A Rare Case of Tongkat Ali-Induced Liver Injury: A Case Report

Drug-induced liver injury (DILI) presents a significant challenge in clinical practice, particularly with the rising popularity of herbal and dietary supplements (HDS) in the United States. Tongkat Ali (Eurycoma longifolia Jack), a Southeast Asian herb, has garnered attention for its purported health benefits, including enhancing testosterone levels. Here, we present a case of a 47-year-old male with acute liver injury following Tongkat Ali use, the first reported case of its kind in the literature. The patient exhibited worsening scleral icterus, elevated liver enzymes, and jaundice shortly after initiating Tongkat Ali supplementation, prompting hospitalization and subsequent clinical improvement upon discontinuation of the supplement. Differential diagnosis and exclusion of other etiologies were essential in establishing the causal link between Tongkat Ali consumption and liver damage, underscoring the difficulty in diagnosing HDS-induced liver injury. The rise in DILI cases parallels the expanding use of nutraceuticals, necessitating vigilance among healthcare professionals. While mechanisms of herbal-induced liver injury remain unclear, genetic predisposition and metabolic factors may be implicated. This case emphasizes the importance of heightened awareness among healthcare providers regarding the potential hepatotoxic effects of herbal supplements, particularly in individuals consuming multiple agents. Further research into the safety profile and mechanisms of Tongkat Ali-induced liver injury is warranted to inform clinical management and promote safer supplement use.

National Trends and Predictors of Opioid Administration in Patients Presenting With Abdominal Pain to the Emergency Department (2010-2018)

Given the current opioid crisis, in this study, we assess the national trend and factors associated with opioid administration for patients presenting to the emergency department with abdominal pain. This is a retrospective cross-sectional study conducted using the National Hospital Ambulatory Medical Care Survey from 2010 to 2018. Weighted multiple logistic regression was applied to assess the independent factors associated with opioid administration in the emergency department. Trends of opioid administration were evaluated using the linear trend analysis. There were an estimated total of 100,925,982 emergency department visits for abdominal pain. Overall, opioid was administered in 16.8% of visits. Age less than 25 years was associated with lower odds of receiving opioids. Patients living in the Northeast had the lower odds of receiving opioids (odds ratio [OR] = 0.82, p = .006) than patients living in the Midwest. Patients in the West had the highest odds of receiving opioids (OR = 1.16, p = .01). Non-Hispanic White patients had higher odds of opioid administration (OR = 1.29, p < .001). Trend analysis demonstrated a statistically significant reduction in opioid administration. From 2010 to 2018, opioid administration has approximately decreased in half. Living in the West and the non-Hispanic White racial group were the significant factors associated with a higher risk of opioid administration.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018

OBJECTIVE

The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs).

METHODS

Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval.

RESULTS

There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P =0.03). The overall trend showed a significant decrease in the mean WT ( P value<0.001). In 2009, AA waited 69 minutes longer than NHW ( P value<0.001), while in 2018, this gap was erased with no statistically significant difference ( P value=0.26).

CONCLUSION

Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

Analysis of the economic burden of docusate sodium at a United States tertiary care center

OBJECTIVES

The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate.

METHODS

The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1st, 2015 and December 31st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed.

RESULTS

Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium.

CONCLUSION

A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.

Effect of Patient Age on Timing of Inpatient Esophagogastroduodenoscopy and Outcomes for Non-variceal Upper GI Bleeds

Background Esophagogastroduodenoscopy (EGD) is typically performed within 24 hours of presentation for patients admitted to a hospital for patients presenting with a non-variceal upper gastrointestinal bleed (UGIB). To date, no studies have been performed to identify the impact of patient age on the timing of inpatient EGD and patient outcomes in non-variceal UGIB. Our aim was to assess the differences in the timing of EGD, blood transfusion requirements, development of hemorrhagic shock, development of acute renal failure, mortality, length of stay, and total hospital charges for patients aged 18-59 and those aged 60 and older. Methods Admissions for non-variceal UGIB were identified from the National (Nationwide) Inpatient Sample (NIS) database from 2016 and 2017. Patients who initially presented with hemorrhagic shock were excluded. Patients were divided into two age groups, those aged 18-59 and those aged 60 or older. We classified EGDs as early and delayed. Since the NIS database identifies days as midnight to midnight, we categorized early EGDs as those performed on day 0 and day 1. Delayed EGD were categorized as those performed on days 2 and 3. Multivariate logistic regression was performed on propensity-matched data to compare EGD timing, blood transfusion requirements, development of post-hospitalization hemorrhagic shock, development of acute renal failure, and mortality. The following patient and hospital variables were used in regression models: race, sex, insurance status, income quartile, mortality risk score, illness severity score, admission month, admission day, type of admission, region, bed size, and hospital teaching status. Finally, weighted two-sample T-tests were used to compare the length of stay and total hospitalization cost. Results A total of 12,449 weighted cases of inpatient non-variceal UGIB were included in this study. Patients aged 60 and older were more likely to die during the hospitalization (OR= 1.661, 95%CI: 1.108-2.490, p= 0.014), require blood transfusion (OR= 1.257, 95%CI: 1.131-1.396, p<0.001), and develop acute renal failure (OR= 1.672, 95%CI: 1.447-1.945, p<0.001). Patients aged 60 and older were also less likely to receive an early EGD (OR= 0.850, 95%CI: 0.752-0.961, p= 0.009). Total hospital costs (95%CI: -1397.77 - -4005.68, p<0.001) and length of stay (95%CI: -0.428 - -0.594, p<0.001) were both lower in patients aged 18-59 years. There was no difference in the development of post-hospitalization hemorrhagic shock between the two groups (OR= 0.984, 95%CI: 0.707-1.369, p= 0.923). Conclusions Patients aged 60 and older were less likely to have an early EGD and more likely to have worse outcomes. They had increased rates of inpatient mortality, blood transfusion requirements, development of acute renal failure, increased total hospital costs, and longer lengths of stay. There were no differences in the development of post-hospitalization hemorrhagic shock between the two groups.

Role of Gastroesophageal Reflux Disease in Morbidity and Mortality for Patients Admitted With Pulmonary Hypertension

INTRODUCTION

The association between gastroesophageal reflux disease (GERD) and morbidity and mortality in patients with pulmonary arterial hypertension (PH) is unknown. Our objective was to examine the difference in socio-demographics, comorbidities, and morbidity/mortality in PH patients also diagnosed with GERD, compared to PH patients without GERD.

METHODS

We performed a retrospective cross-sectional study of the large U.S. National Inpatient Sample identifying patients with a primary diagnosis of primary pulmonary hypertension (PH). All patients ≥ 18 years old that were admitted with a primary diagnosis of PH from January 1, 2001, to December 31, 2013, in the NIS database were included. We analyzed the socio-demographic and clinical comorbidities in PH patients with and without GERD. We investigated the predictors for complications of PH and differences in hospital utilization in this population.

RESULTS

PH patients with GERD were more likely to be older than 18-29 years. They were more likely to be Caucasian and female and less likely to be part of the top 75% median income compared to the bottom 25%. Patients with GERD were more likely insured with Medicare or private insurance but less likely to have Medicaid or be uninsured. Patients were more likely to be obese, and have asthma, chronic bronchitis, obstructive sleep apnea, hypertension, and hypothyroidism but were less likely to have diabetes or a history of alcohol use. PH Patients with GERD were less likely to have myocardial infarctions, cardiac arrests, pulmonary embolisms, pulmonary hemorrhages, cardiac interventions, acute respiratory failure, acute renal failure, or urinary tract infections compared to those without GERD. Patients with GERD were, however, more likely to have acute heart failure exacerbations and aspiration pneumonia. Patients with a diagnosis of GERD had lower mortality, length of stay (LOS), and hospital costs compared to their counterparts.

CONCLUSIONS

The concomitant presence of GERD is associated with fewer adverse outcomes in patients with PH. Though it is well understood that treatment of GERD is beneficial for lung disease, the exact role of GERD in PH has not been identified. This study helps characterize the important role appropriately treated GERD may play in preventing morbidity and mortality due to PH.

