Is Induction of Labor with Early Rupture of Membranes Associated with an Increased Rate of Clinical Chorioamnionitis?

Objective: The objective of this study was to determine if early rupture of membranes (ROM) in women undergoing induction of labor (IOL) at term is associated with an increased rate of clinical chorioamnionitis. Study Design: A retrospective cohort study was performed on women undergoing IOL. Early ROM was defined as ROM at a modified Bishop score less than 5, cervical dilation less than 4 cm, or cervical effacement less than 80%. The rate of clinical chorioamnionitis was compared between women with early and late ROM. Results: The rate of clinical chorioamnionitis was 8.6% (24/279). ROM at an effacement of less than 80% was associated with a rate of clinical chorioamnionitis of 15.4% (12/78) compared to 6.0% (12/201) at an effacement of equal to or greater than 80%, p = 0.017. The rate of cesarean delivery was higher for patients with early ROM by any definition: 32% compared to 17.5% by modified Bishop score (p = 0.031), 32.4% versus 18.2% by cervical dilation (p = 0.049), and 33.3% versus 14.9% by cervical effacement (p = 0.001). Conclusions: In patients undergoing IOL, early ROM may be associated with an increased rate of clinical chorioamnionitis when performed at a cervical effacement of less than 80% and an increased rate of cesarean delivery.

Characteristics, Treatment, and Outcomes Associated with <i>Clostridium difficile</i>Associated Diarrhea in a Veterans Affairs Medical Center

We conducted a study to assess the characteristics, treatment and outcomes associated with Clostridium difficile associated diarrhea in a Veterans Affairs Medical Center. Fifty-eight consecutive individual cases of C. difficile infection in 2013 were observed within the Veterans Affairs New Jersey Health Care System (VA NJHCS). We molecularly typed all 58 individual strains and identified the associated characteristics, treatment and outcomes. Forty-four out of 58 specimens (76%) which were probed had characteristics of the epidemic strain BI/NAP1/027 making this virulent strain to be the predominate strain at the VA NJHCS. All C. difficile BI/NAP1/027 strains were resistant to fluoroquinolones and sensitive to fidaxomicin, metronidazole and vancomycin. Fidaxomicin had the most potent in vitro activity (MIC90 = 0.5 μg/ml) against the BI/NAP1/027 strain. Twenty-six of 44 patients (59%) with the virulent strain were from a long-term care facility (LTCF). Patients possessing the virulent strain from the LTCF had a mean APACHE II score of 14.1 and a predicted death rate of 21.9%. Two-third of patients were treated with metronidazole alone (mean APACHE II scores 9.6), and one-third required oral vancomycin and metronidazole (mean APACHE II scores 14.1). There were no C. difficile infection related deaths. C. difficile BI/NAP1/027, an epidemic strain, is the endemic strain at the VA NJHCS, but no increased mortality was seen with infection with this strain.

Clinical characteristics and outcomes of autoimmune pancreatitis based on serum immunoglobulin G4 levels:A single-center,retrospective cohort study

Autoimmune pancreatitis(AIP)is a complex,poorly understood disease gaining increasing attention."Clinical Characteristics and Outcome of AIP Based on Serum IgG4 levels,"investigated AIP with a focus on serum immunoglobulin(Ig)G4 levels.The 213 patients with AIP were classified according to serum IgG4 levels:Abnormal(elevated)and normal.Patients with higher IgG4 levels exhibited a more active immune system and increased relapse rates.Beyond IgG4,the IgA levels and age independently contributed to relapse risk,guiding risk assessment and tailored treatments for better outcomes.However,limitations persist,such as no IgA correlation with IgG4 levels,absent data on autoantibodypositive AIP cases critical for Asian diagnostic criteria,and unexplored relapse rates in high serum IgG AIP by subtype.Genetic factors and family histories were not addressed.As the understanding and referral of seronegative AIPs increase,there's a growing need for commercially available,highly sensitive,and specific autoantibodies to aid in diagnosing individuals with low or absent serum IgG4 levels.

