Search

GOALS We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis. BACKGROUND ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis. STUDY Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes. RESULTS A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P

Background Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system. Methods This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization. Results We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001). Conclusions For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.

Background There is a paucity of contemporary national estimates for Clostridium difficile infection (CDI) hospitalizations by age group, sex, and region in the US population. Also, there is lack of contemporary national statistics on CDI hospitalizations with comorbidities. Methods We analyzed the 2017 National Inpatient Sample (NIS) to determine the population-based rates of CDI hospitalizations, characteristics of hospitalizations with CDI, and the rates of comorbidities associated with CDI hospitalizations. Results There were 329,460 CDI-related hospitalizations in 2017 (almost 1% of all hospitalizations). The average age for patients admitted with CDI as a principal or secondary diagnosis was 64.7 years (almost 20 years older when compared with all other hospitalizations). Patients 85 years and older had the highest rate of CDI hospitalizations (716 per 100,000 hospitalizations), and patients less than 18 years of age had the lowest rate (12 per 100,000 hospitalizations). There was a progressive increase in the CDI hospitalization rates with each successive age group. The hospitalization rates were higher in females (114 per 100,000 hospitalizations) than males (88 per 100,000 hospitalizations). The CDI hospitalization rate was highest in the Northeast (109 per 100,000 hospitalizations) and lowest in the West (84 per 100,000 hospitalizations). Fluid and electrolyte disturbance (63.3%) and renal failure (33.4%) were the two most common comorbidities associated with CDI hospitalizations. When CDI is a secondary diagnosis, major loss of function, extreme likelihood of dying, septicemia, and septic shock were more common in comparison to CDI as a principal diagnosis. Conclusions CDI hospitalization rates were highest in the elderly over 85 years old and declined with successive decreases in age. Women had higher CDI hospitalization rates than men, and fluid and electrolyte disturbances and renal failure were the most common comorbid conditions. The presence of CDI as a comorbid condition at the time of hospitalization for other principal diagnoses or development of CDI during a hospitalization for other principal diagnoses significantly increases the risk of in-hospital morbidity and mortality.

BACKGROUND Gallstones and cholecystectomy have been proposed as risk factors for non-alcoholic fatty liver disease (NAFLD). The reason for this may be that both gallstones, as well as NAFLD share several risk factors with regards to their development. Currently, there is a lack of sufficient evidence showing an association between these clinical conditions. AIM To determine whether there is a meaningful association between gallstones and cholecystectomy with NAFLD. METHODS We queried the National Inpatient Sample database from the years 2016 and 2017 using International Classification of Diseases, 10th revision, Clinical Modification diagnosis codes to identify hospitalizations with a diagnosis of gallstone disease (GSD) (includes calculus of gallbladder without cholecystitis without obstruction and acquired absence of gallbladder) as well as NAFLD (includes simple fatty liver and non-alcoholic steatohepatitis). Odds ratios (ORs) measuring the association between GSD (includes gallstones and cholecystectomy) and NAFLD were calculated using logistic regression after adjusting for confounding variables. RESULTS Out of 14294784 hospitalizations in 2016-2017, 159259 were found to have NAFLD. The prevalence of NAFLD was 3.3% in patients with GSD and 1% in those without. NAFLD was prevalent in 64.3% of women with GSD as compared to 35.7% of men with GSD. After controlling for various confounders associated with NAFLD and GSD, multivariate-adjusted analysis showed that there was an association between NAFLD with gallstones [OR = 6.32; 95% confidence interval (CI): 6.15-6.48] as well as cholecystectomy (OR = 1.97; 95%CI: 1.93-2.01). The association between NAFLD and gallstones was stronger in men (OR = 6.67; 95%CI: 6.42-6.93) than women (OR = 6.05; 95%CI: 5.83-6.27). The association between NAFLD and cholecystectomy was stronger in women (OR = 2.01; 95%CI: 1.96-2.06) than men (OR = 1.85; 95%CI: 1.79-1.92). P value was less than 0.001 for all comparisons. CONCLUSION NAFLD is more prevalent in women with GSD than men. The association between NAFLD and cholecystectomy/gallstones indicates that they may be risk factors for NAFLD.