Trends and Complication Rates in Ulcerative Colitis Patients With and Without Helicobacter pylori Infections

Background Previous studies have shown an inverse relationship between ulcerative colitis (UC) and Helicobacter pylori infections (HPI). Though these two conditions have opposite geographic distributions, there may also be a physiological explanation for the decreased incidence of H. pylori infections in patients with UC. The purpose of this study is to analyze trends and complication rates of ulcerative colitis patients with and without HPI. Materials and methods The National Inpatient Sample (NIS) database was queried for patients with a primary diagnosis of UC, stratified by the presence of H. pylori infection. Patient demographics, length of stay, total hospital charges, and mortality were compared by H. pylori status. Additionally, complication rates were also compared between the two groups. Chi-squared and independent t-tests were used to compare outcomes and demographics, and multiple logistic regression was used to analyze primary and secondary outcomes. Results Patients with UC and HPI had a lower mortality rate (8.22 vs. 3.48, P<0.05, adjusted odds ratio [AOR] 0.33) and lower hospital charges ($65,652 vs. $47,557, p<0.05, AOR 1) with similar length of stay. Patients with UC and HPI also had lower rates of intestinal perforation (2.16% vs. 1.12%, p=0.05, AOR 0.408) and intrabdominal abscess formation (0.89% vs. 0.12%, AOR 0.165, p=0.072), though this difference was not significant. From 2001 to 2013, the incidence of UC has increased while the incidence of HPI has decreased. Conclusions The lower hospital charges and mortality rate as well as decreased rates of intestinal perforation and abscess formation suggest that there may be a physiologic role that HPI plays in modulating UC. Further studies into the interaction of these two conditions would be beneficial in clarifying their relationship and may help guide treatment of UC.

Neoadjuvant Treatment Versus Upfront Surgery in Resectable Pancreatic Cancer: A Cost-Effectiveness Analysis

PURPOSE

Pancreatic cancer (PC) has an overall 5-year survival rate of 10%. The use of neoadjuvant chemoradiation is debated in resectable disease. The purpose of this study is to evaluate the cost-effectiveness of neoadjuvant chemoradiation followed by pancreaticoduodenectomy (NACRT) versus upfront pancreaticoduodenectomy and adjuvant chemotherapy (USR) in resectable PC.

METHODS

A decision tree model was used to estimate the cost-effectiveness of NACRT versus USR. Values from the published literature populate the tree: costs from Medicare (FY2021) reimbursements, and morbidity and survival data for quality-adjusted life-years (QALYs). Patients with resectable pancreatic adenocarcinoma who qualified for resection were included. The ICER was the primary outcome. The model was validated using one-way and two-way deterministic, as well as probabilistic sensitivity analyses.

RESULTS

The base case was modeled using a 65-year-old male. NACRT yielded 1.61 QALYs at $45,483.52 USD. USR yielded 1.47 QALYs at a discount of $6,840.96 USD. The ICER was $48,130 USD, which favors NACRT. One-way sensitivity analyses upheld these results except when ≤ 21.0% of NACRT patients proceeded to surgery and when ≤ 85.4% of NACRT patients were resectable at surgery. Two-way sensitivity analyses also favored NACRT except in cases when the proportion of resected disease after NACRT decreased. NACRT was favored in 94.3% of 100,000 random-sampling simulations.

CONCLUSION

It is more cost-effective to administer NACRT before surgery for patients with resectable PC. On the basis of sensitivity analyses, USR with adjuvant therapy is only favored if rates of resection and eligibility for resection after NACRT decrease. NACRT should be considered in all patients unless there is an absolute contraindication.

Outcomes of gout in patients with cirrhosis: A national inpatient sample-based study

BACKGROUND

Hyperuricemia is a prerequisite for the development of gout. Elevated serum uric acid (UA) levels result from either overproduction or decreased excretion. A positive correlation between serum UA levels, cirrhosis-related complications and the incidence of nonalcoholic fatty liver disease has been established, but it is unknown whether hyperuricemia results in worsening cirrhosis outcomes. We hypothesize that patients with cirrhosis will have poorer gout outcomes.

AIM

To explore the link between cirrhosis and the incidence of gout-related complications.

METHODS

This was a cross-sectional study. The national inpatient sample was used to identify patients hospitalized with gout, stratified based on a history of cirrhosis, from 2001 to 2013 via the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcomes were mortality, gout complications and joint interventions. The χ² test and independent t-test were performed to assess categorical and continuous data, respectively. Multiple logistic regression was used to control for confounding variables.

RESULTS

Patients without cirrhosis were older (70.37 ± 13.53 years vs 66.21 ± 12.325 years; P < 0.05). Most patients were male (74.63% in the cirrhosis group vs 66.83%; adjusted P < 0.05). Patients with cirrhosis had greater rates of mortality (5.49% vs 2.03%; adjusted P < 0.05), gout flare (2.89% vs 2.77%; adjusted P < 0.05) and tophi (0.97% vs 0.75%; adjusted P = 0.677). Patients without cirrhosis had higher rates of arthrocentesis (2.45% vs 2.21%; adjusted P < 0.05) and joint injections (0.72% vs 0.52%; adjusted P < 0.05).

CONCLUSION

Gout complications were more common in cirrhosis. Those without cirrhosis had higher rates of interventions, possibly due to hesitancy with performing these interventions given the higher complication risk in cirrhosis.

Outcomes of Patients Hospitalized for Acute Diverticulitis With Comorbid Generalized Anxiety Disorder

Introduction Diverticular disease and anxiety disorders are common in the general population. Prior research on diverticular disease showed that these patients have an increased frequency of anxiety and depression. The objective of this study was to explore the impact of generalized anxiety disorder (GAD) on the outcomes of adult patients admitted with acute diverticulitis. Methods Using the National Inpatient Sample database from the year 2014 and International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes, acute diverticulitis patients were selected. The outcomes of diverticulitis patients with and without GAD were explored. The outcomes of interest included inpatient mortality, hypotension/shock, acute respiratory failure, acute hepatic failure, sepsis, intestinal abscess, intestinal obstruction, myocardial infarction, acute renal failure, and colectomy. A multivariate logistic regression analysis was performed to determine if GAD is an independent predictor for the outcomes. Results Among 77,520 diverticulitis patients in the study, 8,484 had comorbid GAD. GAD was identified as a risk factor for intestinal obstruction (adjusted odds ratio (aOR) 1.22, 95% CI: 1.05-1.43, p<0.05), and intestinal abscess (aOR 1.19, 95% CI: 1.10-1.29, p<0.05). GAD was found to be a protective factor for hypotension/shock (aOR 0.83, 95% CI: 0.76-0.91, p<0.05) and acute respiratory failure (aOR 0.76, 95% CI: 0.62-0.93, p<0.05). The aORs of sepsis, inpatient mortality, myocardial infarction, acute renal failure, and colectomy were not statistically significant. Conclusions Patients with acute diverticulitis who are also diagnosed with GAD are at increased risk for intestinal obstruction and intestinal abscess, which may be due to the influence GAD has on the gut microbiota as well as the impact of GAD pharmacotherapy on gut motility. There was also a decreased risk for acute respiratory failure and hypotension/shock appreciated in the GAD cohort which may be attributable to the elevated healthcare resource utilization seen generally in GAD patients, which may allow for presentation to the emergency department, hospitalization, and treatment earlier in the diverticulitis disease course.

Pre-existing Opioid Use Worsens Outcomes in Patients With Diverticulitis

Background and objective Diverticulitis occurs in 10-25% of patients with diverticulosis. Although opioids can decrease bowel motility, there is scarce data on the effect of chronic opioid use on the outcomes of diverticulitis. In this study, we aimed to explore the outcomes of diverticulitis in patients with pre-existing opioid use. Methods Data between 2008 and 2014 from the National Inpatient Sample (NIS) database was extracted using the International Classification of Diseases, 9th Revision (ICD-9) codes. Univariate and multivariate analyses were used to generate odds ratios (OR). Elixhauser Comorbidity Index (ECI) scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis. Inclusion criteria included patients with a primary diagnosis of diverticulitis. Exclusion criteria included patients less than 18 years of age, and a diagnosis of opioid use disorder in remission. Studied outcomes included inpatient mortality, complications (including perforation, bleeding, sepsis event, ileus, abscess, obstruction, and fistula), length of hospital stay, and total costs.  Results A total of 151,708 patients with diverticulitis and no active opioid use and 2,980 patients with diverticulitis and active opioid use were hospitalized in the United States from 2008 to 2014. Opioid users had a higher OR for bleeding, sepsis, obstruction, and fistula formation. Opioid users had a lower risk of developing abscesses. They had longer lengths of stay, higher total hospital charges, and higher Elixhauser readmission scores. Conclusion Hospitalized diverticulitis patients with comorbid opioid use are at an elevated risk of in-hospital mortality and sepsis. This could be attributed to complications from injection drug use predisposing opioid users to these risk factors. Outpatient providers caring for patients with diverticulosis should consider screening their patients for opioid use and try offering them medication-assisted treatment to reduce their risk of poor outcomes.

