind placebo-controlled trial (RCT) with 5108 participants randomized to receive monthly 100,000 IU vitamin D (n = 2558) or identical placebo (n = 2550). The outcome was time to first diverticular disease hospitalization from randomization to the end of intervention (July 2015), including a prespecified subgroup analysis in participants with baseline deseasonalized 25-hydroxyvitamin D (25(OH)D) levels < 50 nmol/L.

RESULTS

Over a median of 3.3 years follow-up, 74 participants had diverticular disease hospitalization. There was no difference in the risk of diverticular disease hospitalization between vitamin D supplementation (35/2558 = 1.4%) and placebo (39/2550 = 1.5%) groups (adjusted hazard ratio (HR) = 0.90; p = 0.65), although in participants with deseasonalized 25(OH)D < 50 nmol/L (n = 1272), the risk was significantly lower in the vitamin D group than placebo (HR = 0.08, p = 0.02).

DISCUSSION

Monthly 100,000 IU vitamin D₃ does not reduce the risk of diverticular disease hospitalization in the general population. Further RCTs are required to investigate the effect of vitamin D supplementation on the diverticular disease in participants with low 25(OH)D levels.

Acute Diverticulitis in Elderly Patients: Does Age Really Matter?

OBJECTIVE

Contrasting results are reported on the clinical course of acute diverticulitis (AD) in the geriatric population. The aim of this study is to compare the AD clinical outcomes between patients aged up to 80 years and those ≥80 years.

METHODS

A total of 1,139 patients were enrolled: 276 patients aged ≥80 years were compared with a group of 863 patients aged <80 years. The primary outcome was to compare the overall mortality. Secondary outcomes included major complications, in-hospital length of stay (LOS), and need for surgical procedures.

RESULTS

Patients ≥80 years with AD had different clinical presentation compared with younger patients: they had less fever (21.4 vs. 35.2%; p < 0.001) and abdominal pain (47.8 vs. 65.6%; p < 0.001) rates, but a higher digestive tract bleeding (31.5 vs. 12.3%; p < 0.001) and fatigue (12.7 vs. 7.1%; p = 0.004) rates. Median LOS, cumulative major complications, and mortality rates were higher for patients ≥80 years.Multivariate analysis identified age, absence of abdominal pain, and dyspnea at presentation as independent predictors of intrahospital death or major complications.

CONCLUSIONS

Patients with AD and age ≥80 years have a higher mortality rate and cumulative major complications as compared with younger patients. Invasive treatments were associated to a poor prognosis in this group.

Readmission for Treatment Failure After Nonoperative Management of Acute Diverticulitis: A Nationwide Readmissions Database Analysis

BACKGROUND

The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood.

OBJECTIVE

The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database.

DESIGN

This was a retrospective cohort study.

SETTINGS

A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included.

PATIENTS

Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included.

INTERVENTIONS

Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage.

MAIN OUTCOME MEASURES

Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured.

RESULTS

In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis.

LIMITATIONS

The study was limited by residual confounding from missing covariates and its observational study design.

CONCLUSIONS

The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).

Paradigm shift: the Copernican revolution in diverticular disease

Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.

Seasonal Variation in Acute Cholecystitis: An Analysis of Cholecystectomies Spanning Three Decades

BACKGROUND

Seasonal variation in the occurrence of medical illnesses reflects the effect of the environment, provides insight into pathogenesis, and can assist health care administrators in allocating resources accordingly. Seasonal variation has been reported in various infectious and surgical diseases, but has been rarely studied in acute cholecystitis. Our objective was to study seasonal variation in acute cholecystitis at our institution.

METHODS

We performed a retrospective analysis of patients who underwent cholecystectomy for acute cholecystitis from January 1988 to December 2018. Chi-square goodness-of-fit test was used to analyze seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively.