Peptic ulcer disease (PUD) is more prevalent in cirrhotic patients and it has been associated with poor outcomes. However, there are no population-based studies from the United States (U.S.) that have investigated this association. Our study aims to estimate the incidence trends, predictors, and outcomes PUD patients with underlying cirrhosis.We analyzed Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project (HCUP) data for years 2002-2014. Adult hospitalizations due to PUD were identified by previously validated ICD-9-CM codes as the primary diagnosis. Cirrhosis was also identified with presence of ICD-9-CM codes in secondary diagnosis fields. We analyzed trends and predictors of PUD in cirrhotic patients and utilized multivariate regression models to estimate the impact of cirrhosis on PUD outcomes.Between the years 2002-2014, there were 1,433,270 adult hospitalizations with a primary diagnosis of PUD, out of which 70,007 (4.88%) had cirrhosis as a concurrent diagnosis. There was a significant increase in the proportion of hospitalizations with a concurrent diagnosis of cirrhosis, from 3.9% in 2002 to 6.6% in 2014 (p 0.001). In an adjusted multivariable analysis, in-hospital mortality was significantly higher in hospitalizations of PUD with cirrhosis (odd ratio [OR] 1.78; 95% confidence interval [CI] 1.63-1.97; P 0.001), however, there was no difference in the discharge to facility (OR 1.00; 95%CI 0.94 - 1.07; P = 0.81). Moreover, length of stay (LOS) was also higher (6 days vs. 4 days, P 0.001) among PUD with cirrhosis. Increasing age and comorbidities were associated with higher odds of in-hospital mortality among PUD patients with cirrhosis.Our study shows that there is an increased hospital burden as well as poor outcomes in terms of higher in-hospital mortality among hospitalized PUD patients with cirrhosis. Further studies are warranted for better risk stratification and improvement of outcomes.

Acquired ectopic splenic tissue is called splenosis, which is common after the history of trauma or surgical exploration. We present a rare case of intrahepatic splenosis in 36-year-old male patient mimicking a liver neoplasm on imaging however presented with left flank pain for 5 months and had remote history of splenectomy after splenic rupture from trauma. We discuss various imaging modalities and the role of various magnetic resonance imaging sequences and nuclear medicine examination. We also discuss the differentiating features to be kept to make the correct diagnosis along with a brief review of literature. We mentioned signal intensities of splenic lesions and normal signal intensity of spleen in different magnetic resonance imaging sequences and with high suspicion how we can diagnose splenosis and avoid unnecessary biopsy and its result related stress. Keywords: Splenosis, Accessory spleen, Intrahepatic splenosis, Peritoneal splenosis, Pelvic Splenosis, Diffusion weighted imaging (DWI), Metastasis, Splenic trauma

Background: It is well-known that patients with chronic kidney disease and end-stage renal disease are at increased risk of pulmonary embolism than patients with normal kidney function. However, the data on trends, outcomes, and predictors of mortality in pulmonary embolism patients with chronic kidney disease and end-stage renal disease in the United States are limited. Methods: We queried the National Inpatient Sample database from 2010 to 2014. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with normal kidney function, chronic kidney disease, and end-stage renal disease. The frequency of pulmonary embolism, complications, in-hospital mortality, and length of stay were calculated for each cohort. Multivariable logistic regression models were constructed to determine the predictors of mortality. Results: In the study population (2010–2014), there were 766,176 pulmonary embolism hospitalizations with normal kidney function, 79,824 with chronic kidney disease, and 9147 with end-stage renal disease. Among the study cohorts, the mortality rate was 2.7% in normal kidney function, 4.5% in chronic kidney disease, and 6.8% in end-stage renal disease hospitalizations. Median length of stay was highest in the end-stage renal disease cohort and lowest in the normal kidney function cohort. After adjusting for confounders, pulmonary embolism patients with chronic kidney disease died 1.15 times more often than those with normal kidney function and pulmonary embolism patients with end-stage renal disease died 4.2 times more often than those with normal kidney function. Conclusion: The mortality rate and length of stay in pulmonary embolism patients with chronic kidney disease and end-stage renal disease were significantly higher than those in pulmonary embolism patients with normal kidney function. Also, pulmonary embolism patients with chronic kidney disease and end-stage renal disease were at higher risk of in-hospital mortality than those with normal kidney function. There was statistically significant higher risk of mortality in elderly and Black patients with pulmonary embolism and concurrent chronic kidney disease or end-stage renal disease.