Quality of YouTube Videos Related to Colorectal Cancer Screening

Introduction YouTube, an unregulated video-sharing website, is the second most visited website on the internet. As more patients turn to the internet for information about colon cancer screening, it is important to understand what they are consuming online. Our goal was to evaluate YouTube videos about colon cancer screening to better understand the information patients are accessing. Methods We searched YouTube on October 28, 2020, using the following search terms sorted by relevance and view count: colonoscopy, colon cancer screening, virtual colonoscopy, colonoscopy alternatives, and cologuard. Videos longer than 10 minutes, not in English, and duplicates were excluded. Three evaluators graded each video using the DISCERN criteria. Numerical data were averaged into a composite score. Two-sided t-tests and one-way ANOVA tests were used to compare mean ratings between groups. Results Fifty videos were analyzed, with a total of 23,148,938 views, averaging 462,979 views per video. The average overall rating was 3.16/5. There was no difference between search methods, search terms, or presence of a physician. The average ratings for videos with gastroenterologists (3.08), other physicians (3.35), and non-physicians (3.09) were not significantly different. Videos without physicians had more views on average (1,148,677) compared to videos with gastroenterologists (157,846, p=0.013) or other physicians (35,730, p=0.013). Conclusion YouTube videos related to colon cancer screening were of good quality regardless of search terms, search methods, or presence of a physician. However, videos without physicians were viewed more frequently. Physicians should continue making videos that address deficits while increasing viewership.

Trends Regarding Racial Disparities Among Malnourished Patients With Percutaneous Endoscopic Gastrostomy (PEG) Tubes

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is performed in patients who cannot tolerate oral intake and who may require more than 30 days of nutritional support. These patients are at high risk for malnutrition, which itself can contribute to worsening clinical status. Racial disparities regarding access to sources of nutrition have been established. We aim to determine if such racial disparities regarding the diagnosis of malnutrition exist in this high-risk population.

METHODS

The National Inpatient Sample (NIS) was queried for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses coding for PEG tube placement with or without a diagnosis of malnutrition. Results were stratified by race. Rates of PEG tube complications were assessed. Categorical and continuous data were assessed via chi-squared and analysis of variance (ANOVA) tests respectively. Binary and multiple logistic regression was used to control for confounders.

RESULTS

Black patients had the highest rates of malnutrition diagnoses, mechanical complications from gastrostomy placement, and the lowest rates of palliative care discussions. Asian or Pacific Islander patients had the highest rates of aspiration pneumonia, gastrointestinal bleeding, the greatest mortality rates, and the longest hospital stays.

DISCUSSION

Racial minorities had worse outcomes while Caucasians had shorter hospital stays and lower complication rates. Such disparities can be multifactorial in etiology, with lack of nutritional access, poor doctor-patient communication, and differential rates of insurance coverage contributing to poorer outcomes among racial minorities. More change is required to promote equity when managing patients with end-of-life diseases necessitating methods of nutritional support.

Outcomes of Patients Who Developed Clostridioides difficile Infection During Hospitalization and Had a History of Comorbid Post-Traumatic Stress Disorder

Introduction: Clostridioides difficile (C. difficile), is a common cause of nosocomial diarrhea. Antibiotic use is a risk factor for developing C. difficile infection (CDI). Clinical presentations of CDI range from mild diarrhea to fulminant colitis. A history of anxiety increases the risk of developing irritable bowel syndrome following CDI. Post-traumatic stress disorder (PTSD) is a common form of anxiety and is associated with several medical comorbidities. This study explores the impact PTSD has on the outcomes of adult patients who develop CDI while hospitalized.

Methods: Hospitalized adults who had developed CDI were selected from the 2014 National Inpatient Sample database using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes. The outcomes of CDI patients with and without comorbid PTSD were explored. The outcomes assessed in this study were inpatient mortality, sepsis, hypotension/shock, acute renal failure, acute respiratory failure, megacolon, colonic perforation, and intestinal abscess. Independent t-tests and chi-squared tests were used to compare means and proportions, respectively. A multivariate logistic regression analysis was utilized to determine whether PTSD is an independent predictor of the outcomes.

Results: Among 72,383 hospitalized adults who developed CDI in the year 2014, 465 also had a diagnosis of PTSD. PTSD was found to be an independent risk factor for inpatient mortality (adjusted odds ratio {aOR} 2.93, 95% confidence interval (CI): 1.39-6.21, p = 0.005), and sepsis (aOR 1.61, 95% CI: 1.24-2.07, p = 0.001). However, PTSD was not a risk factor for hypotension/shock (aOR 1.26, 95% CI: 0.97-1.63, p = 0.080), acute renal failure (aOR 1.02, 95% CI: 0.81-1.28, p = 0.895), or acute respiratory failure (aOR 1.15, 95% CI: 0.83-1.58, p = 0.412) in patients with CDI. Due to small sample sizes of patients who developed megacolon, colonic perforation, and intestinal abscess, further analysis of these outcomes was not performed.

Conclusion: Inpatients who develop CDI with comorbid PTSD are at increased risk for sepsis and inpatient mortality. These findings may be due to the impact of PTSD’s dysregulation of the hypothalamic-pituitary axis leading to low cortisol production, increased serum cytokine concentrations, and/or increased intestinal inflammation. Awareness of these increased risks when triaging CDI patients with PTSD and possibly increased psychiatric interventions to treat PTSD may be necessary to help reduce the risk of sepsis and inpatient mortality in this subgroup of patients.

Outcomes of Inflammatory Bowel Disease in Hospitalized Patients With Generalized Anxiety Disorder

Background

The development of inflammatory bowel disease (IBD), which encompasses ulcerative colitis and Crohn’s disease, is multifactorial. Stress from anxiety is a risk factor for IBD. Generalized anxiety disorder (GAD) is twice as likely in IBD patients. This study explores the outcomes of patients hospitalized for IBD with comorbid GAD.

Methods

A retrospective analysis utilizing the 2014 USA National Inpatient Sample database was performed to assess the outcomes of hospitalized IBD patients with and without GAD. The outcomes analyzed were sepsis, acute hepatic failure, hypotension/shock, acute respiratory failure, acute deep vein thrombosis, acute renal failure, intestinal obstruction, myocardial infarction, ileus, inpatient mortality, colectomy, intestinal abscess, intestinal perforation, and megacolon. A multivariate logistic regression analysis was employed to explore whether GAD is a risk factor for these outcomes.

Results

Among 28,173 IBD hospitalized patients in the study, GAD was a comorbid diagnosis in 3,400 of those patients. IBD patients with coexisting GAD were found to be at increased risk for acute hepatic failure (adjusted odds ratio (aOR) 1.80, p = 0.006), sepsis (aOR 1.33, p < 0.001), acute respiratory failure (aOR 1.24, p = 0.018), inpatient mortality (aOR 1.87, p < 0.001), intestinal abscess (aOR 2.35, p = 0.013), and intestinal perforation (aOR 1.44, p = 0.019). The aORs for the remaining outcomes were not statistically significant.

Conclusions

In hospitalized IBD patients, GAD is a risk factor for sepsis, acute hepatic failure, acute respiratory failure, intestinal abscess, intestinal perforation, and inpatient mortality. IBD and GAD are becoming increasingly common, which will likely lead to a larger number of complications among inpatients with these comorbidities.

Malnutrition Imparts Worse Outcomes in Patients With Diverticulitis: A Nationwide Inpatient Sample Database Study

Introduction

Studies show that malnutrition can lead to worsening morbidity and mortality in patients. However, to our knowledge, no large database study has been conducted describing the effects of malnutrition in patients with diverticulitis. In this article, we aim to assess the impact of pre-existing malnutrition on outcomes of patients admitted for diverticulitis.

Methods

Data between 2008 and 2014 from the Nationwide Inpatient Sample database were extracted. Inclusion criteria for both groups included patients with a primary diagnosis of diverticulitis using the International Classification of Diseases, Ninth Revision codes. Exclusion criteria included all patients less than 18 years of age. The test group consisted of patients with a primary diagnosis of diverticulitis and a concurrent diagnosis of malnutrition. In-hospital mortality, length of stay, total cost, and complications, including various forms of sepsis, perforation, bleeding, and GI bleeding, were compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Multivariate analysis included age, sex, race, income quartile, and calculated Elixhauser scores. Elixhauser comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis.

