Sepsis during short bowel syndrome hospitalizations:Identifying trends,disparities,and clinical outcomes in the United States

BACKGROUND Short bowel syndrome(SBS)hospitalizations are often complicated with sepsis.There is a significant paucity of data on adult SBS hospitalizations in the United States and across the globe.AIM To assess trends and outcomes of SBS hospitalizations complicated by sepsis in the United States.METHODS The National Inpatient Sample was utilized to identify all adult SBS hospitalizations between 2005-2014.The study cohort was further divided based on the presence or absence of sepsis.Trends were identified,and hospitalization characteristics and clinical outcomes were compared.Predictors of mortality for SBS hospitalizations complicated with sepsis were assessed.RESULTS Of 247097 SBS hospitalizations,21.7%were complicated by sepsis.Septic SBS hospitalizations had a rising trend of hospitalizations from 20.8%in 2005 to 23.5%in 2014(P trend<0.0001).Compared to non-septic SBS hospitalizations,septic SBS hospitalizations had a higher proportion of males(32.8%vs 29.3%,P<0.0001),patients in the 35-49(45.9%vs 42.5%,P<0.0001)and 50-64(32.1%vs 31.1%,P<0.0001)age groups,and ethnic minorities,i.e.,Blacks(12.4%vs 11.3%,P<0.0001)and Hispanics(6.7%vs 5.5%,P<0.0001).Furthermore,septic SBS hospitalizations had a higher proportion of patients with intestinal transplantation(0.33%vs 0.22%,P<0.0001),inpatient mortality(8.5%vs 1.4%,P<0.0001),and mean length of stay(16.1 d vs 7.7 d,P<0.0001)compared to the non-sepsis cohort.A younger age,female gender,White race,and presence of comorbidities such as anemia and depression were identified to be independent predictors of inpatient mortality for septic SBS hospitalizations.CONCLUSION Septic SBS hospitalizations had a rising trend between 2005-2014 and were associated with higher inpatient mortality compared to non-septic SBS hospitalizations.

Association of non-alcoholic fatty liver disease with gallstone disease in the United States hospitalized patient population

BACKGROUND Gallstones and cholecystectomy have been proposed as risk factors for nonalcoholic 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.

Hyperkalemia:Major but still understudied complication among heart transplant recipients

Hyperkalemia is a recognized and potentially life-threatening complication ofheart transplantation. In the complex biosystem created by transplantation,recipients are susceptible to multiple mechanisms for hyperkalemia which arediscussed in detail in this manuscript. Hyperkalemia in heart transplantationcould occur pre-transplant, during the transplant period, or post-transplant. Pretransplantcauses of hyperkalemia include hypothermia, donor heart preservationsolutions, conventional cardioplegia, normokalemic cardioplegia, continuouswarm reperfusion technique, and ex-vivo heart perfusion. Intra-transplant causesof hyperkalemia include anesthetic medications used during the procedure,heparinization, blood transfusions, and a low output state. Finally, post-transplantcauses of hyperkalemia include hemostasis and drug-induced hyperkalemia.Hyperkalemia has been studied in kidney and liver transplant recipients, butthere is limited data on the incidence, causes, management, and prevention inheart transplant recipients. Hyperkalemia is associated with an increased risk ofhospital mortality and readmission in these patients. This review describes thecurrent literature pertaining to the causes, pathophysiology, and treatment ofhyperkalemia in patients undergoing heart transplantation and focuses primarilyon post-heart transplantation.