We report a case of acute pancreatitis that developed after four days of remdesivir therapy in a patient being treated for COVID-19. Despite improvement in patient's respiratory status, abdominal pain worsened and clinical signs and symptoms progressed to a diagnosis of acute pancreatitis 4 days after initiation of remdesivir therapy. Withdrawal of remdesivir paired with medical management of acute pancreatitis led to the resolution of pancreatitis within three days. To our knowledge, this is the first case report depicting remdesivir as a possible cause of acute pancreatitis.

Uremic pericarditis occurs as a result of inflammation of the pericardium due to toxins and immune complexes in patients with renal disease. The initial clinical manifestations of pericarditis and acute coronary syndrome may be similar, and initial EKG findings may overlap. The management of this disease needs the combined efforts of internists, cardiologists, and nephrologists. Its incidence has been reduced since the introduction of renal replacement therapy. Dialysis continues to be the mainstay of treatment.

This report describes a rare case of multiple left coronary artery to pulmonary artery/left atrial fistulae causing a coronary steal phenomenon. A 58-year-old male with apical hypertrophic cardiomyopathy was seen in an outpatient office for exertional chest pain and dyspnea and subsequently had a positive exercise nuclear stress test. Coronary angiogram revealed 70-80% mid-left anterior descending artery stenosis with multiple proximal coronary artery to left atrial/pulmonary artery fistulae. Due to symptomatic coronary artery fistulae with coronary steal phenomenon, the patient underwent surgical correction of fistulae with bypass graft to left anterior descending artery. To our knowledge, this is the first case report on co-existing apical hypertrophic cardiomyopathy and coronary artery-left atrial/pulmonary artery fistulae. This article reviews current guidelines for management of coronary artery fistula.

Objectives Cardiac transplant patients are at increased risk of Coronary Allograft Vasculopathy which requires percutaneous coronary intervention (PCI). Background We aim to determine national epidemiology describing trends, mortality, and morbidity risks in patients with heart transplant undergoing PCI. Methods We used Nationwide Inpatient Sample (NIS) data from 2002 to 2014 to identify adult hospitalizations with PCI using ICD 9 codes. Acute myocardial infarction (AMI), cardiac transplant status and complications were identified using validated ICD-9-CM diagnosis codes. Endpoints were in-hospital mortality and peri-procedural complications. Propensity match analysis was performed to compare the end-points between DES and BMS. Results Total 8,613,900 patients underwent PCI, of which 1,531(0.002%) patients had prior heart transplant status. Among these 1,531 PCIs, 311(20%) were due to AMI including 125(8%) due to STEMI. 74% of PCIs were done in males and 78% of the PCIs were performed in the 60-79 age group. Out of 1,380 stents placed, 1,090 were DES (79%) and 290 (21%) were BMS. Mortality was higher in the BMS versus DES (8.34% vs. 3.45%, p = .012), CONCLUSION: We concluded that majority of the population who underwent PCI were older males. DES was used more than BMS. The use of BMS is associated with increased mortality, cardiac complications and Acute Kidney Injury requiring dialysis compared with DES which likely is representative of preferential use of DES in these patient population.

Hemophagocytic lymphohistocytosis (HLH) is a hyperinflammatory syndrome characterized by fever, hepatosplenomegaly, and pancytopenia. It may be associated with genetic mutations or viral/bacterial infections, most commonly Epstein-Barr virus (EBV) and cytomegalovirus. As for the novel coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), also known as COVID-19 (coronavirus disease-2019), the cytokine storm it triggers can theoretically lead to syndromes similar to HLH. In this article, we report a case of a 28-year-old female who presented with high-grade fevers, found to have both SARS-CoV-2 and EBV infections, and eventually began to show signs of early HLH. To our knowledge, this is the first case reported in literature that raises the possibility of SARS-CoV-2–related HLH development.