Results

There were a total of 1,520,919 patients in the study, of which 427,679 (2.8%) had a pre-existing diagnosis of malnutrition. On univariate analysis, there was a significant increase in mortality in patients with malnutrition (OR: 10.2, p < 0.01). Additionally, patients with malnutrition appeared to have longer lengths of stay (mean: 12.9, p < 0.01) and greater cost of hospitalization (mean: 194436.82, p < 0.01). Patients with malnutrition had greater rates of sepsis events (OR: 12.0, p < 0.01), perforation (OR: 2.8, p < 0.01), and GI bleed (OR: 1.84, p < 0.01). On multivariate analysis, malnutrition appeared to significantly increase mortality (OR: 3.3, p < 0.01).

Discussion

Patients who present with diverticulitis with malnutrition appear to have significantly worse outcomes. We hypothesize that malnutrition leads to a shift in the gut microbiota, resulting in increased inflammation. As a result, these patients may have an increased risk of worse outcomes, such as sepsis and death. Addressing nutrition in patients with diverticulosis or those with a history of diverticulitis may improve outcomes.

This abstract was previously presented at the Digestive Disease Week Conference on May 22, 2022. Abstracts accepted at the conference were published in supplements of the journals Gastroenterology and GIE: Gastrointestinal Endoscopy.

Outcomes of Hospitalized Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) With and Without a History of Peripheral Artery Disease

Introduction

Peripheral artery disease (PAD) is a common illness associated with an increased risk of complications and mortality. Gastroenterologists considering endoscopic retrograde cholangiopancreatography (ERCP) in these patients should weigh the benefits and risks carefully. Our goal is to analyze the hospital burden and complication rates in patients with PAD undergoing ERCP.

Methods

Using data from the National Inpatient Sample (NIS), patients over the age of 18 with and without PAD undergoing ERCP were identified utilizing the International Classification of Diseases (ICD)-9 codes. Primary outcomes included inpatient mortality, length of stay, and hospital charges. Secondary outcomes included rates of bile duct perforation, post-ERCP bleeding, acute pancreatitis, and cholangitis. Supplemental data, including household income and primary payer, were also analyzed. Independent t-tests were used for continuous data, chi-square tests for categorical data, and confounding variables (diabetes, age, gender, race) were controlled via multiple logistic regression.

Results

Most of the PAD group were male, while those in the non-PAD group were female (adjusted p<0.05). Mortality was higher in the PAD group (11.2% versus 8%; adjusted p<0.05). Members of the PAD group had longer lengths of stay (11.6 days versus 11 days; adjusted p<0.05) and more costly hospital stays ($108,006.49 versus $94,399.09; p<0.05). Members of the PAD group had higher rates of post-ERCP bleeding (5.2% versus 3.7%; adjusted p<0.05) and lower rates of cholangitis (6% versus 4%; adjusted p<0.05) and acute pancreatitis (6.9% versus 3.4%; adjusted p<0.05). 

Conclusion

Patients with PAD had an increased hospital burden but had a decreased risk of post-ERCP complications, including cholangitis and pancreatitis. Physicians performing risk stratification for patients with PAD undergoing ERCP must consider these specific complications and ensure that patients undergoing this procedure are fully aware of the dangers and benefits of ERCP prior to consenting to the procedure.

D-Lactic Acidosis in Short Bowel Syndrome

D-lactic acidosis (D-LA) is closely associated with short bowel syndrome (SBS). Decreased intestinal absorption results in the delivery of carbohydrates to the colon, where the fermentation by colonic flora leads to D-LA. Systemic absorption of D-lactic acid results in anion-gap metabolic acidosis (AGMA), LA, and neurologic symptoms. In this report, we describe the case of a 43-year-old man with Crohn’s disease (CD) and bowel resection who presented with abdominal pain and slurred speech. He was found to have AGMA and persistent LA despite receiving intravenous fluids, which improved after carbohydrate restriction. A high index of suspicion for D-LA should be maintained when encountering patients who have undergone bowel resection and with unexplained AGMA.

Outcomes of Hospitalized Acute Alcoholic Hepatitis (AH) in Patients With Bipolar 1 Disorder (B1D)

Introduction: Alcoholic hepatitis (AH) is a common cause of hospital admissions and is associated with a high mortality rate. AH occurs frequently in patients with heavy alcohol use. Alcohol use disorder (AUD) commonly presents with comorbid psychiatric disorders such as bipolar disorder. Bipolar disorder patients are also known to be at an increased risk for chronic liver diseases. Bipolar 1 disorder (B1D) is often considered the most severe presentation among different types of bipolar disorder. This study assesses the clinical outcomes of patients admitted for AH with concomitant B1D.

Methods: Adult patients with AH were identified within the 2014 National Inpatient Sample (NIS) database. International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes were used to select for all of the diagnoses for this study. AH patients were subdivided into those with and without B1D. The outcomes of interest were sepsis, hepatic encephalopathy, acute respiratory failure, acute kidney injury, ischemic stroke, hepatic failure, coagulopathy, and inpatient mortality. A multivariate logistic regression analysis was performed to explore whether B1D is an independent predictor for the outcomes.

Results: Among 4,453 patients with AH identified, 166 patients also had B1D. AH patients with comorbid B1D were seen to be younger (42.9 years old vs. 46.2 years old, p < 0.05) and more commonly female (55.4% vs. 36.5%, p < 0.05). The B1D subgroup of AH patients were found to less likely develop acute hepatic failure (adjusted odds ratio (aOR) 0.13, 95% confidence interval (CI): 0.02-0.97, p < 0.05). The adjusted odds ratios for the remaining outcomes were not statistically significant.

Conclusions: Our study indicates that B1D may be an independent protective factor against acute hepatic failure in patients hospitalized with AH. This finding can be explained by frequent laboratory monitoring and psychiatric assessments performed by psychiatrists treating B1D patients, as well as the impact B1D has on cortisol release induced by hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis.

Do Socio-Demographics Play a Role in the Prevalence of Red Flags and Pursuant Colonoscopies in Patients With Irritable Bowel Syndrome?

Background

Irritable bowel syndrome (IBS) is a “brain-gut disorder” that lacks laboratory, radiologic, or physical exam findings. Colonoscopies are not routinely performed unless “red flag” symptoms, such as bleeding or abnormal weight loss, are present. Socio-demographics have been implicated as sources of potential disparities in appropriate care.

Aims

We hypothesize that the incidence of red flag symptoms and pursuant colonoscopies differ by socio-demographic status in patients with IBS.

Methods

Patients diagnosed with IBS were extracted from the National Inpatient Sample 2001-2013 using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Gastrointestinal bleed, blood in stool, weight loss, and anemia were pooled into red flag symptoms. Colonoscopies during the admission were identified using ICD-9 procedural codes. Chi-square analysis and binomial logistic regression were used to evaluate potential disparities with α<0.01.

Results

Patients with Medicaid or Medicare or those without insurance had higher odds of presenting with red flag symptoms compared to those with private insurance. Medicaid patients and uninsured patients had higher odds of undergoing colonoscopies. All patients that were not Caucasian had higher odds of presenting with red flags and subsequently undergoing colonoscopies. Older patients had higher odds of presenting with concerning red flag symptoms but lower odds of undergoing colonoscopies.

Conclusions

The incidence of red flag symptoms and performance of colonoscopies differed by socio-demographics in patients with IBS. Patients with non-private or those without insurance were more likely to have red flags and undergo a colonoscopy. Age and race also increased rates of red flag symptoms while having a mixed effect on pursuant colonoscopies. This may represent discrepancies in healthcare utilization in a vulnerable population.

Outcomes of Upper Gastrointestinal Bleeding in Hospitalized Patients With Generalized Anxiety Disorder

Background

Upper gastrointestinal bleeding (UGIB) has a high morbidity and mortality. Social deprivation is a risk factor for UGIB and is associated with anxiety. The primary pharmaceutical therapeutic agents for anxiety are selective serotonin reuptake inhibitors. Anxiety is prevalent in the general population and generalized anxiety disorder (GAD) is a common form of anxiety. This study explores the impact of GAD on the outcomes of adult patients hospitalized with UGIB.

Methods

Adult UGIB patients were selected utilizing the National (Nationwide) Inpatient Sample database from year 2014 and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The outcomes of UGIB patients with and without GAD were investigated. The outcomes explored include inpatient mortality, hypotension/shock, acute renal failure, acute hepatic failure, acute respiratory failure and acute myocardial infarction. A multivariate logistic regression analysis was used to determine if GAD is an independent predictor of the outcomes.