RESULTS

Overall, 3924 patients underwent cholecystectomy for acute cholecystitis during the study period. The frequency of cholecystectomies performed varied between months (minimum February n = 259, maximum July n = 372, P < 0.001) and seasons (minimum winter n = 789, maximum summer n = 1101 P < 0.001). Age and gender distribution across months and seasons was similar (P > 0.05).

CONCLUSIONS

Our findings confirm seasonal variation in occurrence of acute cholecystitis with summer season witnessing the most and the winter season encountering the least patients with acute cholecystitis. Validation of our findings through prospectively collected data at national level is the way forward.

Epidemiology, Pathophysiology, and Treatment of Diverticulitis

Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require urgent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.

Genome-wide association analyses identify 39 new susceptibility loci for diverticular disease

Diverticular disease is common and has a high morbidity. Treatments are limited owing to the poor understanding of its pathophysiology. Here, to elucidate its etiology, we performed a genome-wide association study of diverticular disease (27,444 cases; 382,284 controls) from the UK Biobank and tested for replication in the Michigan Genomics Initiative (2,572 cases; 28,649 controls). We identified 42 loci associated with diverticular disease; 39 of these loci are novel. Using data-driven expression-prioritized integration for complex traits (DEPICT), we show that genes in these associated regions are significantly enriched for expression in mesenchymal stem cells and multiple connective tissue cell types and are co-expressed with genes that have a role in vascular and mesenchymal biology. Genes in these associated loci have roles in immunity, extracellular matrix biology, cell adhesion, membrane transport and intestinal motility. Phenome-wide association analysis of the 42 variants shows a common etiology of diverticular disease with obesity and hernia. These analyses shed light on the genomic landscape of diverticular disease.

Diverticular Disease: An Update on Pathogenesis and Management

Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review.

Pathophysiology of diverticular disease

Inflammation of diverticula, or outpouchings of the colonic mucosa and submucosa through the muscularis layer, leads to diverticulitis. The development of diverticular disease, encompassing both diverticulosis and diverticulitis, is a result of genetic predisposition, lifestyle, and environmental factors, including the microbiome. Areas covered: Previous reports implicated genetic predisposition, environmental factors, and colonic dysmotility in diverticular disease. Recent studies have associated specific host immune responses and the microbiome as contributors to diverticulitis. To review pertinent literature describing pathophysiological factors associated with diverticulosis or diverticulitis, we searched the PubMed database (March 2018) for articles considering the role of colonic architecture, genetic predisposition, environment, colonic motility, immune response, and the microbiome. Expert commentary: In the recent years, research into the molecular underpinnings of diverticular disease has enhanced our understanding of diverticular disease pathogenesis. Although acute uncomplicated diverticulitis is treated with broad spectrum antibiotics, evaluation of the microbiome has been limited and requires further comprehensive studies. Evidence suggests that a deregulation of the host immune response is associated with both diverticulosis and diverticulitis. Further examining these pathways may reveal proteins that can be therapeutic targets or aid in identifying biological determinants of clinical or surgical decision making.

Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017

Diverticulosis is a common anatomical condition, which appears to be age-dependent. Individuals who develop chronic gastrointestinal symptoms or complications are referred to as having diverticular disease. Although the diagnosis of this condition can be relatively straightforward, randomized controlled trials are scarce and management often follows tradition rather than principles of evidence-based medicine. This report deals with the topics discussed during a symposium held during the United European Gastroenterology Week (Barcelona, October 2017). During the meeting, the role of dysbiosis in the pathogenesis of diverticular disease and its treatment were thoroughly discussed, by examining the efficacy and mechanisms of action of the currently used drugs. Recent studies have shown the presence of dysbiosis in patients with diverticular disease and suggest an imbalance in favor of bacteria with pro-inflammatory and pathogenetic potential. These microbiota changes correlate with mucosal immune activation, mirrored by a marked increase of macrophages in colonic mucosa, both in the diverticular region and at distant sites. The low-grade inflammation, driven by bacteria-induced immune activation, could be involved in the pathophysiology of symptoms. As a consequence, pharmacological approaches targeting enteric bacteria (with poorly absorbed antibiotics, like rifaximin, or probiotics) or intestinal inflammation (with 5-ASA derivatives or rifaximin) have shown capability of controlling symptoms and also preventing complications, albeit more research is needed to establish the optimal regimen (daily dose and duration) of therapy. Well-designed randomized-controlled trials (RCTs), including homogeneous populations of patients, are therefore needed. The future of management of many GI diseases, including symptomatic uncomplicated diverticular disease, will rely on the so-called 'microbiota-directed therapies'.