Background and study aims Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Multiple drugs and techniques have been studied for the prevention of PEP. Topical epinephrine has shown mixed results and is still not widely accepted as an alternative for prevention of PEP. We performed a systematic review and meta-analysis to evaluate the efficacy of topical epinephrine in preventing PEP. Methods A comprehensive literature review was conducted by searching Cochrane library database, Embase and PubMed up to August 2019, to identify all studies that evaluated use of topical epinephrine alone or in conjunction with other agents for prevention of PEP. Outcomes included prevention of PEP with use of topical epinephrine and evaluation of whether addiing epinephrine provides any additional benefit in preventing PEP. All analysis was conducted using Revman 5.3. Results Eight studies, including six randomized controlled trials and two observational studies with 4123 patients, were included in the meta-analysis. Overall, there was no difference in incidence of PEP in patients who underwent ERCP and were treated with epinephrine spray versus those who were not, RR = 0.63 (CI 0.32–1.24) with heterogeneity (I2 = 72 %). However, on a subgroup analysis, topical epinephrine significantly decreases the risk of PEP when compared to placebo alone (means no intervention was done including no rectal indomethacin)., RR = 0.32 (0.18–0.57). In another subgroup analysis, there was no statistically significant difference in using topical epinephrine along with rectal indomethacin in preventing PEP compared to rectal indomethacin alone RR = 0.87 (0.46–1.64). Conclusion Topical epinephrine does not provide any additional benefit in preventing PEP when used in conjunction with rectal indomethacin. In subgroup analysis, topical epinephrine appeared to decrease risk of PEP in the absence of rectal indomethacin, and could be considered when rectal indomethacin is unavailable or if there is a contraindication to its use.

Background The 30-day readmission rates are being used as a quality measure by Centers for Medicare and Medicaid Services (CMS) for specific medical and surgical conditions. Acute respiratory distress syndrome (ARDS) is one of the important causes of morbidity and mortality in the United States (US). The characteristics and predictors of 30-day readmission in ARDS patients in the US are not widely known, which we have depicted in our study. Objective The aim of this study is to identify 30-day readmission rates, characteristics, and predictors of ARDS patients using the largest publicly available nationwide database. Methods We used the National Readmission Database from the year 2013 to extract the patients with ARDS by primary discharge diagnosis with ICD9-CM codes. All-cause unplanned 30-day readmission rates were calculated for patients admitted between January and November 2013. The independent predictors for unplanned 30-day readmission were identified by survey logistic regression. Results After excluding elective readmission, the all-cause unplanned 30-day readmission rate for ARDS patients was 18%. Index admissions readmitted within 30-day had a significantly higher baseline burden of comorbidities with a Charlson Comorbidity Index (CCI) ≥1 as compared to those who were not readmitted within 30 days. In multivariate regression analysis, several predictors associated with 30-day readmission were self-pay/no charge/other (OR 1.19, 95%CI: 1.02-1.38; p = 0.02), higher-income class (OR 0.86, 95%CI:0.79-0.99; p = 0.03), private insurance (OR 0.81, 95%CI:0.67-0.94; p = 0.01), and teaching metropolitan hospital (OR 0.72, 95%CI:0.61-0.94; p = 0.01). Conclusion The unplanned 30-day readmission rates are higher in ARDS patients in the US. Several modifiable factors such as insurance, socioeconomic status, and hospital type are associated with 30-day readmission among ARDS patients.

Objective Our aim is to describe characteristics of liver transplant patients undergoing percutaneous coronary interventions (PCI) as well as in-hospital outcomes including the mortality and peri-procedural complications from the largest publicly available inpatient database in the United States from 2002 to 2014. Background Outcomes of PCI are well studied in patients with end-stage liver disease but not well studied in patients who receive liver transplant (LT). Methods Data derived from Nationwide Inpatient Sample (NIS) were analyzed for years 2002-2014. Adult Hospitalizations with PCI were identified using ICD-9-CM procedure codes. LT status and various complications were identified by using previously validated ICD-9-CM diagnosis codes. Endpoints were in-hospital mortality and peri-procedural complications. Propensity match analysis was performed to compare the endpoints between two groups. Results During the study period, 8,595,836 patients underwent PCI; 4,080 (0.04%) patients had prior LT status. 93% of patients were above age 59 years, 79% were males and 69% were nonwhites. Out of the total patients with LT status, 73% had hypertension, 57% had diabetes mellitus, and 47% had renal failure. Post-PCI complications were studied further in both liver and non-LT patients after 1:1 propensity match which showed the incidence of acute kidney injury (AKI) was higher in LT group (12.3 vs 10.7%, p = .024) but dialysis requiring AKI was similar. Conclusion Among the LT recipients undergoing PCI, majority were nonwhite males. Almost more than half of the recipients had diabetes mellitus and renal failure. Incidence of AKI was higher in LT group, but other peri-procedural complications were comparable.