Results

Among 19,850 UGIB patients studied, 2357 had comorbid GAD. GAD was identified as a risk factor for acute renal failure (adjusted odds ratio [aOR] 1.37, 95% confidence interval [CI] 1.30-1.57, p < 0.05) and inpatient mortality (aOR 1.50, 95% CI 1.01-2.06, p < 0.05). The aORs of hypotension/shock, acute hepatic failure, acute respiratory failure and acute myocardial infarction were not statistically significant.

Conclusion

UGIB patients with comorbid GAD are at elevated risk of inpatient mortality and acute renal failure. These results may gain increasing relevance as GAD prevalence has increased since the start of the coronavirus disease 2019 (COVID-19) pandemic.

The Boseman Effect: A Missed Opportunity?

Introduction

Public figures, namely celebrities, are highly influential people whose actions and thoughts are often emulated, especially regarding healthcare. Understanding trends in public interest may provide an opportunity for further patient education. Given the changes of the COVID-19 pandemic along with the highly publicized death of actor Chadwick Boseman, who died from complications of colon cancer, we analyzed trends in colon cancer searches over a 15-month period.

Methods

Google Trends (Google, Mountain View, California) was used to access search histories in the United States from January 1, 2020, through April 30, 2021. Four search terms were analyzed: “colon cancer”, “colonoscopy”, “Cologuard”, and “virtual colonoscopy”. Google Trends reports data as relative search volume (RSV), a scaled number from 0-100 reflecting interest in a particular search term over a set time. Search terms were analyzed on the same RSV scale with one-way ANOVAs comparing search volumes during four eight-week blocks.

Results

Google Trends data was reported weekly. Search volume for colon cancer was higher (17.3, p=0.00) over the eight weeks following Boseman’s death, while search volume for colonoscopy returned to normal (21.5, p=0.95) when compared to pre-pandemic levels.

Conclusion

The peak in colon cancer searches in late August of 2020 corresponds to the death of Chadwick Boseman on 8/28/2020. Colonoscopy interest decreased during the COVID-19 pandemic before returning to previous levels around the time of Boseman’s death without experiencing the same spike in interest. This discrepancy represents a missed opportunity for patient education on this preventable disease.

Hospital Utilization, Treatment Modalities, and Mortality Using Different Biopsy Methods in Infants With Biliary Atresia

Objectives

To present a nationwide retrospective analysis of the sequelae and aftereffects of different liver biopsy methods in the care of pediatric patients with biliary atresia.

Methods

The National Inpatient Sample 2001-2013 database was queried for a primary diagnosis of biliary atresia and stratified based on biopsy type including percutaneous, surgical, laparoscopic, and transjugular. Patient demographics, length of stay, hospital costs, type of treatment, and mortality were compared by biopsy type. One-way analysis of variance test and multivariable logistic regression were used for analysis with α < 0.05.

Results

A total of 4,306 patients with biliary atresia were identified, of whom 2,293 underwent no biopsy, and 723 and 1,080 underwent a percutaneous or surgical biopsy, respectively. Significant differences in socio-demographics were demonstrated between the biopsy types. The length of stay and hospital charges were statistically significantly different between the biopsy types where patients without biopsies had the smallest length compared to percutaneous, surgical, and combination of biopsies. Overall, the Kasai procedure was done more frequently compared to direct liver transplantation, and compared to other biopsy types, undergoing a combination of biopsies had the highest odds of undergoing either procedure.

Conclusions

When comparing different biopsy methods, surgical biopsies of the liver outperformed percutaneous biopsies in hospital utilization and progression to definitive treatments with the Kasai procedure. Our research indicated that vulnerable populations such as minorities or the indigent may undergo inferior treatments or infrequently undergo definitive treatment. The need for definitive diagnostic guidelines is understated in patients with biliary atresia.

Association between aspartate aminotransferase-to-alanine aminotransferase ratio and insulin resistance among US adults

OBJECTIVE

To determine whether a low aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT ratio) is associated with insulin resistance among those without liver dysfunction.

METHODS

In this cross-sectional study of the National Health and Nutrition Examination Survey (NHANES) 2011-2016, we included 2747 (1434 male and 1313 nonpregnant female) adults ≥20 years without evidence of liver dysfunction (ALT<30 in male and <19 in female, negative viral serologies, no excess alcohol consumption, no elevated transferrin saturation, AST/ALT <2). Serum AST/ALT ratio was categorized into sex-specific quartiles (female: <1.12, 1.12-1.29, 1.29-1.47, ≥1.47 and male: <0.93, 0.93-1.09, 1.09-1.26, ≥1.26). The primary outcome was insulin resistance, as determined by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) index score ≥3. Covariate-adjusted odds ratios (ORs) were estimated. Study analysis completed from 13 March 2020 to 21 April 2021.

RESULTS

Among the 2747 individuals, 33% had insulin resistance. Those in the lowest quartile (Q1) of AST/ALT had 75% higher adjusted odds of insulin resistance compared to the highest quartile (Q4) [aOR (95% confidence interval (CI), 1.75 (1.20-2.57)]. This association was more pronounced in those with elevated BMI [Q1 vs. Q4; BMI ≥ 25: 2.29 (1.58-3.33), BMI < 25: 0.66 (0.26-1.69); NAFLD per Fatty Liver Index ≥ 60: 2.04 (1.21-3.44), No NAFLD: 1.68 (0.94-3.01)].

CONCLUSION

Lower AST/ALT ratio is associated with increased insulin resistance among those with healthy-range ALT, especially in those with BMI greater than or equal to 25 kg/m2.

The effects of diabetes mellitus on clinical outcomes of hospitalized patients with acute diverticulitis

OBJECTIVES

Acute diverticulitis is a common gastrointestinal illness due to diverticular inflammation and focal necrosis. Diabetes mellitus has been reported to influence the outcomes of patients with diverticular disease. Our study aimed to examine the inpatient outcomes and complications of patients with acute diverticulitis and coexisting diabetes mellitus.

METHODS

The Nationwide Inpatient Sample was used to identify adult patients in 2014 admitted for acute diverticulitis. Primary outcomes were mortality, length of stay (LOS), and total hospitalization charges. Secondary outcomes were complications of acute diverticulitis and interventions.

RESULTS

In total, 44 330 of patients with acute diverticulitis and diabetes mellitus were included in the analysis. Acute diverticulitis patients with diabetes mellitus had a higher rate of diverticular bleeding (P < 0.0001), but lower rates of abscess (P < 0.0001), obstruction (P < 0.0001) and colectomy (P < 0.0001) when compared to acute diverticulitis patients without diabetes mellitus. Complicated diabetes mellitus was associated with a longer LOS (P = 0.00003) and greater total hospitalization charges (P = 0.0021) compared to uncomplicated diabetes mellitus when coexisting with acute diverticulitis.

CONCLUSIONS

Acute diverticulitis with diabetes mellitus is associated with a higher rate of diverticular bleeding, lower rates of abscess, obstruction, and colectomy compared to acute diverticulitis without diabetes mellitus. When coexisting with acute diverticulitis, complicated diabetes mellitus is not associated with higher rates of mortality or diverticulitis-related complications compared to uncomplicated diabetes mellitus.

Inpatient Outcomes of Acute Pancreatitis Among Patients With Systemic Lupus Erythematosus: A Nationwide Analysis

Objectives

This study explores the characteristics and outcomes, including inpatient mortality, length of stay, and pancreatitis complications in patients hospitalized with acute pancreatitis (AP) with coexisting systemic lupus erythematosus (SLE).

Methods

Patients hospitalized with AP from the National Inpatient Sample from 2014 were selected. Patient characteristics and outcomes of AP were compared between the groups with and without SLE. Age, sex, race, Elixhauser Comorbidity Index (ECI), and etiologies of pancreatitis were measured. The outcomes of interest were inpatient mortality, length of stay, and complications, including respiratory failure, acute renal failure, myocardial infarction, hypotensive shock, sepsis, stroke, and ileus. Chi-squared tests and independent t-tests were used to compare proportions and means, respectively. Multivariate logistic regression analysis was performed to determine if SLE is an independent predictor for the outcomes, adjusting for age, sex, race, ECI, and etiologies of pancreatitis.