Emerging therapeutics in the management of COVID-19

Abstract The severe acute respiratory syndrome coronavirus 2(coronavirus disease 2019,COVID-19)pandemic has placed a tremendous burden on healthcare systems globally.Therapeutics for treatment of the virus are extremely inconsistent due to the lack of time evaluating drug efficacy in clinical trials.Currently,there is a deficiency of published literature that comprehensively discusses all therapeutics being considered for the treatment of COVID-19.A review of the literature was performed for articles related to therapeutics and clinical trials in the context of the current COVID-19 pandemic.We used PubMed,Google Scholar,and Clinicaltrials.gov to search for articles relative to the topic of interest.We used the following keywords:“COVID-19”,“therapeutics”,“clinical trials”,“treatment”,“FDA”,“ICU”,“mortality”,and“management”.In addition,searches through the references of retrieved articles was also performed.In this paper,we have elaborated on the therapeutic strategies that have been hypothesized or trialed todate,the mechanism of action of each therapeutic,the clinical trials finished or inprocess that support the use of each therapeutic,and the adverse effects associated with each therapeutic.Currently,there is no treatment that has been proven to provide significant benefit in reducing morbidity and mortality.There are many clinical trials for numerous different therapeutic agents currently underway.By looking back and measuring successful strategies from previous pandemics in addition to carrying out ongoing research,we provide ourselves with the greatest opportunity to find treatments that are beneficial.

Increasing thirty-day readmissions of Crohn’s disease and ulcerative colitis in the United States:A national dilemma

BACKGROUND The prevalence of Crohn’s disease(CD)and ulcerative colitis(UC)is on the rise worldwide.This rising prevalence is concerning as patients with CD and UC may frequently relapse leading to recurrent hospitalizations and increased healthcare utilization.AIM To identify trends and adverse outcomes for 30 d readmissions for CD and UC.METHODS This was a retrospective,interrupted trends study involving all adult(≥18 years)30 d readmissions of CD and UC from the National Readmission Database(NRD)between 2008 and 2018.Patients<18 years,elective,and traumatic hospitalizations were excluded from this study.We identified hospitalization characteristics and readmission rates for each calendar year.Trends of inpatient mortality,mean length of hospital stay(LOS)and mean total hospital cost(THC)were calculated using a multivariate logistic trend analysis adjusting for age,gender,insurance status,comorbidity burden and hospital factors.Furthermore,trends between CD and UC readmissions were compared using regression of the interaction coefficient after adjusting for age and gender to determine relative trends between the two populations.Stata®Version 16 software(StataCorp,TX,United States)was used for statistical analysis and P value≤0.05 were considered statistically significant.RESULTS Total number of 30 d readmissions increased from 6202 in 2010 to 7672 in 2018 for CD and from 3272 in 2010 to 4234 in 2018 for UC.We noted increasing trends for 30-day all-cause readmission rate of CD from 14.9%in 2010 to 17.6%in 2018(P-trend<0.001),CD specific readmission rate from 7.1%in 2010 to 8.2%in 2018(P-trend<0.001),30-day all-cause readmission rate of UC from 14.1%in 2010 to 15.7%in 2018(P-trend=0.003),and UC specific readmission rate from 5.2%in 2010 to 5.6%in 2018(P-trend=0.029).There was no change in the risk adjusted trends of inpatient mortality and mean LOS for CD and UC readmissions.However,we found an increasing trend of mean THC for UC readmissions.After comparison,there was no statistical difference in the trends for 30 d all-cause readmission rate,inpatient mortality,and mean LOS between CD and UC readmissions.CONCLUSION There was an increase in total number of 30 d readmissions for CD and UC with a trend towards increasing 30 d all-cause readmission rates.

Challenges in hyperglycemia management in critically ill patients with COVID-19

Hyperglycemia is commonly associated with adverse outcomes especially in patients requiring intensive care unit stay.Data from the corona virus disease 2019(COVID-19)pandemic indicates that individuals with diabetes appear to be at similar risk for COVID-19 infection to those without diabetes but are more likely to experience increased morbidity and mortality.The proposed hypothesis for hyperglycemia in COVID-19 include insulin resistance,critical illness hyperglycemia(stress-induced hyperglycemia)secondary to high levels of hormones like cortisol and catecholamines that counteract insulin action,acute cytokine storm and pancreatic cell dysfunction.Diabetic patients are more likely to have severe hyperglycemic complications including diabetic ketoacidosis and hyperosmolar hyperglycemic state.Management of hyperglycemia in COVID-19 is often complicated by use of steroids,prolonged total parenteral or enteral nutrition,frequent acute hyperglycemic events,and restrictions with fluid management due to acute respiratory distress syndrome.While managing hyperglycemia special attention should be paid to mode of insulin delivery,frequency of glucose monitoring based on patient and caregiver safety thereby minimizing exposure and conserving personal protective equipment.In this article we describe the pathophysiology of hyperglycemia,challenges encountered in managing hyperglycemia,and review some potential solutions to address them.