Background Gastrointestinal bleeding (GIB) has been reported to be more common in patients with chronic renal failure and end-stage renal disease requiring hemodialysis with higher mortality than in the general population. Limited epidemiological data exist on the annual number of hospitalizations, demographic variation, cost of care, and outcomes for GIB in patients with acute kidney injury (AKI) requiring and not requiring hemodialysis (HD). The main objective of this study was to analyze the trends of GIB in patients with AKI requiring HD and those not requiring HD during hospitalization. Methods and Results We analyzed the National (Nationwide) Inpatient Sample (NIS) database for all subjects with a discharge diagnosis of AKI as the primary or secondary diagnosis during the period from 2001 to 2011. Subjects with a discharge diagnosis of hemodialysis and GIB were then identified from the pool and trends were analyzed. A significant rise in the annual number of hospitalizations with AKI was found with a greater proportion being discharged without HD. From 2001 to 2011, there were 19,393,811 hospitalizations with a discharge diagnosis of AKI of which 1,424,692 (7.3%) received HD (HD group), whereas 17,969,119 (92.7%) did not receive HD (non-HD group) (p < 0.0001). The male gender was more commonly affected by GIB than the female gender in both groups (p < 0.0001). The cost of care per hospitalization for GIB patients in the HD group increased over the study period with average found to be $61,463 (adjusted for inflation, p < 0.0001), whereas for GIB patients in the non-HD group, it showed a slight decrease in trend with the average found to be $28,419 (p < 0.0001). All-cause mortality was higher for GIB patients in the HD group (38.1%) than in the non-HD group (25.1%) (p < 0.0001). Conclusions GIB is more common and associated with higher all-cause inpatient mortality in patients receiving HD in comparison to non-HD patients.

Introduction Clostridium difficile infection (CDI) has been attracting attention lately as the most common hospital acquired infection. Patients with neutropenia because of malignancy seem to be at an increased risk for developing CDI. There is currently limited data that assesses the national burden and outcomes of CDI in Febrile Neutropenia (FN). Methods We analyzed the National Inpatient Sample (NIS) database for all subjects with discharge diagnosis of FN with or without CDI (ICD-9 codes 288.00, 288.03,780.60, and 008.45) as primary or secondary diagnosis during the period from 2008 to 2014. All analyses were performed with SAS, version 9.4 (SAS Institute). Results From 2008 to 2014 there were total 19422 discharges of FN patients with CDI. There was a rising incidence of CDI in patients with FN from 4.11% (in 2008) to 5.83% (in 2014). The In-hospital mortality showed a decreasing trend from 7.79% (in 2008) to 5.32% (in 2014), likely because of improvements in diagnostics and treatment. The overall mortality (6.37% vs. 4.61%), length of stay >5 days (76.45% vs. 50.98%), hospital charges >50,000 dollars (64.43% vs. 40.29%), colectomy and colostomy (0.35% vs. 0.15%), and discharge to skilled nursing facility (10.47% vs. 6.43%) was significantly more in FN patients with CDI versus without CDI over 7 years (2008 to 2014). Age above 65 years, Hispanic race, hematological malignancies, urban hospital settings, and sepsis were significant predictors of mortality in febrile neutropenia patients with CDI. Discussion Despite the significant decrease in mortality, the incidence of CDI is rising in hospitalized FN patients with underlying hematological malignancies. Risk factor modification, with the best possible empiric antibiotic regimen is imperative for reducing mortality and health care costs in this cohort.