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

BACKGROUND Hyperuricemia is a prerequisite for the development of gout.Elevated serum uric acid(UA)levels result from either overproduction or decreased excretion.A positive correlation between serum UA levels,cirrhosis-related complications and the incidence of nonalcoholic fatty liver disease has been established,but it is unknown whether hyperuricemia results in worsening cirrhosis outcomes.We hypothesize that patients with cirrhosis will have poorer gout outcomes.AIM To explore the link between cirrhosis and the incidence of gout-related complications.METHODS This was a cross-sectional study.The national inpatient sample was used to identify patients hospitalized with gout,stratified based on a history of cirrhosis,from 2001 to 2013 via the International Classification of Diseases,Ninth Revision,Clinical Modification codes.Primary outcomes were mortality,gout complications and joint interventions.Theχ^(2)test and independent t-test were performed to assess categorical and continuous data,respectively.Multiple logistic regression was used to control for confounding variables.RESULTS Patients without cirrhosis were older(70.37±13.53 years vs 66.21±12.325 years;P<0.05).Most patients were male(74.63%in the cirrhosis group vs 66.83%;adjusted P<0.05).Patients with cirrhosis had greater rates of mortality(5.49%vs 2.03%;adjusted P<0.05),gout flare(2.89%vs 2.77%;adjusted P<0.05)and tophi(0.97%vs 0.75%;adjusted P=0.677).Patients without cirrhosis had higher rates of arthrocentesis(2.45%vs 2.21%;adjusted P<0.05)and joint injections(0.72%vs 0.52%;adjusted P<0.05).CONCLUSION Gout complications were more common in cirrhosis.Those without cirrhosis had higher rates of interventions,possibly due to hesitancy with performing these interventions given the higher complication risk in cirrhosis.

Hepatic pseudotumor associated with Strongyloides infection:A case report

BACKGROUND Strongyloides sterocoralis is a parasitic infection caused by a roundworm that is transmitted through soil contaminated with larvae.It can infrequently cause hepatic abscesses in immunocompromised patients and is rarely reported to form hepatic lesions in immunocompetent hosts.CASE SUMMARY We present a case study of a 45-year-old female who presented with right upper quadrant abdominal pain and constitutional symptoms for several weeks.Crosssectional imaging identified several malignant-appearing liver masses.Further investigation,including serological testing and histopathologic examination,revealed the presence of serum Strongyloides antibodies and hepatic granulomas with extensive necrosis.Following treatment with ivermectin for 2 wk,there was complete resolution of the liver lesions and associated symptoms.CONCLUSION This case highlights the importance of considering parasitic infections,such as Strongyloides,in the differential diagnosis of hepatic masses.Early recognition and appropriate treatment can lead to a favorable outcome and prevent unnecessary invasive procedures.Increased awareness among clinicians is crucial to ensure the timely diagnosis and management of such cases.

Anesthetic and Obstetric Considerations of Moyamoya Disease in Pregnancy after Intracranial Bypass Grafting: A Case Report and Literature Review

Moyamoya disease (MD) is a chronic idiopathic vasculopathy characterized by bilateral stenosis of the distal internal carotid arteries (ICA’s) with subsequent formation of abnormal collateral vessels. The underlying etiology is unknown [1]. Patients with MD are predisposed to intracranial hemorrhage or cerebral ischemia given the fragile nature of the collateral circulation. Although there is no curative treatment for MD, there are surgical palliative procedures that can augment cerebral blood flow to areas of impaired perfusion and circumvent the abnormal collateral circulation. Medical management exists for patients who are not surgical candidates. Because the incidence of MD peaks during the second and third decades of life, it can potentially affect women of childbearing age [2]. However, the optimal anesthetic and obstetric management of the parturient with MD remains controversial. We present a case of a primigravida with a history of MD who underwent intracranial bypass grafting prior to conception and subsequently had a successful cesarean delivery that was complicated by transient ischemic attacks (TIA) in the postpartum period.

