Role of fecal microbiota transplant in management of hepatic encephalopathy: Current trends and future directions

Fecal microbiota transplantation(FMT)offers a potential treatment avenue for hepatic encephalopathy(HE)by leveraging beneficial bacterial displacement to restore a balanced gut microbiome.The prevalence of HE varies with liver disease severity and comorbidities.HE pathogenesis involves ammonia toxicity,gut-brain communication disruption,and inflammation.FMT aims to restore gut microbiota balance,addressing these factors.FMT's efficacy has been explored in various conditions,including HE.Studies suggest that FMT can modulate gut microbiota,reduce ammonia levels,and alleviate inflammation.FMT has shown promise in alcohol-associated,hepatitis B and C-associated,and non-alcoholic fatty liver disease.Benefits include improved liver function,cognitive function,and the slowing of disease progression.However,larger,controlled studies are needed to validate its effectiveness in these contexts.Studies have shown cognitive improvements through FMT,with potential benefits in cirrhotic patients.Notably,trials have demonstrated reduced serious adverse events and cognitive enhancements in FMT arms compared to the standard of care.Although evidence is promising,challenges remain:Limited patient numbers,varied dosages,administration routes,and donor profiles.Further large-scale,controlled trials are essential to establish standardized guidelines and ensure FMT's clinical applications and efficacy.While FMT holds potential for HE management,ongoing research is needed to address these challenges,optimize protocols,and expand its availability as a therapeutic option for diverse hepatic conditions.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians:A United States national experience

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an essential therapeutic tool for biliary and pancreatic diseases.Frail and elderly patients,especially those aged≥90 years are generally considered a higher-risk population for ERCP-related complications.AIM To investigate outcomes of ERCP in the Non-agenarian population(≥90 years)concerning Frailty.METHODS This is a cohort study using the 2018-2020 National Readmission Database.Patients aged≥90 were identified who underwent ERCP,using the international classification of diseases-10 code with clinical modification.Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail.The primary outcome was mortality,and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP.We used univariate and multivariate regression models for analysis.RESULTS A total of 9448 patients were admitted for any indications of ERCP.Frail and non-frail patients were 3445(36.46%)and 6003(63.53%)respectively.Indications for ERCP were Choledocholithiasis(74.84%),Biliary pancreatitis(9.19%),Pancreatico-biliary cancer(7.6%),Biliary stricture(4.84%),and Cholangitis(1.51%).Mortality rates were higher in frail group[adjusted odds ratio(aOR)=1.68,P=0.02].The Intra-procedural complications were insigni-ficant between the two groups which included bleeding(aOR=0.72,P=0.67),accidental punctures/lacerations(aOR=0.77,P=0.5),and mechanical ventilation rates(aOR=1.19,P=0.6).Post-ERCP complication rate was similar for bleeding(aOR=0.72,P=0.41)and post-ERCP pancreatitis(aOR=1.4,P=0.44).Frail patients had a longer length of stay(6.7 d vs 5.5 d)and higher mean total charges of hospitalization($78807 vs$71392)compared to controls(P<0.001).The 30 d all-cause readmission rates between frail and non-frail patients were similar(P=0.96).CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail.Larger studies are warranted to investigate and mitigate modifiable risk factors.

Comparison of success rate and intraocular pressure spikes between selective laser trabeculoplasty and micropulse laser trabeculoplasty in African American and Hispanic patients

AIM:To examine the efficacy and safety of micropulse laser trabeculoplasty(MLT)versus selective laser trabeculoplasty(SLT)in a large cohort of primarily African American and Hispanic patients.METHODS:A single center retrospective comparative cohort review conducted at Cook County Health facilities that included patients with a diagnosis of open angle glaucoma or ocular hypertension who received an SLT or MLT procedure between January 2017 and May 2021.RESULTS:Totally 131 eyes of 99 patients were analyzed.The 77 eyes received SLT and 54 received MLT.Seven out of 77 eyes in the SLT group(9.1%)and 1 out of 54 eyes in the MLT group(1.9%)had an IOP spike(defined as>5 mm Hg)at either 1h or 1wk after procedure(P=0.05,Chisquared test with Haldane-Anscombe correction).The procedure failure rate at one year was 50%for SLT and 48%for MLT(P=0.31).CONCLUSION:MLT has a significantly lower incidence of pressure spikes and a similar treatment failure rate at 1-year post-procedure,demonstrating that it is a reasonable alternative compared to SLT.