Background Cardiotoxicity associated with anthracycline-based chemotherapies has limited their use in patients with preexisting cardiomyopathy or heart failure. Dexrazoxane protects against the cardiotoxic effects of anthracyclines, but in the USA and some European countries, its use had been restricted to adults with advanced breast cancer receiving a cumulative doxorubicin (an anthracycline) dose > 300 mg/m2. We evaluated the off-label use of dexrazoxane as a cardioprotectant in adult patients with preexisting cardiomyopathy, undergoing anthracycline chemotherapy. Methods Between July 2015 and June 2017, five consecutive patients, with preexisting, asymptomatic, systolic left ventricular (LV) dysfunction who required anthracycline-based chemotherapy, were concomitantly treated with off-label dexrazoxane, administered 30 min before each anthracycline dose, regardless of cancer type or stage. Demographic, cardiovascular, and cancer-related outcomes were compared to those of three consecutive patients with asymptomatic cardiomyopathy treated earlier at the same hospital without dexrazoxane. Results Mean age of the five dexrazoxane-treated patients and three patients treated without dexrazoxane was 70.6 and 72.6 years, respectively. All five dexrazoxane-treated patients successfully completed their planned chemotherapy (doxorubicin, 280 to 300 mg/m2). With dexrazoxane therapy, changes in LV systolic function were minimal with mean left ventricular ejection fraction (LVEF) decreasing from 39% at baseline to 34% after chemotherapy. None of the dexrazoxane-treated patients experienced symptomatic heart failure or elevated biomarkers (cardiac troponin I or brain natriuretic peptide). Of the three patients treated without dexrazoxane, two received doxorubicin (mean dose, 210 mg/m2), and one received daunorubicin (540 mg/m2). Anthracycline therapy resulted in a marked reduction in LVEF from 42.5% at baseline to 18%. All three developed symptomatic heart failure requiring hospitalization and intravenous diuretic therapy. Two of them died from cardiogenic shock and multi-organ failure. Conclusion The concomitant administration of dexrazoxane in patients with preexisting cardiomyopathy permitted successful delivery of anthracycline-based chemotherapy without cardiac decompensation. Larger prospective trials are warranted to examine the use of dexrazoxane as a cardioprotectant in patients with preexisting cardiomyopathy who require anthracyclines.

Background Recent evidence suggests that among patients receiving vancomycin, receipt of concomitant piperacillin-tazobactam increases the risk of nephrotoxicity. Well-controlled, adequately powered studies comparing rates of acute kidney injury (AKI) among patients receiving vancomycin + piperacillin-tazobactam (VPT) compared to similar patients receiving vancomycin + cefepime (VC) are lacking. In this study we compared the incidence of AKI among patients receiving combination therapy with VPT to a matched group receiving VC. Methods A retrospective, matched, cohort study was performed. Patients were eligible if they received combination therapy for ≥48 hours. Patients were excluded if their baseline serum creatinine was >1.2mg/dL or they were receiving renal replacement therapy. Patients receiving VC were matched to patients receiving VPT based on severity of illness, intensive care unit status, duration of combination therapy, vancomycin dose, and number of concomitant nephrotoxins. The primary outcome was the incidence of AKI. Multivariate modeling was performed using Cox proportional hazards. Results A total of 558 patients were included. AKI rates were significantly higher in the VPT group than the VC group (81/279 [29%] vs 31/279 [11%]). In multivariate analysis, therapy with VPT was an independent predictor for AKI (hazard ratio = 4.27; 95% confidence interval, 2.73-6.68). Among patients who developed AKI, the median onset was more rapid in the VPT group compared to the VC group (3 vs 5 days P = Conclusion The VPT combination was associated with both an increased AKI risk and a more rapid onset of AKI compared to the VC combination.

A 64-year old male presented to the hospital with a 1-week history of stools with bright red blood. Subsequent colonoscopy with a biopsy revealed a low-lying, moderately differentiated, rectal adenocarcinoma. A pelvic magnetic resonance imaging done afterwards showed a possible T3N1 rectal cancer with intact muscularis mucosa and a singular presacral lymph node enlargement. Furthermore, a suspicious peripheral prostatic enlargement and a possible left iliac crest sclerotic bone lesion were incidentally identified. 18F-FDG (fluorodeoxyglucose) PET (positron emission tomography) scan confirmed a primary FDG avid rectal tumor and a presacral lymph node; however, there was no prostate or iliac crest uptake. A serum prostate-specific antigen performed in the hospital returned with a value of 37 ng/mL, which prompted a prostate biopsy, eventually returning as positive for adenocarcinoma. Consequently, a 68Ga-PSMA PET scan to rule out possible metastatic prostate disease revealed increased PSMA expression in the prostate only. After consultation with the radiologist and nuclear medicine physician who concluded the iliac crest lesion is likely not cancerous, the final diagnosis of T3N1 rectal cancer with simultaneous high-grade prostate adenocarcinoma was declared. This case highlights the low sensitivity of 18F-FDG PET scans for prostate cancer, the need for routine serum prostate-specific antigen screening, and the progression of 68Ga-PSMA PET as a diagnostic tool for prostate cancer.