Benign Gynecomastia with Abscess

Gynecomastia is a common finding in male patients, however, abscess is a rare finding in male patients. Typical management for benign gynecomastia is to continued surveillance and no additional annual imaging is required [1]. Breast abscess in male is managed with incision and drainage and antibiotics [2], however, the management of gynecomastia superimposed with recurrent ab-scess does not have clear management and should be managed on an indi-vidual basis. We present a case of a 44-year-old man who with a recurrent left breast abscess in addition to persistent gynecomastia. The abscess was drained and cultured. The culture grew Citrobacter koseri(diversus) and patient was placed on Bactrim DS for 7 days and was referred to the breast clinic for fur-ther evaluation. This study aims to elucidate and review the literature to iden-tify similar cases and potential management of male patients with recurrent abscess and gynecomastia.

Hepatocellular carcinoma:A comprehensive review

Hepatocellular carcinoma(HCC) is rapidly becoming one of the most prevalent cancers worldwide. With a rising rate, it is a prominent source of mortality. Patients with advanced fibrosis, predominantly cirrhosis and hepatitis B are predisposed to developing HCC. Individuals withchronic hepatitis B and C infections are most commonly afflicted. Different therapeutic options, including liver resection, transplantation, systemic and local therapy, must be tailored to each patient. Liver transplantation offers leading results to achieve a cure. The Milan criteria is acknowledged as the model to classify the individuals that meet requirements to undergo transplantation. Mean survival remains suboptimal because of long waiting times and limited donor organ resources. Recent debates involve expansion of these criteria to create options for patients with HCC to increase overall survival.

Varicella zoster virus vaccines: potential complications and possible improvements

Varicella zoster virus(VZV) is the causative agent of varicella(chicken pox) and herpes zoster(shingles). After primary infection, the virus remains latent in sensory ganglia, and reactivates upon weakening of the cellular immune system due to various conditions, erupting from sensory neurons and infecting the corresponding skin tissue. The current varicella vaccine(v-Oka) is highly attenuated in the skin, yet retains its neurovirulence and may reactivate and damage sensory neurons. The reactivation is sometimes associated with postherpetic neuralgia(PHN), a severe pain along the affected sensory nerves that can linger for years, even after the herpetic rash resolves. In addition to the older population that develops a secondary infection resulting in herpes zoster, childhood breakthrough herpes zoster affects a small population of vaccinated children. There is a great need for a neuro-attenuated vaccine that would prevent not only the varicella manifestation, but, more importantly, any establishment of latency, and therefore herpes zoster. The development of a genetically-defined live-attenuated VZV vaccine that prevents neuronal and latent infection, in addition to primary varicella, is imperative for eventual eradication of VZV, and, if fully understood, has vast implications for many related herpesviruses and other viruses with similar pathogenic mechanisms.

Liver injury induced by paracetamol and challenges associated with intentional and unintentional use

Drug induced liver injury(DILI)is a common cause of acute liver injury.Paracetamol,also known as acetaminophen,is a widely used anti-pyretic that has long been established to cause liver toxicity once above therapeutic levels.Hepatotoxicity from paracetamol overdose,whether intentional or nonintentional,is the most common cause of DILI in the United States and remains a global issue.Given the increased prevalence of combination medications in the form of pain relievers and antihistamines,paracetamol can be difficult to identify and remains a significant cause of acute hepatotoxicity,as evidenced by its contribution to over half of all acute liver failure cases in the United States.This is especially concerning given that,when co-ingested with other medications,the rise in serum paracetamol levels may be delayed past the 4-hour post-ingestion mark that is currently used to determine patients that require medical therapy.This review serves to describe the clinical and pathophysiologic features of hepatotoxicity secondary to paracetamol and provide an update on current available knowledge and treatment options.