Systemic adverse effects and toxicities associated with immunotherapy:A review

Immunotherapy is rapidly evolving secondary to the advent of newer immunotherapeutic agents and increasing approval of the current agents by the United States Food and Drug Administration to treat a wide spectrum of cancers.Immunotherapeutic agents have gained immense popularity due to their tumorspecific action.Immunotherapy is slowly transforming into a separate therapeutic entity,and the fifth pillar of management for cancers alongside surgery,radiotherapy,chemotherapy,and targeted therapy.However,like any therapeutic entity it has its own adverse effects.With the increasing use of immunotherapeutic agents,it is vital for physicians to acquaint themselves with these adverse effects.The aim of this review is to investigate the common systemic adverse effects and toxicities associated with the use of different classes of immunotherapeutic agents.We provide an overview of potential adverse effects and toxicities associated with different classes of immunotherapeutic agents organized by organ systems,as well as an extensive discussion of the current recommendations for treatment and clinical trial data.As we continue to see increasing usage of these agents in clinical practice,it is vital for physicians to familiarize themselves with these effects.

Trends of alcoholic liver cirrhosis readmissions from 2010 to 2018:Rates and healthcare burden associated with readmissions

BACKGROUND Alcoholic liver cirrhosis(ALC)is a chronic liver disease with varying disease severity.Readmissions of ALC are associated with poor outcomes.AIM To identify and assess trends of readmissions for ALC over an eight-year period.METHODS This retrospective interrupted trend study analysed 30-d readmissions of ALC in the United States from 2010 to 2018 using the National Readmissions Database.Hospitalization for ALC was the reason for index admission obtained using the International Classification of Diseases codes(571.2 and K70.3X).Biodemographic characteristics and hospitalization trends were highlighted over time.A multivariate regression analysis model was used to calculate the trend for riskadjusted odds of 30-d all-cause ALC readmissions,ALC specific readmission rate,ALC readmission proportion,inpatient mortality,mean length of stay(LOS)and mean total hospital cost(THC)following adjustments for age,gender,grouped Charlson Comorbidity Index,insurance,mean household income,and hospital characteristics.RESULTS There was a trend towards increasing total 30-d readmissions of ALC from 7660 in 2010 to 15085 in 2018(P<0.001).Patients readmitted for ALC were noted to have an increasing comorbidity burden over time.We noted a rise in the risk-adjusted 30-d all-cause readmission of ALC from 24.9%in 2010 to 29.9%in 2018(P<0.001).ALC-specific readmission rate increased from 6.3%in 2010 to 8.4%in 2018(P<0.001)while ALC readmission proportion increased from 31.4%in 2010 to 36.3%in 2018(P<0.001).Inpatient mortality for 30-d readmissions of ALC declined from 10.5%in 2010 to 8.2%in 2018(P=0.0079).However,there was a trend towards increasing LOS from 5.6 d in 2010 to 6.3 d in 2018(P<0.001)and increasing THC from 13790 dollars in 2010 to 17150 dollars in 2018(P<0.001).The total days of hospital stay attributable to 30-d readmissions of ALC increased by 119.2%while the total attributable hospital costs increased by 149%by the end of 2018.CONCLUSION There was an increase in the 30-d readmission rate and comorbidity burden for ALC;however,inpatient mortality declined.Additionally,there was a trend towards increasing LOS and THC for these readmissions.