Results

Among 434,280 AP patients identified in the study, 3,015 patients had SLE. Among patients hospitalized with AP, those with SLE were younger, more likely to be female, more likely to be non-White, had higher ECI, and stayed longer in the hospital. Patients without SLE were more likely to have a history of cholelithiasis, alcohol abuse, and hypertriglyceridemia. AP patients presenting with SLE were at higher risk for respiratory failure, acute renal failure, hypotensive shock, stroke, and sepsis. Higher inpatient mortality was also associated with coexisting SLE.

Conclusions

Patients admitted for AP with SLE have worse outcomes compared to those without SLE. Understanding the potential effects of SLE on AP and optimizing patient care in this population accordingly may improve the quality of care and outcomes.

Celiac Artery Compression Syndrome: A Unique Presentation

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, celiac axis syndrome, and Dunbar Syndrome, is a rare disorder that results from compression of the celiac artery by the median arcuate ligament. The following is a case that depicts an interesting presentation of a patient diagnosed with this rare condition. A 44-year-old male with a history of mutism was brought in by his family for weight loss of 100 lbs with intermittent abdominal pain, weakness and lethargy over a period of five years. His family reported that he had poor nutritional intake, and could only eat a small amount before he seemed to be in pain, and eventually refused to eat. He had no other prior medical history except for mutism, no family history of malignancy, no history of trauma, surgeries, smoking or substance use, and did not take any medications. Physical exam was largely unremarkable. Mesenteric vascular duplex demonstrated severe grade stenosis of the celiac trunk with post-stenotic velocity of 520 cm/sec. Contrast enhanced computed tomography angiography revealed acute angle J-configuration of the takeoff of the celiac axis, with stenosis at its origin and focal post-stenotic dilatation, confirming the diagnosis of CACS.

CACS is an elusive diagnosis that should be considered in patients where other causes of abdominal pain and weight loss have been ruled out. The disease can present with the classic triad of post-prandial abdominal pain, weight loss, and an abdominal bruit. Imaging modalities including mesenteric vascular duplex, computed tomography abdominal angiography, magnetic resonance angiography and celiac artery angiography can help make the diagnosis. Treatment involves surgical decompression via division of the median arcuate ligament, with most patients experiencing significant and long-lasting relief from their symptoms.

Reflux esophagitis is associated with higher risks of acute stroke and transient ischemic attacks in patients hospitalized with atrial fibrillation: A nationwide inpatient sample analysis

Reflux esophagitis (RE) is a subset of gastroesophageal reflux disease (GERD) with endoscopic evidence of esophageal inflammation, which has been linked to an increased incidence of atrial fibrillation (AF). However, data on the effect of RE on patient outcomes is limited. We sought to examine the potential association of RE with outcomes of patients with AF in a nationwide study.The National Inpatient Sample (NIS) database was queried to identify hospitalized adult patients with AF and RE between 2010 and 2014. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges. AF related complications such as acute stroke, transient ischemic attack (TIA) and acute heart failure were assessed as secondary outcomes. Propensity score matching and multivariate regression analysis were used.Six lakh sixty seven thousands five hundred twenty patients were admitted for primary diagnosis of AF out of which 5396 had a secondary diagnosis of RE. In the AF with RE cohort, the average age was 73.6 years, 41.5% were male, and 79.9% were Caucasian. There was a greater prevalence of concomitant dyslipidemia, chronic liver disease and chronic pulmonary disease (P < .01) when compared to the AF without RE cohort. Patients with AF and RE also had higher incidence of acute strokes and TIAs (P < .05), longer LOS (P < .001), and higher hospital charges (P < .05) with no difference in acute heart failure (P = .08), hospital mortality (P = .12), or CHA2DS2-VASc score (P = .67).In hospitalized patients with AF, RE was associated with a higher rate of acute stroke and TIAs, longer LOS, and greater hospital charges.

Cost-effectiveness analysis of gastric cancer management using perioperative chemotherapy versus adjuvant chemoradiation therapy

e16079

Background: The most commonly used treatment options for gastric cancer include complete resection with adequate margins with either perioperative chemotherapy (PCT) or adjuvant chemoradiotherapy (CRT). While both treatment strategies have shown superiority over surgical resection alone, it is not clear which treatment strategy is more optimal. Methods: Our decision tree model was built to analyze the survival and costs associated with the two major management methods: perioperative chemotherapy and adjuvant chemoradiation therapy. Costs were obtained from Medicare reimbursement rates using a third-party payer perspective. Our model’s effectiveness was represented using quality-adjusted life years (QALYs). Our analysis tested the robustness of our conclusions by utilizing one-way, two-way, and probabilistic sensitivity analyses. Results: PCT was the preferred treatment strategy for diagnosed gastric cancer over CRT, with a cost of $54,326.10 and 4.08 QALYs. CRT was the costliest economic strategy with a cost of $77,987.52 and 4.28 QALYs and an ICER of 115,907.48. We set a threshold of $100,000 per QALYs gained which CRT surpassed making PCT the preferred treatment modality. Over 100,000 simulations, 51.4% of simulations favored PCT. CRT became favored when CRT non-curative procedure rates rose 3% higher than PCT non-curative procedure rates and when PCT complication rates rose 15% higher than CRT complication rates. Conclusions: In our simulated patients with diagnosed gastric cancer, the most cost-effective treatment strategy was PCT. We see cost-effectiveness alternating to favor CRT with changes in non-curative procedure rates and adjuvant therapy complication rates.[Table: see text]

Clinical outcomes and resource utilization analysis in patients with rheumatoid arthritis undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND AND AIM

The literature is lacking on associations of endoscopic retrograde cholangiopancreatography (ERCP) related outcomes in rheumatoid arthritis (RA) patients. The aim of this study is to evaluate the effects of RA on clinical outcomes and hospital resource utilization in patients undergoing ERCP.

METHODS

The National Inpatient Sample database was used to identify hospitalized patients who had underwent an ERCP study from 2012 to 2014 using International Classification of Diseases-Ninth Edition (ICD-9) codes. Primary outcomes were mortality, hospital charges, and length of stay. Secondary outcomes were ERCP-related complications. Chi-squared tests for categorical data and independent t-test for continuous data were utilized. Multivariate analysis was performed to assess the primary outcomes.

RESULTS

There was 83 890 ERCP procedures performed, of which 970 patients had RA. In patients with RA, 74.2% were female, and the average age was 65.7 years. RA primary outcomes of mortality rate and hospital cost were lower and statistically significant. There was no statistically significant difference in secondary outcomes except for lower cholecystectomy rates in RA patients.

CONCLUSION

With a high inflammatory state, it was hypothesized that RA would be associated with worse outcomes after ERCP. Yet, the primary outcomes of mortality and hospital cost were found to be lower than controls, with no difference in secondary outcomes. We posit that immunosuppressants used to treat RA provides a protective effect to overall complications with ERCP.

Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study

Background

The timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis without cholangitis is unclear. We accessed a national database to analyze the outcomes of urgent (<24 h) and early (24-72 h) ERCP in this cohort.

Methods

The cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the 2 cohorts.

Results

Overall, 105,433 admissions were evaluated. There was a significant rise in urgent ERCP performed over the study period. Older patients, males, patients with comorbidities, African American and Hispanic patient populations were less likely to receive urgent ERCP. High ERCP volume hospitals, teaching hospitals, and hospitals in the Midwest and West were more likely to perform urgent ERCP. There were no differences in mortality rates or complication rates between the 2 cohorts. However, there were significant differences in length of stay and healthcare cost analysis.

Conclusions

The increasing use of urgent ERCP did not result in a clinically significant benefit in terms of mortality, length of stay, or healthcare cost analysis. The use of urgent ERCP is also not uniform across various demographic and hospital cohorts. Urgent ERCP may be over-utilized, and it may be reasonable to perform ERCP in this patient population based on the physician’s suspicion about the severity of disease.