Outcomes in patients with COVID-19 and new onset heart blocks: Insight from the National Inpatient Sample database

BACKGROUND Coronavirus disease 2019(COVID-19)caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)has resulted in a worldwide health crisis since it first appeared.Numerous studies demonstrated the virus’s predilection to cardiomyocytes;however,the effects that COVID-19 has on the cardiac conduc-tion system still need to be fully understood.AIM To analyze the impact that COVID-19 has on the odds of major cardiovascular complications in patients with new onset heart blocks or bundle branch blocks(BBB).METHODS The 2020 National Inpatient Sample(NIS)database was used to identify patients admitted for COVID-19 pneumonia with and without high-degree atrioven-tricular blocks(HDAVB)and right or left BBB utilizing ICD-10 codes.The patients with pre-existing pacemakers,suggestive of a prior diagnosis of HDAVB or BBB,were excluded from the study.The primary outcome was inpatient mortality.Secondary outcomes included total hospital charges(THC),the length of hospital stay(LOS),and other major cardiac outcomes detailed in the Results section.Univariate and multivariate regression analyses were used to adjust for confounders with Stata version 17.RESULTS A total of 1058815 COVID-19 hospitalizations were identified within the 2020 NIS database,of which 3210(0.4%)and 17365(1.6%)patients were newly diagnosed with HDAVB and BBB,respectively.We observed a significantly higher odds of in-hospital mortality,cardiac arrest,cardiogenic shock,sepsis,arrythmias,and acute kidney injury in the COVID-19 and HDAVB group.There was no statistically significant difference in the odds of cerebral infarction or pulmonary embolism.Encounters with COVID-19 pneumonia and newly diagnosed BBB had a higher odds of arrythmias,acute kidney injury,sepsis,need for mechanical ventilation,and cardiogenic shock than those without BBB.However,unlike HDAVB,COVID-19 pneumonia and BBB had no significant impact on mortality compared to patients without BBB.CONCLUSION In conclusion,there is a significantly higher odds of inpatient mortality,cardiac arrest,cardiogenic shock,sepsis,acute kidney injury,supraventricular tachycardia,ventricular tachycardia,THC,and LOS in patients with COVID-19 pneumonia and HDAVB as compared to patients without HDAVB.Likewise,patients with COVID-19 pneumonia in the BBB group similarly have a higher odds of supraventricular tachycardia,atrial fibrillation,atrial flutter,ventricular tachycardia,acute kidney injury,sepsis,need for mechanical ventilation,and cardiogenic shock as compared to those without BBB.Therefore,it is essential for healthcare providers to be aware of the possible worse predicted outcomes that patients with new-onset HDAVB or BBB may experience following SARS-CoV-2 infection.

Liver transplant in primary sclerosing cholangitis:Current trends and future directions

Primary sclerosing cholangitis(PSC)is a chronic and progressive immunemediated cholangiopathy causing biliary tree inflammation and scarring,leading to liver cirrhosis and end-stage liver disease.Diagnosis of PSC is challenging due to its nonspecific symptoms and overlap with other liver diseases.Despite the rising incidence of PSC,there is no proven medical therapy that can alter the natural history of the disease.While liver transplantation(LT)is the most effective approach for managing advanced liver disease caused by PSC,post-transplantation recurrence of PSC remains a challenge.Therefore,ongoing research aims to develop better therapies for PSC,and continued efforts are necessary to improve outcomes for patients with PSC.This article provides an overview of PSC’s pathogenesis,clinical presentation,and management options,including LT trends and future aspects.It also highlights the need for improved therapeutic options and ethical considerations in providing equitable access to LT for patients with PSC.Additionally,the impact of liver transplant on the quality of life and psychological outcomes of patients with PSC is discussed.Ongoing research into PSC’s pathogenesis and post-transplant recurrence is crucial for improved understanding of the disease and more effective treatment options.