Emerging concepts in alcoholic hepatitis

Severe alcoholic hepatitis is implicated as a costly,worldwide public health issue with high morbidity and mortality. The one-month survival for severe alcoholic hepatitis is low with mortality rates high as 30%-50%. Abstinence from alcohol is the recommended firstline treatment. Although corticosteroids remain as the current evidence based option for selected patients with discriminant function > 32, improvement of short-term survival rate may be the only benefit. Identification of individuals with risk factors for the development of severe alcoholic hepatitis may provide insight to the diverse clinical spectrum and prognosis of the disease. The understanding of the complex pathophysiologic processes of alcoholic hepatitis is the key to elucidating new therapeutic treatments. Newer research describes the use of gut microbiota modification, immune modulation, stimulation of liver regeneration, caspase inhibitors, farnesoid X receptors, and the extracorporeal liver assist device to aid in hepatocellular recovery. Liver transplantation can be considered as the last medical option for patients failing conventional medical interventions. Although the preliminary data is promising in patients with low risk of recividism, controversy remains due to organ scarcity. This review article comprehensively summarizes the epidemiology, pathophysiology, risk factors, and prognostic indicators of severe alcoholic hepatitis with a focus on the current and emerging therapeutics.

Cellular based treatment modalities for unresectable hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the most common primary malignancy of the liver and is unfortunately associated with an overall poor prognosis and high mortality.Early and intermediate stages of HCC allow for treatment with surgical resection,ablation and even liver transplantation,however disease progression warrants conventional systemic therapy.For years treatment options were limited to molecular-targeting medications,of which sorafenib remains the standard of care.The recent development and success of immune checkpoint inhibitors has proven to be a breakthrough in the treatment of HCC,but there is an urgent need for the development of further novel therapeutic treatments that prolong overall survival and minimize recurrence.Current investigation is focused on adoptive cell therapy including chimeric antigen receptor-T cells(CAR-T cells),T cell receptor(TCR)engineered T cells,dendritic cells,natural killer cells,and tumor infiltrating lymphocyte cells,which have shown remarkable success in the treatment of hematological and solid tumor malignancies.In this review we briefly introduce readers to the currently approved systemic treatment options and present clinical and experimental evidence of HCC immunotherapeutic treatments that will hopefully one day allow for revolutionary change in the treatment modalities used for unresectable HCC.We also provide an up-to-date compilation of ongoing clinical trials investigating CAR-T cells,TCR engineered T cells,cancer vaccines and oncolytic viruses,while discussing strategies that can help overcome commonly faced challenges when utilizing cellular based treatments.

Risk scoring model for prediction of non-home discharge after transcatheter aortic valve replacement

Background Patients undergoing transcatheter aortic valve replacement(TAVR) are likely to be discharged to a location other than home. We aimed to determine the association between preoperative risk factors and non-home discharge after TAVR. Methods Patients discharged alive after TAVR at three centers were identified from a prospectively maintained database randomly divided into 80% derivation and 20% validation cohorts. Logistic regression models were fit to identify preoperative factors associated with non-home discharge in the derivation cohort. Multivariable models were developed and a nomogram based risk-scoring system was developed for use in preoperative counseling. Results Between June 2012 and December 2018, a total of 1,163 patients had TAVR at three centers. Thirty-seven patients who died before discharge were excluded. Of the remaining 1,126 patients(97%) who were discharged alive, the incidence of non-home discharge was 25.6%(n = 289). The patient population was randomly divided into the 80%(n = 900) derivation cohort and 20%(n = 226) validation cohort. Mean ± SD age of the study population was 83 ± 8 years. In multivariable analysis, factors that were significantly associated with non-home discharge were extreme age, female sex, higher STS scores, use of general anesthesia, elective procedures, chronic liver disease, non-transfemoral approach and postoperative complications. The unbiased estimate of the C-index was 0.81 and the model had excellent calibration. Conclusions One out of every four patients undergoing TAVR is discharged to a location other than home. Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.