Quantitative analysis of translocation of tetraniliprole as a seed dresser

To ensure the plant health and safety of natural enemies and pollinators, seed dressing is preferred over foliar application. It is an eco-friendly approach of crop protection at low doses. Tetraniliprole as a seed dresser was applied on maize seeds at 3.6 and 7.2 g a.i./kg as a proposed dose and twice the proposed dose, respectively. The present field study assessed the quantitative translocation of tetraniliprole and its toxic metabolite chinazolinone in maize leaves, immature cob, stove, and grains using the QuEChERS method. The quantification of residue was carried on HPLC equipped with reverse phase ZORBAX Eclipse Plus C18 column (4.6 × 250; 5 μ) and diode array detector. Limit of detection and limit of quantification were worked out to be 0.01 and 0.05 mg kg^-1, respectively. All calibration curves showed a good linear relationship (r² > 0.99) within test ranges (0.01-0.5 μg ml^-1). Samples of maize leaves were collected on the 20th day after sowing considered "0" day. Initial residues of tetraniliprole in maize leaves were 0.921 and 1.377 mg kg^-1 at proposed and twice the proposed dose, respectively, and reached below limit of quantification (LOQ) 0.05 mg kg^-1 on the 7th and 15th day, respectively. Chinazolinone was not detected at both the doses. Estimation of tetraniliprole as well as its metabolite persistivity in immature cob at fruiting stage, mature grain, stove, and soil collected at harvest time revealed residues below LOQ.

The impact of bariatric surgery on in-patient clinical outcomes among patients with autoimmune hepatitis

Autoimmune hepatitis (AIH) is a form of liver inflammation in which immune cells target hepatocytes, inducing chronic inflammatory states. Bariatric surgery (BS) was shown to reduce inflammation in severely obese patients. We hypothesize that obese patients with AIH and BS have lower prevalence of liver-related complications and in-patient mortality compared to those without BS.The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with a diagnosis of AIH. Of those, hospitalizations with BS were selected as cases and those with morbid obesity as controls. Case-control 1:2 matching was done based on sex, age, race, and comorbidities. Primary outcomes were prevalence of liver-related complications and in-patient mortality. Independent risk factors of in-patient clinical outcomes were identified using multivariate regression analysis.From 137,834 hospitalizations with a diagnosis of AIH, 688 with BS were selected as cases, and 1295 were matched as controls. The prevalence of ascites was higher in the BS group compared to the control (odds ratio 1.73, 95% confidence interval (CI) 1.27-2.36). The prevalence of cirrhosis (36.8% vs 33.2%), portal hypertension (7.4% vs 10.0%), hepatic encephalopathy (10.6% vs 8.7%), and varices and variceal bleeding (3.9% vs 5.5%) was not statistically different from case controls, (P > .05).BS was an independent risk factor for ascites (adjusted odds ratio (aOR) 1.87; 95% CI 1.36-2.56) and hepatic encephalopathy (aOR 1.42; 95% CI 1.03-1.97) but was an independent protective factor against in-patient mortality (aOR 0.21, 95% CI 0.08-0.55) once adjusted for age, sex, race, and comorbidities.

Sarcoidosis is associated with lower risks of penetrating disease and colectomy in hospitalized patients with inflammatory bowel disease

Background and Aim

Inflammatory bowel disease (IBD) and sarcoidosis, primarily considered distinct entities, share commonalties in pathophysiology and clinical manifestations. This study aimed to examine the in‐hospital outcomes of patients with concurrent IBD and sarcoidosis.

Methods

The National Inpatient Sample was used to identify hospitalized adult patients with IBD and sarcoidosis from 2010 to 2014. Primary outcomes were in‐hospital mortality, rates of septic shock, acute renal failure, respiratory failure, length of stay, and total hospitalization charges. Secondary outcomes were IBD‐specific complications and surgery interventions.

Results

A total of 3995 patients with IBD and coexisting sarcoidosis (IBD/sarcoidosis), of which 2500 patients had Crohn's disease with coexisting sarcoidosis (Crohn's disease [CD]/sarcoidosis) and 1495 patients had ulcerative colitis with coexisting sarcoidosis (ulcerative colitis [UC]/sarcoidosis), were included. Patients with IBD/sarcoidosis had a lower risk of penetrating disease (adjusted odds ratio [aOR] 0.3, 95% confidence interval [CI] 0.16–0.55, P < 0.0001) and colectomy (aOR 0.48, 95% CI 0.27–0.84, P < 0.05). Subgroup analysis demonstrated lower rates of colectomy when comparing CD/sarcoidosis (P < 0.05) and UC/sarcoidosis (P = 0.0003) versus CD or UC alone. There was no difference in mortality.

Conclusion

IBD/sarcoidosis is associated with lower risks of penetrating disease and colectomy when compared to patients with IBD alone.

Severe Gastrointestinal Mucositis Following Concurrent Palbociclib and Palliative Radiation Therapy

BACKGROUND/AIM

Palbociclib is an FDA-approved cyclin-dependent kinase inhibitor for the treatment of advanced breast cancer. Limited information is available regarding the toxicity of palbociclib and concurrent radiation therapy.

CASE REPORT

Herein, we report a case of esophageal toxicity in a patient treated with palbociclib and radiation therapy. A 63-year-old woman was treated with palbociclib followed by palliative radiation therapy. The patient presented three days after completing radiation therapy with severe odynophagia, and dysphagia and was found to have grade 2-3 esophageal ulcers. Palbociclib and radiation therapy was held on admission, and a resolution of her symptoms and improvement in her oral intake was noted at which time she was restarted on palbociclib with no further radiation treatment.

CONCLUSION

Caution is advised when patients are undergoing concurrent palbociclib and even low-dose palliative radiation treatment. In these patients, providers should maintain a high index of suspicion for toxicities such as dermatitis or mucositis.

Gut-organ axis: a microbial outreach and networking

Human gut microbiota (GM) includes a complex and dynamic population of microorganisms that are crucial for well-being and survival of the organism. It has been reported as diverse and relatively stable with shared core microbiota, including Bacteroidetes and Firmicutes as the major dominants. They are the key regulators of body homeostasis, involving both intestinal and extra-intestinal effects by influencing many physiological functions such as metabolism, maintenance of barrier homeostasis, inflammation and hematopoiesis. Any alteration in GM community structures not only trigger gut disorders but also influence other organs and cause associated diseases. In recent past, the GM has been defined as a 'vital organ' with its involvement with other organs; thus, establishing a link or a bi- or multidirectional communication axis between the organs via neural, endocrine, immune, humoral and metabolic pathways. Alterations in GM have been linked to several diseases known to humans; although the exact interaction mechanism between the gut and the organs is yet to be defined. In this review, the bidirectional relationship between the gut and the vital human organs was envisaged and discussed under several headings. Furthermore, several disease symptoms were also revisited to redefine the communication network between the gut microbes and the associated organs.

A practical criterion for focusing of unstained cell samples using a digital holographic microscope

Digital holographic microscopy (DHM) is an important technique that may be used for quantitative phase imaging of unstained biological cell samples. Since the DHM technology is not commonly used in clinics or bioscience research labs, at present there is no well-accepted focusing criterion for unstained samples that users can follow while recording image plane digital holograms of cells. The usual sharpness metrics that are useful for auto-focusing of stained cells do not work well for unstained cells as there is no amplitude contrast. In this work, we report a practical method for estimating the best focus plane for unstained cells in the digital hologram domain. The method is based on an interesting observation that for the best focus plane the fringe pattern associated with individual unstained cells predominantly shows phase modulation effect in the form of bending of fringes and minimal amplitude modulation. This criterion when applied to unstained red blood cells shows that the central dip in the doughnut-like phase profile of cells is maximal in this plane. The proposed methodology is helpful for standardizing the usage of DHM technology across different users and application development efforts. LAY DESCRIPTION: Digital holographic microscopy (DHM) is slowly but steadily becoming an important microscopy modality and gaining acceptability for basic bio-science research as well as clinical usage. One of the important features of DHM is that it allows users to perform quantitative imaging of unstained transparent cells. Instead of using dyes or fluorescent labelling, DHM systems use quantitative phase as a contrast mechanism which depends on the natural refractive index variation within the cell samples. Since minimal wet lab processing is required in order to image cell samples with a DHM, cells can be imaged in their natural state. While DHM is gaining popularity among users, the imaging protocols across the labs or users need to be standardized in order to make sure that the same quantitative phase parameters are used for tasks such as quantitative phased based cell classification. One of the important operational tasks for any microscopy work is to focus the sample under study. While focusing comes naturally to users of brightfield microscopes based on image contrast, the focusing is not straightforward when samples are unstained so that they do not offer any amplitude contrast. When performing quantitative phase imaging, defocus can actually change the phase profile of the cell due to near-zone (Fresnel) diffraction effects. So unless a standardized focusing methodology is used, it will be difficult for multiple DHM users (potentially at different sites) to agree on quantitative results out of their phase images. DHM literature has prior works which perform numerical focusing of recovered complex wave-field in the hologram plane to find the best focus plane. However such methods are not user friendly and do not allow user the same focusing experience as in a brightfield microscope. The numerical focusing is therefore a reasonably good method for an optics researcher but not necessarily so for a microscopy technician looking at cell samples with a DHM system in a clinical setting. The present work provides a simple focusing criterion for unstained samples that works directly in the hologram domain. The technique is based on an interesting observation that the when an unstained cell sample is in the best-focus plane, its corresponding hologram (or fringe pattern) predominantly shows phase modulation manifested by bending of fringes at the location of the cell. This criterion can be converted into a simple numerical method as we have used to find the best-focus plane using a stack of through focus holograms. We believe that the technique can be used manually by visually observing the holograms or can be converted to an auto-focus algorithm for a motorized DHM system.