Readmission rates and outcomes in adults with and without COVID-19 following inpatient chemotherapy admission:A nationwide analysis

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has received considerable attention in the scientific community due to its impact on healthcare systems and various diseases.However,little focus has been given to its effect on cancer treatment.AIM To determine the effect of COVID-19 pandemic on cancer patients’care.METHODS A retrospective review of a Nationwide Readmission Database(NRD)was conducted to analyze hospitalization patterns of patients receiving inpatient chemotherapy(IPCT)during the COVID-19 pandemic in 2020.Two cohorts were defined based on readmission within 30 d and 90 d.Demographic information,readmission rates,hospital-specific variables,length of hospital stay(LOS),and treatment costs were analyzed.Comorbidities were assessed using the Elixhauser comorbidity index.Multivariate Cox regression analysis was performed to identify independent predictors of readmission.Statistical analysis was conducted using Stata■Version 16 software.As the NRD data is anonymous and cannot be used to identify patients,institutional review board approval was not required for this study.RESULTS A total of 87755 hospitalizations for IPCT were identified during the pandemic.Among the 30-day index admission cohort,55005 patients were included,with 32903 readmissions observed,resulting in a readmission rate of 59.8%.For the 90-day index admission cohort,33142 patients were included,with 24503 readmissions observed,leading to a readmission rate of 73.93%.The most common causes of readmission included encounters with chemotherapy(66.7%),neutropenia(4.36%),and sepsis(3.3%).Comorbidities were significantly higher among readmitted hospitalizations compared to index hospitalizations in both readmission cohorts.The total cost of readmission for both cohorts amounted to 1193000000.00 dollars.Major predictors of 30-day readmission included peripheral vascular disorders[Hazard ratio(HR)=1.09,P<0.05],paralysis(HR=1.26,P<0.001),and human immunodeficiency virus/acquired immuno-deficiency syndrome(HR=1.14,P=0.03).Predictors of 90-day readmission included lymphoma(HR=1.14,P<0.01),paralysis(HR=1.21,P=0.02),and peripheral vascular disorders(HR=1.15,P<0.01).CONCLUSION The COVID-19 pandemic has significantly impacted the management of patients undergoing IPCT.These findings highlight the urgent need for a more strategic approach to the care of patients receiving IPCT during pandemics.

Acute pancreatitis in liver transplant hospitalizations:Identifying national trends,clinical outcomes and healthcare burden in the United States

BACKGROUND Acute pancreatitis(AP)in liver transplant(LT)recipients may lead to poor clinical outcomes and development of severe complications.AIM We aimed to assess national trends,clinical outcomes,and the healthcare burden of LT hospitalizations with AP in the United States(US).METHODS The National Inpatient Sample was utilized to identify all adult(≥18 years old)LT hospitalizations with AP in the US from 2007–2019.Non-LT AP hospitalizations served as controls for comparative analysis.National trends of hospitalization characteristics,clinical outcomes,complications,and healthcare burden for LT hospitalizations with AP were highlighted.Hospitalization characteristics,clinical outcomes,complications,and healthcare burden were also compared between the LT and non-LT cohorts.Furthermore,predictors of inpatient mortality for LT hospitalizations with AP were identified.All P values≤0.05 were considered statistically significant.RESULTS The total number of LT hospitalizations with AP increased from 305 in 2007 to 610 in 2019.There was a rising trend of Hispanic(16.5%in 2007 to 21.1%in 2018,P-trend=0.0009)and Asian(4.3%in 2007 to 7.4%in 2019,p-trend=0.0002)LT hospitalizations with AP,while a decline was noted for Blacks(11%in 2007 to 8.3%in 2019,P-trend=0.0004).Furthermore,LT hospitalizations with AP had an increasing comorbidity burden as the Charlson Comorbidity Index(CCI)score≥3 increased from 41.64%in 2007 to 62.30%in 2019(P-trend<0.0001).We did not find statistically significant trends in inpatient mortality,mean length of stay(LOS),and mean total healthcare charge(THC)for LT hospitalizations with AP despite rising trends of complications such as sepsis,acute kidney failure(AKF),acute respiratory failure(ARF),abdominal abscesses,portal vein thrombosis(PVT),and venous thromboembolism(VTE).Between 2007–2019,6863 LT hospitalizations with AP were compared to 5649980 non-LT AP hospitalizations.LT hospitalizations with AP were slightly older(53.5 vs 52.6 years,P=0.017)and had a higher proportion of patients with CCI≥3(51.5%vs 19.8%,P<0.0001)compared to the non-LT cohort.Additionally,LT hospitalizations with AP had a higher proportion of Whites(67.9%vs 64.6%,P<0.0001)and Asians(4%vs 2.3%,P<0.0001),while the non-LT cohort had a higher proportion of Blacks and Hispanics.Interestingly,LT hospitalizations with AP had lower inpatient mortality(1.37%vs 2.16%,P=0.0479)compared to the non-LT cohort despite having a higher mean age,CCI scores,and complications such as AKF,PVT,VTE,and the need for blood transfusion.However,LT hospitalizations with AP had a higher mean THC($59596 vs$50466,P=0.0429)than the non-LT cohort.CONCLUSION In the US,LT hospitalizations with AP were on the rise,particularly for Hispanics and Asians.However,LT hospitalizations with AP had lower inpatient mortality compared to non-LT AP hospitalizations.