BACKGROUND: An estimated 22 million adults use marijuana in the USA. The role of marijuana in the progression of hepatic fibrosis remains unclear. AIMS: We carried out a systematic review and meta-analysis to evaluate the impact of marijuana on prevalence and progression of hepatic fibrosis in chronic liver disease. PATIENTS AND METHODS: We searched several databases from inception through 10 November 2017 to identify studies evaluating the role of marijuana in chronic liver disease. Our main outcome of interest was prevalence/progression of hepatic fibrosis. Adjusted odds ratios (ORs) and hazards ratios (HRs) were pooled and analyzed using random-effects model. RESULTS: Nine studies with 5 976 026 patients were included in this meta-analysis. Prevalence of hepatic fibrosis was evaluated in nonalcoholic fatty liver disease (NAFLD), hepatitis C virus (HCV), and hepatitis C and HIV coinfection by two, four, and one studies. Progression of hepatic fibrosis was evaluated by two studies. Pooled OR for prevalence of fibrosis was 0.91 (0.72–1.15), I(2) = 75%. On subgroup analysis, pooled OR among NAFLD patients was 0.80 (0.75–0.86), I(2) = 0% and pooled OR among HCV patients was 1.96 (0.78–4.92), I(2) = 77%. Among studies evaluating HR, pooled HR for progression of fibrosis in HCV–HIV coinfected patients was 1.03 (0.96–1.11), I(2) = 0%. CONCLUSION: Marijuana use did not increase the prevalence or progression of hepatic fibrosis in HCV and HCV–HIV-coinfected patients. On the contrary, we noted a reduction in the prevalence of NAFLD in marijuana users. Future studies are needed to further understand the therapeutic impact of cannabidiol-based formulations in the management of NAFLD.

Introduction:Angiodysplasia is the most common vascular lesion of the gastrointestinal (GI) tract. However, limited epidemiological data exists on hospitalizations related to angiodysplasia of the intestine (ADOI) in the United States (U.S.). The aim of this study is to analyze inpatient trends and outcomes in hospitalizations with ADOI.Methods:We analyzed the National Inpatient Sample (NIS) database for all subjects with discharge diagnosis of angiodysplasia of the intestine with or without hemorrhage (ICD-9 code 569.85 and 569.84 respectively) as principal and/or secondary diagnosis during the period from 2001 to 2011.Results:In 2001, there were 39,244 admissions with discharge diagnosis of ADOI as compared to 41,214 in 2011 (p

Variceal bleeding remains a fatal complication of portal hypertension. Periampullary varices are rare and, due to their location, are difficult to diagnose and treat. Similar to esophagogastric varices, they are the result of high portosystemic pressures secondary to intrahepatic causes such as cirrhosis and extrahepatic causes such as portal or splenic vein thrombosis. We report a case of a periampullary varix resulting in hemobilia during endoscopic retrograde cholangiopancreatography (ERCP).

Gastrointestinal (GI) tuberculosis (TB) is rare and can occur in the context of active pulmonary disease or as a primary infection with no pulmonary symptoms. It typically presents with vague abdominal symptoms, making it difficult to discern from alternative disease processes. Although the ileocecal region is the most commonly affected site, tuberculous enteritis can involve any aspect of the GI tract. To demonstrate the importance of maintaining a high clinical suspicion for the disease, we present a case of GI TB presenting as severe malnutrition and segmental colitis of the left colon.

Objectives To compare the in-hospital outcomes in cirrhosis patients undergoing transcatheter aortic valve replacement (TAVR) versus those undergoing surgical aortic valve replacement (SAVR). Background Over the last 10 years, TAVR has emerged as a therapeutic option for treating severe aortic stenosis in high-risk patients. Cirrhosis patients have a high risk of operative morbidity and mortality while undergoing cardiac surgery. This study's hypothesis was that TAVR is a safer alternative compared to SAVR in cirrhosis patients. Methods The study population was derived from the National Inpatient Sample (NIS) for the years 2011–2012 using ICD-9-CM procedure codes 35.21 and 35.22 for SAVR, and 35.05 and 35.06 for TAVR. Patients