Ferrous Sulfate-Induced Esophageal Injury Leading to Esophagitis Dissecans Superficialis

Medication-induced esophagitis is a well-known but relatively rare clinical diagnosis, most common in patients with preexisting esophageal dysmotility, obstruction, or altered anatomy. Esophagitis dissecans superficialis (EDS) is a rare endoscopic finding characterized by sloughing of large fragments of the esophageal mucosal lining. The causes of EDS include prior trauma, heavy smoking history, ingestion of alcoholic and hot beverages, and immunosuppression. We present a unique case of EDS secondary to ferrous sulfate-induced pill esophagitis. The patient was a 94-year-old male who presented with dysphagia to solids, odynophagia, and weight loss. Esophagogastroduodenoscopy (EGD) revealed EDS. Biopsies demonstrated vacuolar degeneration at the midlevel of the epithelium with overlying hyperkeratosis and parakeratosis, with noted black/brown pigment present at the level of the split in the epithelium. The patient was started on a liquid diet with no oral administration of pills. EGD was repeated and showed a significant improvement in esophageal mucosa and resolution of strictures. Although medication-induced esophagitis is not classically associated with EDS, specific circumstances that are associated with pill esophagitis may lead to progression to EDS. In the case of our patient, prolonged contact of ferrous sulfate to the esophageal mucosa is thought be a result of an enlarged left atrium and pulmonary arteries secondary to longstanding coronary artery disease and an enlarged left bronchus secondary to chronic obstructive pulmonary disease and right pneumonectomy. These anatomical changes likely led to an extended duration of contact and are believed to have led to erosion of the superficial esophageal mucosa, eventually progressing to EDS.

Endoscopic Retrograde Cholangiopancreatography Leading to Pharyngeal Perforation

Endoscopic retrograde cholangiopancreatography (ERCP) had become the favored method to access the pancreaticobiliary system because it is a safer and less invasive method compared to surgery. However, as with any procedure, ERCP comes with its own risks and potential complications. We present a unique case of a patient who underwent ERCP and developed necrotizing infection of the neck and a submandibular abscess. The patient is a 66-year-old female who presented to an outside hospital with complaint of right upper quadrant abdominal pain, workup of which revealed choledocholithiasis. ERCP was attempted; however, cannulation was unsuccessful. The patient was discharged home after the procedure, but within 48 h she presented to our institution complaining of left-sided neck pain, dysphagia, and drooling. CT of the neck revealed extensive gas and fluid collections at the left submandibular space. The patient was taken to the operating room for drainage of the left neck abscess. Drainage and irrigation of the abscess yielded Streptococcus mitis and Hemophilus parainfluenza. The rest of patient's hospital course was uncomplicated, and she was discharged with appropriate follow-up. In the case of our patient, ERCP was complicated by a perforation of the hypopharynx. Pharyngeal perforation can be subclassified into supraglottic and infraglottic. The most frequent cause of perforations is due to increased pressure in an intrinsically weak anatomical region of the pharynx. Such perforations are commonly due to the advancement of the endotracheal tube or transthoracic echo probe, but can also be due to advancement of an endoscope.

Effect of hospital teaching status on endoscopic retrograde cholangiopancreatography mortality and complications in the USA

BACKGROUND

Our aim was to assess the differences in outcomes of cholecystitis, pancreatitis, gastrointestinal (GI) bleed, GI perforation, and mortality in teaching versus nonteaching hospitals nationwide among therapeutic and diagnostic ERCPs. We hypothesized that complication rates would be higher in teaching hospitals given greater patient complexity.

METHODS

Inpatient diagnostic and therapeutic ERCPs were identified from the National Inpatient Sample (NIS) from 2008 to 2012. The presence of ACGME-approved residency programs is required to qualify as a teaching hospital. Nonteaching urban and rural hospitals were grouped together. We identified hospital stays complicated by pancreatitis, cholecystitis, GI hemorrhage, perforation, and mortality. Logistic regression propensity-matched analysis was performed in SPSS to compare differences in complication rates between teaching and nonteaching hospitals.

RESULTS

A total of 1,466,356 weighted cases of inpatient ERCPs were included in this study: of those, 367 and188 were diagnostic, 1,099,168 were therapeutic, 766,230 were at teaching hospitals, and 700,126 were at nonteaching hospitals. Mortality rates were higher in teaching hospitals when compared to nonteaching hospitals for diagnostic (OR 1.266, p < 0.001) and therapeutic ERCPs (OR 1.157, p = 0.001). There was no significant difference in rates of post-ERCP cholecystitis, pancreatitis, or perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to nonteaching hospitals (OR 1.181, p = 0.003). Likewise, length of stay was increased in teaching hospitals (7.9 vs 6.9 days, p < 0.001, for diagnostic and 6.5 vs 5.8 days, p < 0.001, for therapeutic ERCPs).

CONCLUSIONS

In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates of GI hemorrhage in diagnostic ERCPs, which may be due to a higher comorbidity index in those patients admitted to teaching hospitals.

The weekend effect does not influence management of inflammatory bowel disease

Background

The weekend effect describes worsened outcomes due to perceived inefficiency occurring over the weekend. This effect has not been studied in inflammatory bowel disease (IBD) despite increasing prevalence in the community. Therefore, our aim is to assess differences in the outcomes of weekend versus weekday management of IBD exacerbations.

Methods

The National Inpatient Sample database comprises approximately 20% of admissions to nonfederal hospitals in the United States. Complications requiring hospitalization (“flares”) were the criteria upon which patient selection was based. A total of 193, 848 flares were identified from 2008 to 2014 using the International Classification of Diseases 9th edition codes. Differences in time to first procedure, length of stay (LOS), and cost were evaluated for patients with flares between weekend and weekday admissions.

Results

The time to first procedure was 3.33 days on weekends versus 3.19 days on weekdays (P < 0.001). The mean LOS was shorter when admissions occurred on weekends versus weekdays (8.01 days vs 8.22 days, P < 0.001). Finally, the cost of hospitalization was higher for weekday admissions versus weekend admissions ($18 072 vs $17 495, P < 0.001).

Conclusion

Our results showed a similar LOS and cost associated with the management of exacerbations on the weekend compared to weekdays. While many high‐risk conditions exhibit increased mortality and prolonged hospital course over the weekend, this phenomenon does not appear to affect IBD. These findings indicate efficient patient care on the weekend and can be utilized for logistical purposes such as resource allocation and procedure scheduling in the endoscopy suite.

Trends in Post-Therapeutic Endoscopic Retrograde Cholangiopancreatography Gastrointestinal Hemorrhage, Perforation and Mortality from 2000 to 2012: A Nationwide Study

BACKGROUND/AIMS

Recent trends in complications following inpatient therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) remain poorly defined. We studied trends of gastrointestinal (GI) hemorrhage, perforation, and mortality following inpatient therapeutic ERCPs from 2000 to 2012 with the hypothesis that ERCPs would have down trending complication rates.

METHODS

First, we isolated therapeutic ERCPs in patients 18 years or older using the International Classification of Diseases, Ninth Edition in the 2000 to 2012 National Inpatient Sample databases. Procedures complicated by hemorrhage, perforation, and mortality were identified. Multivariate logistic regressions were used to calculate trends in complication rates and secondary variables, including hospital and patient demographics. Time series regressions were then built for each complication to assess for trends from 2000 to 2012.

RESULTS

The mortality rate decreased from 1.77 to 1.24%, a trend that was confirmed by time series regression. Perforation rates increased from 0.07 to 0.10% for therapeutic ERCPs. However, time series regression did not show a significant trend. GI hemorrhage rates increased from 1.36 to 1.57% and this uptrend was confirmed by our time series regression.

CONCLUSION

Therapeutic ERCPs have become safer, as demonstrated by a down trending mortality rate. Over the same time, GI hemorrhage rates trended upwards, while no change was noted in perforation rates.