Resveratrol engages selective apoptotic signals in gastric adenocarcinoma cells

AIM: To investigate the intracellular apoptotic signals engaged by resveratrol in three gastric adenocarcinoma cancer cell lines, two of which (AGS and SNU-1) express p53 and one (KATO-Ⅲ) with deleted p53. METHODS: Nuclear fragmentation was used to quanti- tate apoptotic cells; caspase activity was determined by photometric detection of cleaved substrates; formation of oxidized cytochrome C was used to measure cytochrome C activity, and Western blot analysis was used to determine protein expression. RESULTS: Gastric cancer cells, irrespective of their p53 status, responded to resveratrol with fragmentation of DNA and cleavage of nuclear lamins A and B and PARP. Resveratrol, however, has no effect on mitochondria-associated apoptotic proteins Bcl-2, Bcl- xl, Bax, Bid or Smac/Diablo, and did not promote sub- cellular redistribution of cytochrome C, indicating that resveratrol-induced apoptosis of gastric carcinoma cells does not require breakdown of mitochondrial membrane integrity. Resveratrol up-regulated p53 protein in SNU-1 and AGS cells but there was a difference in response of intracellular apoptotic signals between these cell lines. SNU-1 cells responded to resveratrol treatment with down-regulation of survivin, whereas in AGS and KATO- Ⅲ cells resveratrol stimulated caspase 3 and cytochrome C oxidase activities. CONCLUSION: These findings indicate that even within a specific cancer the intracellular apoptotic signals engaged by resveratrol are cell type dependent and suggest that such differences may be related to differentiation or lack of differentiation of these cells.

Management of low colorectal anastomotic leak:Preserving the anastomosis

Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy(Hartmann's procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.

Comparison of treatment modalities in pancreatic pseudocyst: A population based study

BACKGROUND Current therapeutic techniques for pancreatic pseudocyst include surgical management with a laparoscopic approach or an open surgical procedure,percutaneous catheter drainage and endoscopic drainage.Yet it remains controversial whether different treatment approaches affect inpatient outcome.AIM To investigate inpatient outcome of different treatment approaches in treating pancreatic pseudocyst.METHODS Here we conducted a retrospective analysis of pancreatic pseudocyst-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.International Classification of Diseases 10 clinical modification and procedure codes are used.RESULTS A total of 7060 patients meeting the above criteria were identified.Our study revealed laparoscopic approach associated with the lowest rate of red blood cell transfusion(P<0.001),and it had lower short-term complications including acute renal failure(P=0.01),urinary tract infection(P=0.01),sepsis(P<0.001)and acute respiratory failure(P=0.01).Laparoscopic surgical approach associated with the shortest mean length of stay(P=0.009),and it had the lowest total charge(P=0.03).All three modalities have similar inpatient mortality(P=0.28).The study also revealed that percutaneous drainage associated with more emergent admission(P<0.001),rural hospital performs the most open surgical drainage(P<0.001)and patients who received laparoscopic drainage are more likely to be discharged home(P<0.001).CONCLUSION Laparoscopic drainage of pancreatic pseudocysts associated with the least shortterm complications and had better outcomes comparing to percutaneous and open surgical drainage from 2016 National Inpatient Sample database.

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.

Aorto-right atrial fistula: Late complication of tricuspid valve infective endocarditis

Abnormal connections between the ascending aortaand the cardiac chambers are rare, especially in thecontext of right-sided infective endocarditis(IE). Trans-thoracic echocardiography(TTE) with color-flow Dop-pler, transesophageal echocardiography(TEE), or bothmay be required for diagnosis. We present the case ofa woman admitted with right-sided heart failure(HF)symptoms. She had a previous history of tricuspid valveIE 30 years ago. TTE and TEE revealed an aorto-rightatrium fistula located just under the non-coronary cuspinto the right atrium at the level of the previously af-fected tricuspid valve. The Patient refused surgery andwas discharged home on HF medications. She has beenstable for the last 3 years. The peculiarity of this caseis the late symptomatic presentation of the aorto-atrialfistula and the unusual association to tricuspid valve IE.