Gastrointestinal amyloidosis: A focused review

Amyloidosis,a heterogenous group of disorders,is characterized by the extracellular deposition of autologous,insoluble,fibrillar misfolded proteins.These extracellular proteins deposit in tissues aggregated inß-pleated sheets arranged in an antiparallel fashion and cause distortion to the tissue architecture and function.In the current literature,about 60 heterogeneous amyloidogenic proteins have been identified,out of which 27 have been associated with human disease.Classified as a rare disease,amyloidosis is known to have a wide range of possible etiologies and clinical manifestations.The exact incidence and prevalence of the disease is currently unknown.In both systemic and localized amyloidosis,there is infiltration of the abnormal proteins in the layers of the gastrointestinal(GI)tract or the liver parenchyma.The gold standard test for establishing a diagnosis is tissue biopsy followed by Congo Red staining and apple-green birefringence of the Congo Red-stained deposits under polarized light.However,not all patients may have a positive tissue confirmation of the disease.In these cases additional workup and referral to a gastroenterologist may be warranted.Along with symptomatic management,the treatment for GI amyloidosis consists of observation or localized surgical excision in patients with localized disease,and treatment of the underlying pathology in cases of systemic amyloidosis.In this review of the literature,we describe the subtypes of amyloidosis,with a primary focus on the epidemiology,pathogenesis,clinical features,diagnosis and treatment strategies available for GI amyloidosis.

Histoplasmosis and inflammatory bowel disease: A case report

BACKGROUND Infection with Histoplasma capsulatum can lead to a disseminated disease involving the gastrointestinal tract presenting as diffuse abdominal pain and inflammatory diarrhea which may mimic inflammatory bowel disease(IBD).CASE SUMMARY In the current report,we discuss the case of a 41-year old male who presented to the emergency department with complaints of high-grade intermittent fevers and severe abdominal pain with associated diarrhea and hematochezia.Laboratory results demonstrated transaminitis and elevated erythrocyte sedimentation rate,C-reactive protein and ferritin levels.The patient’s presentation was thought to be an exacerbation of his underlying IBD,but further investigations revealed a positive Histoplasma antigen in the urine.The patient was offered a colonoscopy and biopsy to confirm the diagnosis;however,he refused.He was treated with itraconazole and showed significant improvement of his symptoms,thereby confirming the diagnosis of gastrointestinal histoplasmosis.CONCLUSION Here within,we provide a review of IBD,evaluation of chronic diarrhea,and gastrointestinal histoplasmosis.

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2[SARSCoV-2,or coronavirus disease 2019(COVID-19)]was declared a pandemic by the World Health Organization on March 11,2020.Worldwide,more than 65 million people have been infected with this SARS-CoV-2 virus,and over 1.5 million people have died due to the viral illness.Although a tremendous amount of medical progress has been made since its inception,there continues to be ongoing research regarding the pathophysiology,treatments,and vaccines.While a vast majority of those infected develop only mild to moderate symptoms,about 5%of people have severe forms of infection resulting in respiratory failure,myocarditis,septic shock,or multi-organ failure.Despite maximal cardiopulmonary support and invasive mechanical ventilation,mortality remains high.Extracorporeal membrane oxygenation(ECMO)remains a valid treatment option when maximal conventional strategies fail.Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints.This article reviews the rationale behind its use,current status of utilization,and future considerations for ECMO in critically ill COVID-19 patients.

Telemedicine,the current COVID-19 pandemic and the future:a narrative review and perspectives moving forward in the USA

A narrative review was conducted to examine the current state of the utilisation of telemedicine amid the current COVID-19 pandemic and to evaluate the benefits of continuing telemedicine usage in the future.A literature review was performed for articles related to telemedicine.Databases including PubMed,Google Scholar,Cochrane Library and Ovid MEDLINE were searched.Three reviewers independently performed article selection based on relevance to our topic.We included all articles between 1990 and 2020 related to telemedicine using the following keywords:‘telemedicine’,‘telehealth’,‘policy’,‘COVID-19’,‘regulation’,‘rural’,‘physical examination’,‘future’.A total of 60 articles were identified,and through careful selection we narrowed the final number of articles to 42 based on relevance to our topic.Telemedicine has been rapidly evolving over the past several decades.Issues with regulation and reimbursement have prevented its full immersion into the healthcare system.During the current pandemic,Centers for Medicare and Medicaid services have expanded access to telemedicine services.The advantages of telemedicine moving forward include its cost-effectiveness,ability to extend access to specialty services and its potential to help mitigate the looming physician shortage.Disadvantages include lack of available technological resources in certain parts of the country,issues with security of patient data,and challenges in performing the traditional patient examination.It is critically important that changes are made to fully immerse telemedicine services into the healthcare landscape in order to be prepared for future pandemics as well as to reap the benefits of this service in the future.