Cannabis use history is associated with increased prevalence of ascites among patients with nonalcoholic fatty liver disease:A nationwide analysis

BACKGROUND Recent studies have revealed the endocannabinoid system as a potential therapeutic target in the management of nonalcoholic fatty liver disease(NAFLD).Cannabis use is associated with reduced risk for NAFLD,we hypothesized that cannabis use would be associated with less liver-related clinical complications in patients with NAFLD.AIM To assess the effects of cannabis use on liver-related clinical outcomes in hospitalized patients with NAFLD.METHODS We performed a retrospective matched cohort study based on querying the 2014 National Inpatient Sample(NIS)for hospitalizations of adults with a diagnosis of NAFLD.The NIS database is publicly available and the largest all-payer inpatient database in the United States.The patients with cannabis use were selected as cases and those without cannabis were selected as controls.Case-control matching at a ratio of one case to two controls was performed based on sex,age,race,and comorbidities.The liver-related outcomes such as portal hypertension,ascites,varices and variceal bleeding,and cirrhosis were compared between the groups.RESULTS A total of 49911 weighed hospitalizations with a diagnosis of NAFLD were identified.Of these,3820 cases were selected as the cannabis group,and 7625 noncannabis cases were matched as controls.Patients with cannabis use had a higher prevalence of ascites(4.5%vs 3.6%),with and without cannabis use,P=0.03.The prevalence of portal hypertension(2.1%vs 2.2%),varices and variceal bleeding(1.3%vs 1.7%),and cirrhosis(3.7%vs 3.6%)was not different between the groups,with and without cannabis use,all P>0.05.Hyperlipidemia,race/ethnicity other than White,Black,Asian,Pacific Islander or Native American,and higher comorbidity score were independent risk factors for ascites in the cannabis group.Among non-cannabis users,obesity and hyperlipidemia were independent protective factors against ascites while older age,Native American and higher comorbidity index were independent risk factors for ascites.CONCLUSION Cannabis was associated with higher rates of ascites,but there was no statistical difference in the prevalence of portal hypertension,varices and variceal bleeding,and cirrhosis.

The Readability of Online Patient Education Materials from Major Anesthesiology Associations and the American Society of Anesthesiologists

Background: As much as 80% of US adults search online for health related information. The value of the information is limited by the patients’ ability to comprehend it. Despite the recommendation by the American Medical Association (AMA) to provide all patient education materials (PEMs) at a 6th grade reading level, many online sources do not conform. This study aims to evaluate the readability of PEMs from major online sources for anesthesiology. Methods: We determined the readability of PEMs from five major anesthesiology organizations and twelve brochures from the American Society of Anesthesiologists (ASA) using ten validated readability scales. PEMs from the various anesthesiology websites were compiled into a single word document for analysis. The twelve patient education brochures from the ASA were downloaded and analyzed separately. We then grouped the twelve documents into one sample and compared it to the other anesthesiology association websites. Results: All of the PEMs provided by the ASA were determined to be higher than a 6th grade reading level with nine being at a 12th grade reading level or above. The PEMs of the five major anesthesiology association websites were beyond the 6th grade reading level with four out of five at greater than the 12th grade reading level. Conclusion: The results showed that the readability of PEMs provided by five major anesthesiology associations and the ASA was beyond the 6th grade. Therefore, the PEMs with improved readability in anesthesiology are needed.

Hemorrhagic ascites from spontaneous ectopic mesenteric varices rupture in NASH induced cirrhosis and successful outcome:A case report

Bleeding from gastro-esophageal varices can often present as the first decompensating event in patients with cirrhosis. This can be a potentially life threatening event associated with a 15%-20% early mortality. We present a rare case of new onset ascites due to intra-abdominal hemorrhage from ruptured mesenteric varices; in a 37 years old male with newly diagnosed nonalcoholic steatohepatitis induced cirrhosis as the first decompensating event. The patient was successfully resuscitated with emergent evacuation of ascites for diagnosis, identification and control of bleeding mesenteric varices and eventually orthotopic liver transplantation with successful outcome. Various clinical presentations, available treatment options and outcomes of ectopic variceal bleeding are discussed in this report.

Maternal Lead Exposure Induces Down-regulation of Hippocampal Insulin-degrading Enzyme and Nerve Growth Factor Expression in Mouse Pups

Lead exposure is a known potential risk factor for neurodegenerative diseases such as Alzheimer’s disease （AD）. Exposure to lead during the critical phase of brain development has been linked with mental retardation and hypophrenia in later life.