Autologous tissue patch rich in stem cells created in the subcutaneous tissue

AIM:To investigate whether we could create natural autologous tissue patches in the subcutaneous space for organ repair. METHODS: We implanted the following three types of inert foreign bodies in the subcutaneous tissue of rats to produce autologous tissue patches of different geometries:(1) a large-sized polyvinyl tube(L = 25 mm,internal diameter = 7 mm) sealed at both ends by heat application for obtaining a large flat piece of tissue patch for organ repair;(2) a fine polyvinyl tubing(L = 25 mm,internal diameter = 3 mm) for creating cylindrically shaped grafts for vascular or nerve repair; and(3) a slurry of polydextran particle gel for inducing a bladder-like tissue. Implantation of inert materials was carried out by making a small incision on one or either side of the thoracic-lumbar region of rats. Subcutaneous pockets were created by blunt dissection around the incision into which the inert bodies were inserted(1 or 2 per rat). The incisions were closed with silk sutures,and the animals were allowed to recover. In case of the polydextran gel slurry 5 m L of the slurry was injected in the subcutaneous space using an 18 gauge needle. After implanting the foreign bodies a newly regenerated encapsulating tissue developed around the foreign bodies. The tissues were harvested after 4-42 d of implantation and studied by gross examination,histology,and histochemistry for organization,vascularity,and presence of mesenchymal stem cells(MSCs)(CD271+CD34+ cells). RESULTS: Implanting a large cylindrically shaped polyvinyl tube resulted in a large flat sheet of tissue that could be tailored to a specific size and shape for use as a tissue patch for repairing large organs. Implanting a smaller sized polyvinyl tube yielded a cylindrical tissue that could be useful for repairing nerves and blood vessels. This type of patch could be obtained in different lengths by varying the length of the implanted tube. Implanting a suspension of inert polydextran suspension gave rise to a bladder-like tissue that could be potentially used for repairing heart valves. Histologically,the three different types of tissue patches generated were organized similarly,consisting of three layers,increasing in thickness until day 14. The inner layer in contact with the inert material was avascular; a middle layer that was highly vascular and filled with matrix,and an outer layer consisting of loose connective tissue. MSCs identified as CD271+CD34+ cells were present in the medial layer and around major blood vessels at day 4 but absent at later time points. The early-harvested tissues,endowed with MSCs,could be used for tissue repair,while the later-harvested tissues,being less vascular but thicker and tougher,could be used as filler tissue for cosmetic purposes. CONCLUSION: An autologous,vascularized tissue patch of desired shape and size can be created in the subcutaneous space by implanting different types of inert bodies.

National trend of heart failure and other cardiovascular diseases in people living with human immunodeficiency virus

BACKGROUND As people living with human immunodeficiency virus(HIV)(PLWH)enjoy longer life expectancy with highly effective antiretroviral therapy,they are encountering challenging cardiovascular health risks.AIM To retrospectively examine the increasing burden of cardiovascular diseases in PLWH over the past decade.METHODS All hospitalizations for heart failure(HF),ischemic heart disease(IHD),and cerebrovascular disease(CeVD)in PLWH were identified using the International Classification of Diseases,Ninth Revision,Clinical Modification(ICD-9-CM)and ICD-10-CM codes in the National Inpatient Sample from 2008 to 2018.Outcomes included number of hospitalizations,in-hospital mortality,length of stay,and total hospital charge.Trend of the outcomes from 2008 to 2018 were analyzed using Cochran-Armitage_(trend)test and simple linear regression.RESULTS The number of hospitalizations for HF in PLWH increased from 4212 in 2008 to 6700 in 2018(P_(trend)<0.01).Similar increasing_(trend)was seen with those for IHD and CeVD over the decade(P_(trend)<0.01).A decreasing_(trend)of in-hospital mortality was observed in all hospitalizations of PLWH(P_(trend)<0.01)and CeVD in PLWH(P_(trend)<0.01),but not in those for HF(P_(trend)=0.67)and IHD(P_(trend)=0.13).The_(trend)of length of stay was decreasing in all hospitalizations of PLWH(P_(trend)<0.01),but increasing in those for HF in PLWH(P_(trend)<0.01).An increasing_(trend)of total hospital charge was observed in hospitalizations for HF,IHD,and CeVD(P_(trend)<0.01).CONCLUSION The burden of cardiovascular diseases has significantly increased in hospitalizations of PLWH from 2008 to 2018.Continued efforts are needed to address the additional cardiovascular risks in this vulnerable population.

