Effect of constipation on outcomes in mechanically ventilated patients

Impact of Constipation on Health Outcomes in Medically Hospitalized Patients: A Prospective Study on Laxative Use and Health Care Outcomes

Background and Objectives: Constipation affects health-related quality of life and increases hospital visits. We conducted this prospective cohort study to assess laxative use, health outcomes of constipation in medically hospitalized patients, and related health outcomes. Materials and Methods: A prospective single-center study included all adult patients admitted under the General Internal Medicine Unit from 1 February 2022, to 31 August 2022. Constipation was defined using the Constipation Assessment Scale (CAS). Patients were assessed for 28 days during their hospital stay and up to 90 days post-discharge. Result: Among the included patients, 62.45% experienced constipation, which was associated with poor health outcomes including delirium (p = 0.048), intensive care admission (p < 0.01), cardiopulmonary arrest (p < 0.01), inpatient mortality (p < 0.01), longer hospital stay (p < 0.01), 90-day mortality (p < 0.01), and 90-day hospital readmission (p < 0.01). Laxative treatment was administered to only 33.93% of patients with constipation and was more commonly used among older patients (p < 0.01), those with high CAS scores (p < 0.01), longer hospital stays (p < 0.01), and critically ill patients (intensive care admission) (p = 0.01), as well as those who had cardiopulmonary arrest (p < 0.01) and high inpatient mortality (p < 0.01). Conclusions: This study identified several associations between constipation and poor health outcomes and highlighted the underutilization of laxatives in treating constipation. It is vital to interpret our results with caution. Therefore, we believe that a randomized controlled trial will help enhance our understanding of the interaction between constipation, laxative use, and poor health outcomes.

Comparison of the management of gastric variceal bleeding techniques

Background and Aim

Managing gastric variceal (GV) hemorrhage is more complicated than managing esophageal variceal (EV) bleeding, resulting in significantly higher morbidity and mortality. We aim to compare the outcomes of endoscopic variceal ligation (EVL), transhepatic intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO) in the management of GV bleeding.

Methods

We utilized the National Inpatient Sample (NIS) database from January 2016 to December 2019 to include adult patients with GV hemorrhage.

Results

Our study identified 7160 hospitalizations with a primary diagnosis of GV hemorrhage who underwent the interventions of interest. EVL was performed in 69.83%, TIPS in 8.72%, and BRTO in 4.88%. Patients with liver cirrhosis had a higher frequency of undergoing BRTO (68.6%), followed by TIPS (64.0%) and esophagogastroduodenoscopy (EGD) + TIPS (63.7%) (P < 0.001). Patients with cirrhosis secondary to alcoholism had a higher prevalence of TIPS (62.4%), followed by EGD + TIPS (69.4%) and BRTO (52.9%) (P < 0.001). Overall, the inpatient mortality was 6.5%. Overall inpatient mortality was highest in the TIPS cohort (8.8%), followed by BRTO (7.1%), EGD + TIPS (6.5%), EVL (6.2%), and EGD + BRTO (2.8%) (P < 0.001); However, the Kaplan-Meier graph showed endoscopy with BRTO had the most favorable 30-day survival, trailed by TIPS alone and BRTO alone.

Conclusion

EVL remains a prominent therapeutic strategy. Remarkably, the combination of endoscopy with BRTO shows promising 30-day survival outcomes. Considering these observations, although EVL holds its primacy, it is essential to further explore the potential benefits of combined therapies in larger studies to ascertain the best treatment strategies.

Development and validation of a clinical score for early diagnosis of constipation in critically ill children

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

Outcomes of endoscopic retrograde cholangiopancreatography-guided gallbladder drainage compared to percutaneous cholecystostomy in acute cholecystitis

Backgrounds/Aims

Endoscopic retrograde cholangiopancreatography-guided gallbladder drainage (ERGD) is an alternative to percutaneous cholecystostomy (PTC) for hospitalized acute cholecystitis (AC) patients.

Methods

We retrospectively analyzed propensity score matched (PSM) AC hospitalizations using the National Inpatient Sample database between 2016 and 2019 to compare the outcomes of ERGD and PTC.

Results

After PSM, there were 3,360 AC hospitalizations, with 48.8% undergoing PTC and 51.2% undergoing ERGD. There was no difference in median length of stay between the PTC and ERGD cohorts (p = 0.110). There was a higher median hospitalization cost in the ERGD cohort, $62,562 (interquartile range [IQR] $40,707-97,978) compared to PTC, $40,413 (IQR $25,244-65,608; p < 0.001). The 30-day inpatient mortality was significantly lower in hospitalizations with ERGD compared to PTC (adjusted hazard ratio 0.16, 95% confidence interval [CI]: 0.1-0.41; p < 0.001). There was no difference in association with blood transfusions, acute renal failure, ileus, small bowel obstruction, and open cholecystectomy conversion (p > 0.05) between hospitalizations with ERGD and PTC. There was lower association of acute hypoxic respiratory failure (adjusted ratio [AOR] 0.46, 95% CI: 0.29-0.72; p = 0.001), hypovolemia (AOR 0.66, 95% CI: 0.49-0.82; p = 0.009) and higher association of lower gastrointestinal bleed (AOR 1.94, 95% CI: 1.48-2.54; p < 0.001) with ERGD compared to PTC.

Conclusions

ERGD is a safer alternative to PTC in patients with AC. The risk complications are lower in ERGD compared to PTC but no difference exists based on mortality or conversion to open cholecystectomy.

Crohn's Disease with Fistula: 10 Year Trends and Mortality in the United States

BACKGROUND/AIMS

Crohn's disease (CD) results in significant morbidity, mortality, and healthcare burden. This study evaluated the temporal trends of CD hospitalizations with a fistula over the last decade to understand the outcomes of severe CD.

METHODS

National Inpatient Sample database from 2009 to 2019 was used to identify CD hospitalizations with a fistula. The outcomes of interest included temporal trend analysis of length of stay (LOS), mean inpatient cost (MIC), and mortality.

RESULTS

There was an increase in the total number of fistulizing CD hospitalizations from 5,386 in 2009 to 12,900 in 2019 (p<0.01). The mean age decreased from 44.9±0.6 to 41.8±0.4 years for the study period (p<0.01). Caucasians were the predominant ethnicity, followed by Africans, Hispanics, and others (p<0.001). The mean LOS for fistulizing CD hospitalizations decreased significantly from 11.57±0.09 days in 2009 to 7.20±0.05 days in 2019 (p<0.001). There was a significant decrease in inpatient mortality from 1.72% in 2009 to 0.73% in 2019 (p<0.01). The MIC did not have a significant trend. There was a decreasing trend toward partial/total colectomies, rectosigmoid, and small bowel surgeries from 2009 to 2019 (p<0.001).

CONCLUSIONS

There has been a rise in CD hospitalizations with fistulizing disease in the last decade. Despite this, the mortality and inpatient LOS have been decreasing significantly. In addition, the increase in CD hospitalizations with fistulizing disease has had no significant effect on hospital costs.