Variation in the Utilization of Minimally Invasive Surgical Operations

OBJECTIVE

The goal of this study was to examine regional variation in use of minimally invasive surgical (MIS) operations.

SUMMARY BACKGROUND DATA

Regional variation exists in performance of surgical operations. Variation in the use of MIS has not been studied.

METHODS

Five operations that are performed open or MIS were selected: cholecystectomy, appendectomy, colectomy, antireflux, and bariatric. A 3-state database from 2008 to 2011 was used; states were divided into hospital service areas (HSAs). For each operation, the percentage of MIS operations was calculated. HSAs with less than 50% or more than 150% of the MIS average were considered outliers. Population demographics, geography, and hospital and physician presence were compared between HSAs. Rates of performance by patient disease and the presence of MIS surgeons were also investigated.

RESULTS

MIS cholecystectomy was performed with low variation; MIS appendectomy, antireflux, and bariatric operations with medium variation; and MIS colectomy with high variation. With the exception of MIS colectomy, there were no differences in the patient demographics, geography, or disease types treated with an MIS approach between HSAs with low-, non-, or high utilization of MIS. There is no correlation between the number of MIS surgeons and the percentage of procedures performed MIS.

CONCLUSIONS

Variation in utilization of MIS exists and differs by operation. Patient demographics, patient disease, and the ability to access care are associated only with variation in use of MIS for colectomy. For all other operations studied, these factors do not explain variation in MIS use. Further investigation is warranted to identify and eliminate causes of variation.

Life-threatening motor vehicle crashes in bright sunlight

Bright sunlight may create visual illusions that lead to driver error, including fallible distance judgment from aerial perspective. We tested whether the risk of a life-threatening motor vehicle crash was increased when driving in bright sunlight.This longitudinal, case-only, paired-comparison analysis evaluated patients hospitalized because of a motor vehicle crash between January 1, 1995 and December 31, 2014. The relative risk of a crash associated with bright sunlight was estimated by evaluating the prevailing weather at the time and place of the crash compared with the weather at the same hour and location on control days a week earlier and a week later.The majority of patients (n = 6962) were injured during daylight hours and bright sunlight was the most common weather condition at the time and place of the crash. The risk of a life-threatening crash was 16% higher during bright sunlight than normal weather (95% confidence interval: 9-24, P < 0.001). The increased risk was accentuated in the early afternoon, disappeared at night, extended to patients with different characteristics, involved crashes with diverse features, not apparent with cloudy weather, and contributed to about 5000 additional patient-days in hospital. The increased risk extended to patients with high crash severity as indicated by ambulance involvement, surgical procedures, length of hospital stay, intensive care unit admission, and patient mortality. The increased risk was not easily attributed to differences in alcohol consumption, driving distances, or anomalies of adverse weather.Bright sunlight is associated with an increased risk of a life-threatening motor vehicle crash. An awareness of this risk might inform driver education, trauma staffing, and safety warnings to prevent a life-threatening motor vehicle crash.

LEVEL OF EVIDENCE

Epidemiologic Study, level III.

Risk factors of admission for acute colonic diverticulitis in a population-based cohort study: The North Trondelag Health Study, Norway

AIM

To assess risk factors of hospital admission for acute colonic diverticulitis.