Safety of upper endoscopy in patients with active cocaine use

BACKGROUND Cocaine is a synthetic alkaloid initially viewed as a useful local anesthetic,but which eventually fell out of favor given its high addiction potential.Its predominantly sympathetic effects raise concern for cardiovascular,respiratory,and central nervous system complications in patients undergoing procedures.Periprocedural cocaine use,often detected via a positive urine toxicology test,has been mostly addressed in the surgical and obstetrical literature.However,there are no clear guidelines on how to effectively risk stratify patients found to be positive for cocaine in the pre-operative setting,often leading to costly procedure cancellations.Within the field of gastroenterology,there is no current data available regarding safety of performing esophagogastroduodenoscopy(EGD)in patients with recent cocaine use.AIM To compare the prevalence of EGD related complications between active(≤5 d)and remote(>5 d)users of cocaine.METHODS In total,48 patients who underwent an EGD at John H.Stroger,Jr.Hospital of Cook County from October 2016 to October 2018 were found to have a positive urine drug screen for cocaine(23 recent and 25 remote).Descriptive statistics were compiled for patient demographics.Statistical tests used to analyze patient characteristics,procedure details,and preprocedural adverse events included ttest,chi-square,Wilcoxon rank sum,and Fisher exact test.RESULTS Overall,20 periprocedural events were recorded with no statistically significant difference in distribution between the two groups(12 active vs 8 remote,P=0.09).Pre-and post-procedure hemodynamics demonstrated only a statistically,but not clinically significant drop in systolic blood pressure and increase in heart rate in the active user group,as well as drop in diastolic blood pressure and oxygen saturation in the remote group(P<0.05).There were no significant differences in overall hemodynamics between both groups.CONCLUSION Our study found no significant difference in the rate of periprocedural adverse events during EGD in patients with recent vs remote use of cocaine.Interestingly,there were significantly more patients(30%)with active use of cocaine that required general anesthesia as compared to remote users(0%).

Reporting cervical effacement as a percentage: How accurate is it?

Objective: To evaluate the accuracy of cervical effacement reported as a percentage by digital cervical exams using cervical length determined by transvaginal ultrasonography as a standard. Methods: Records of pregnant women who had a digital cervical exam and subsequent transvaginal ultrasound scan for cervical length between January 2005 and December 2008 were reviewed. Digital cervical exams were performed by different examiners. Transvaginal ultrasound was performed by one examiner who did not perform any of the digital exams. Cervical effacements were recorded as a percentage and cervical lengths were measured in centimeters. Results: A total of 173 women met the study criteria. Average cervical length for 0% effacement was 3.3 ± 1.1 cm (0.8 - 5.0 cm);20% effacement, 1.6 ± 1.0 cm (0.9 - 3.0 cm);25% effacement, 2.2 ± 0.2 cm (2.0 - 2.3 cm);30% effacement, 2.6 ± 0.4 cm (2.1 - 3.0 cm);40% effacement, 3.0 ± 0.4 cm (2.6 - 3.4 cm);50% effacement, 2.4 ± 1.1 cm (0.6 - 4.6 cm);60% effacement, 2.3 ± 1.4 cm (0.7 - 4.3 cm);70% effacement, 2.2 ± 0.8 cm (1.1 - 3.3 cm);75% effacement, 1.7 ± 1.4 cm (0.7 - 2.7 cm);80% effacement, 2.0 ± 0.9 cm (0.6 - 4.4 cm);90% effacement, 0.7 ± 0.4 cm (0.4 - 0.9 cm);100% effacement, 1.2 ± 1.5 cm (0.3 - 3.0 cm). The coefficient of variation ranges from 10% - 124%. Conclusion: The traditional method of reporting cervical effacement as a percentage is unacceptably inaccurate compared to the actual cervical length determined by vaginal probe ultrasound.