Trends in hospitalization for alcoholic hepatitis from 2011 to 2017:A USA nationwide study

BACKGROUND Severe alcoholic hepatitis(AH)is one of the most lethal manifestations of alcoholassociated liver disease.In light of the increase in alcohol consumption worldwide,the incidence of AH is on the rise,and data examining the trends of AH admission is needed.AIM To examine inpatient admission trends secondary to AH,along with their clinical outcomes and epidemiological characteristics.METHODS The National Inpatient Sample(NIS)database was utilized,and data from 2011 to 2017 were reviewed.We included individuals aged≥21 years who were admitted with a primary or secondary diagnosis of AH using the International Classification of Diseases(ICD)-9 and its correspondent ICD-10 codes.Hepatitis not related to alcohol was excluded.The national estimates of inpatient admissions were obtained using sample weights provided by the NIS.RESULTS AH-related hospitalization demonstrated a significant increase in the USA from 281506(0.7%of the total admission in 2011)to 324050(0.9%of the total admi-ssion in 2017).The median age was 54 years.The most common age group was 45–65 years(range 57.8%–60.7%).The most common race was white(63.2%–66.4%),and patients were predominantly male(69.7%–71.2%).The primary healthcare payers were Medicare(29.4%–30.7%)and Medicaid(21.5%–32.5%).The most common geographical location was the Southern USA(33.6%–34.4%).Most patients were admitted to a tertiary care center(50.2%–62.3%)located in urban areas.Mortality of AH in this inpatient sample was 5.3%in 2011 and 5.5%in 2017.The most common mortality-associated risk factors were acute renal failure(59.6%–72.1%)and gastrointestinal hemorrhage(17.2%–20.3%).The total charges were noted to range between$25242.62 and$34874.50.CONCLUSION The number of AH inpatient hospitalizations significantly increased from 2011 to 2017.This could have a substantial financial impact with increasing healthcare costs and utilization.AH-mortality remained the same.

De novo and recurrence of metabolic dysfunction-associated fatty liver disease after liver transplantation

Metabolic dysfunction-associated fatty liver disease(MAFLD)is a new acronym adopted from the consensus of international experts.Given the increasing prevalence of MAFLD in pre-transplant settings,de novo and recurrent graft steatosis/MAFLD are common in post-transplant settings.The impact of graft steatosis on long-term outcomes is unclear.The current knowledge of incidence rate,risk factors,diagnosis,long-term outcomes,and management of graft steatosis(both de novo and recurrent)is discussed in this review.

Expanding indications for liver transplantation in the era of liver transplant oncology

Despite numerous advances and emerging data,liver transplantation in the setting of gastrointestinal malignancies remains controversial outside of certain accepted indications.In an era of persistent organ shortage and increasing organ demand,allocation of liver grafts must be considered carefully.While hepatocellular carcinoma and hilar cholangiocarcinoma have become accepted indications for transplantation,tumor size and standardized multi-disciplinary treatment protocols are necessary to ensure optimal patient outcomes.As more studies seeking to expand the oncologic indications for liver transplantation are emerging,it is becoming increasingly clear that tumor biology and response to therapy are key factors for optimal oncologic outcomes.In addition,time from diagnosis to transplantation appears to correlate with survival,as stable disease over time portends better outcomes post-operatively.Identifying aggressive disease pre-transplant remains difficult with current imaging and tissue sampling techniques.While tumor size and stage are important prognostic predictors for most malignancies,patient and tumor selection protocols are necessary.As the fields of medical and surgical oncology continue to evolve,it is clear that a protocolized interdisciplinary treatment approach is necessary for combatting any cancer effectively.Disease stability over time and response to neoadjuvant therapy may be the best predictors for successful patient outcomes and can be easily incorporated in our treatment paradigms.Current data evaluating liver transplantation for expanded oncologic indications such as:expanded criteria hepatocellular carcinoma,intrahepatic cholangiocarcinoma,mixed tumors,and liver limited metastatic colorectal carcinomas,incorporate multi-modal therapies and evaluation of tumor treatment response.While further investigation is necessary,initial results suggest there is an expanded role for transplant surgery in malignancy in a new era of liver transplant oncology.