METHODS

The study was conducted as part of the second wave of the population-based North Trondelag Health Study (HUNT2), performed in North Trondelag County, Norway, 1995 to 1997. The study consisted of 42570 participants (65.1% from HUNT2) who were followed up from 1998 to 2012. Of these, 22436 (52.7%) were females. The cases were defined as those 358 participants admitted with acute colonic diverticulitis during follow-up. The remaining participants were used as controls. Univariable and multivariable Cox regression analyses was used for each sex separately after multiple imputation to calculate HR.

RESULTS

Multivariable Cox regression analyses showed that increasing age increased the risk of admission for acute colonic diverticulitis: Comparing with ages < 50 years, females with age 50-70 years had HR = 3.42, P < 0.001 and age > 70 years, HR = 6.19, P < 0.001. In males the corresponding values were HR = 1.85, P = 0.004 and 2.56, P < 0.001. In patients with obesity (body mass index ≥ 30) the HR = 2.06, P < 0.001 in females and HR = 2.58, P < 0.001 in males. In females, present (HR = 2.11, P < 0.001) or previous (HR = 1.65, P = 0.007) cigarette smoking increased the risk of admission. In males, breathlessness (HR = 2.57, P < 0.001) and living in rural areas (HR = 1.74, P = 0.007) increased the risk. Level of education, physical activity, constipation and type of bread eaten showed no association with admission for acute colonic diverticulitis.

CONCLUSION

The risk of hospital admission for acute colonic diverticulitis increased with increasing age, in obese individuals, in ever cigarette smoking females and in males living in rural areas.

Seasonal Variation in Diverticulitis: Evidence From Both Hemispheres

BACKGROUND

Diverticulitis is a common and morbid disease with incompletely understood risk factors and pathophysiology. Geographic and, recently, seasonal trends in diverticulitis have been described in the United States.

OBJECTIVE

The purpose of this study was to investigate and compare seasonal trends in urgent hospital admission for diverticulitis in geographically distinct populations in the northern and southern hemispheres.

DESIGN

Inpatient, urgent admissions for diverticulitis were identified within the Dr Foster Intelligence Global Comparators Dataset, a global benchmarking collaborative.

SETTINGS

Admissions to participating hospitals in the United Kingdom, Australia, and the United States were identified between 2008 and 2013.

PATIENTS

A total of 18,672 urgent admissions for diverticulitis were identified among 5.5-million admissions.

MAIN OUTCOME MEASURES

Four separate hypothesis testing methods were used to identify seasonal trends in diverticulitis admissions among international patient populations.

RESULTS

Seasonal trends were present in all 3 countries. A summer peak was observed in both hemispheres using multiple statistical testing methods. Logistic regression analyses identified summer months as significantly associated with diverticulitis admission in all 3 countries.

LIMITATIONS

This study is limited by restriction to inpatient admissions, reliance on administrative data, and participation of select hospitals within the database.

CONCLUSIONS

These data suggest a shared seasonal risk factor among geographically distinct populations for diverticulitis.

The genetic epidemiology of diverticulosis and diverticular disease: Emerging evidence

Diverticular disease (DD) is one of the most prevalent gastrointestinal disorders. The pathogenesis of diverticulosis and DD is controversially discussed. Current studies call the traditional concept of a fibre-deficient diet causing the development of diverticula into question. Data from two recent twin studies have provided conclusive evidence for a strong genetic component to diverticulosis. Although genomewide association studies have provided new insights into the polygenic architecture of human diseases, genomic research in diverticulosis and DD has just been started. This is an astonishing fact given the high morbidity and mortality of the disease, as well as the substantial economic burden on health care systems. For this review, we provide an update of the molecular pathobiology and summarise recent evidence supporting the hypothesis that distinct, yet unidentified genetic variants contribute to the development of diverticulosis and DD.

Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking

Background

Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding.

Methods

A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed.

Results

Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities.

Conclusion

Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.