The use of percutaneous aortic balloon balvotomy (PABV) in high surgical risk patients has resurged because of development of less invasive endovascular therapies. We compared outcomes of concomitant PABV and percutaneous coronary intervention (PCI) with PABV alone during same hospitalization using nation's largest hospitalization database. We identified patients and determined time trends using the International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code for valvulotomy from Nationwide Inpatient Sample database 1998 to 2010. Only patients >60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications, length of stay (LOS), and cost of hospitalization. Total 2,127 PABV procedures were identified, with 247 in PABV + PCI group and 1,880 in the PABV group. Utilization rate of concomitant PABV + PCI during same hospitalization increased by 225% from 5.1% in 1998 to 1999 to 16.6% in 2009 to 2010 (p

We present a case of colonic mucosa-associated lymphoid tissue (MALT) lymphoma in a 62-year-old woman diagnosed after a positive test for fecal occult blood.

We read the manuscript titled “ Deep infiltrating endometriosis MR imaging with surgical correlation ” by Tang et al . with educational interest (1). We would like to congratulate the authors for presenting valuable pictorial review of deep infiltrating endometriosis (DIE) with meticulous description of magnetic resonance imaging (MRI) findings of endometriosis.

Background: Gastric cancer is associated with significant morbidity and mortality. Over one-half of patients have advanced disease at the time of presentation, leading to a significant burden on the healthcare system. Limited epidemiological data exists on national inpatient hospitalization trends. The aim of this study is to determine the inpatient burden of gastric cancer in the United States. Methods: We analyzed the Nationwide Inpatient Sample (NIS) database for all subjects with the diagnosis of malignant neoplasm of the stomach (ICD-9 code 151.x) as primary diagnosis during the period from 2001–2011. NIS is the largest all-payer inpatient care database in the U.S. Statistical significance of variation in the number of hospitalizations, patient demographics, and comorbidity measures was determined using Cochran-Armitage trend test. Results: From 2001 to 2011, the number of hospitalizations with the diagnosis of malignant neoplasm of the stomach ranged between 22,430 and 25,371, however, the trend was not significant. Men were always more affected than women with no significant change in overall proportion (P Conclusions: The total number of hospitalizations remained relatively stable throughout the study period with higher proportion of men affected every year. Although in-hospital mortality in patients with the diagnosis of gastric cancer decreased over the study period, there was a significant rise in the cost of care.

BACKGROUND Peptic ulcer disease (PUD) is a major public health burden significantly impacting the cost of hospitalization in the United States (US). We examined the trends, characteristics, complications, cost, and seasonality of PUD-related hospitalizations from 2000 to 2011. METHODS With the use of the Nationwide Inpatient Sample from 2000 through 2011, we identified PUD-related hospitalizations using the International Classification of Diseases (ICD-9), 9th Revision, and the Clinical Modification code 531.00 to 534.91 as the principal discharge diagnosis. The total number of hospitalizations for each calendar month of the year were added over a 12-year period, and this number was divided by the number of days in that particular month to obtain the mean hospitalizations per day for each month. RESULTS The study found that 351,921 hospitalizations with the primary discharge diagnosis of peptic ulcer disease (PUD) occurred in the US between 2000 and 2011. This number dropped significantly from 49,524 to 17,499 between 2000 and 2011, and the rate of PUD-related mortality decreased from 4.3% to 3.1%. The mean age of the study population was 66.2 ± 17.4 years; 52.3% were males, and 56.8% were white. The number of hospitalizations in the US peaked in the spring season (916/day), and reached a nadir in the fall season (861/day). The mean cost of PUD hospitalization increased significantly from $11,755 in 2001 to $13,803 in 2011 (relative increase of 17%; p

The incidence and prevalence of peripheral vascular disease has been increasing. When coexistent with coronary artery disease (CAD), it has shown to predict higher mortality along with poorer quality-of-life consequently leading to a marked increase in healthcare costs. Broadly, there has been an increase in utilization of endovascular techniques in the management of peripheral vascular diseases. An inverse relation between volume and outcomes has been noted in these procedures. Additionally, improved resource utilization has also been noted with higher hospital and operator volumes. This has led to proposals to regionalize these procedures to high volume hospitals. There have also been calls to introduce the idea of having a set threshold of procedures for providers. This review presents an overview of published literature on the volume-outcome relationship affecting the outcomes of peripheral endovascular procedures.