Acquired Chiari Malformation: Safety of Neuraxial Anesthesia?

Chiari malformation is a congenital anomaly that primarily involves the downward displacement of the cerebellar tonsils through the foramen magnum and elongation of forth ventricle and lower brainstem. Patients with Chiari I (congenital or acquired) malformation are asymptomatic or may presents with neurologic signs and symptoms. It is always a question of safety of neuraxial anesthesia in these patients. There is potential risk of dural puncture that can initiate the neurologic symptoms or worsen the existing symptoms due to CSF leakage or tonsillar herniation. Other side, performance of neuraxial anesthesia can cause acquired Chiari I type malformation due to CSF leak and intracranial hypotension. We reviewed the case reports and articles regarding safety of neuraxial anesthesia in the setting of Congenital or Acquired Chiari malformation.

Does Chemo-Radiation Therapy Influence Outcomes in Unresectable Locally Advanced State IV Rectal Cancer?

Introduction: The median survival for patients with stage IV rectal cancer is approximately 20 months. Therapy should focus not only on improving survival but also on quality of life. The aim of our study was to determine if chemoradiation (C-RT) would improve palliation for metastatic unresectable locally advanced disease compared to patients receiving palliative chemotherapy alone (C) for stage IV cancer. Methods: Retrospective review of a prospectively maintained database at a single institution was carried out under IRB approval. From January 2004 to December 2008, 43 patients presenting with unresectable stage IV rectal cancer were identified with a median follow-up of 12 months. Patients with evidence of locally advanced disease or bulky disease received infusional 5-FU ± bevacizumab and 3D conformed mega voltage photon therapy (5400 cGy). Patients without evidence of bulky disease received either FOLFOX or FOLFIRI ± bevacizumab. Data on demographics, investigations, treatment, complications, metastasis, number of blood transfusions, days of hospitalization, and surgical intervention were analyzed using SPSS statistical software. p < 0.05 was considered statistically significant. Results: There were 25 and 18 patients in the C and C-RT groups respectively. There was no difference in mean age, sex or overall survival. Three patient (12%) in the C group developed hydronephrosis compared to 8 patients (44%) in the C-RT group (p < 0.05). Six patients (24%) developed bowel obstructions requiring an ostomy in the C group compared to 9 patient (50%) in the C-RT group (p = 0.07). In the C arm, 80% of patients required multiple hospitalizations for symptoms consistent with progression of disease compared to 61% of patients in the C-RT arm (p < 0.01). Conclusion: Chemoradiation in patients with locally advanced unresectable stage IV cancer has not been extensively investigated. At our institution, patients treated with C-RT for bulky stage IV rectal cancer required fewer hospitalizations when compared to those treated with chemotherapy alone.

Differential Diagnosis of Post-Procedural Skin Lesions: A Case Report

Skin reactions caused by interventional pain procedures are well documented in literature, ranging from fistula formation to urticarial allergic reactions and infections. Burn lesions may also occur, however far less common;and as pain physician we must be cognizant of this possible complication and its etiologies. This is difficult in an outpatient setting where a patient cannot be regularly monitored, their adherence to prescribed therapies is unclear, and reporting is often done via phone, ancillary staff, and outside facility records. These compounding factors require clinicians to consider a broad differential and be comfortable with instituting myriad therapies or appropriately involve outside consultation for thorough patient care.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease

BACKGROUND Transcatheter aortic valve replacement(TAVR)is a revolutionary procedure for severe aortic stenosis.The coexistence of chronic kidney disease(CKD)and TAVR introduces a challenge that significantly impacts patient outcomes.AIM To define readmission rates,predictors,and causes after TAVR procedure in CKD stage 1-4 patients.METHODS We used the national readmission database 2018 and 2020 to look into readmission rates,causes and predictors after TAVR procedure in patients with CKD stage 1-4.RESULTS Out of 24758 who underwent TAVR and had CKD,7892(32.4%)patients were readmitted within 90 days,and had higher adjusted odds of being females(adjusted odds ratio:1.17,95%CI:1.02-1.31,P=0.02)with longer length of hospital stay>6 days,and more comorbidities including but not limited to diabetes mellitus,anemia,and congestive heart failure(CHF).CONCLUSION Most common causes of readmission included CHF(18.0%),sepsis,and complete atrioventricular block.Controlling readmission predictors with very close followup is warranted to prevent such high rate of readmission.