Mucosa-Associated Lymphoid Tissue Surgeries as a Possible Risk for Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Background: Inflammatory bowel disease (IBD) is a group of chronic inflammatory gastrointestinal disorders that are caused by genetic susceptibility and environmental factors and affects a significant portion of the global population. The gut-associated lymphoid tissue (GALT) is known to play a crucial role in immune modulation and maintaining gut microbiota balance. Dysbiosis in the latter has a known link to IBD. Therefore, the increasing prevalence of adenoidectomy in children should be explored for its potential association with IBD. The objective of this paper was to assess the association between adenoid tissue removal and the risk of developing Crohn's disease (CD) and ulcerative colitis (UC). Methods: We conducted a pooled meta-analysis to evaluate the extended clinical outcomes in patients who underwent appendicectomy and tonsillectomy compared to those who did not. Our approach involved systematically searching the PubMed database for relevant observational studies written in English. We followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines to collect data from various time periods, and to address the diversity in study results; we employed a random-effects analysis that considered heterogeneity. For outcomes, odds ratios (ORs) were pooled using a random-effects model. Results: Seven studies, out of a total of 114,537, met our inclusion criteria. Our meta-analysis revealed a significant association between appendicectomy and CD (OR: 1.57; 95% confidence interval (CI): 1.01 - 2.43; heterogeneity I2 = 93%). Similarly, we found a significant association between tonsillectomy and CD (OR: 1.93; 95% CI: 0.96 - 3.89; I2 = 62%). However, no significant association was observed between appendicectomy and UC (OR: 0.60; 95% CI: 0.24 - 1.47; I2 = 96%), while a modest association was found between tonsillectomy and UC (OR: 1.24; 95% CI: 1.18 - 1.30; I2 = 0%). Conclusions: In summary, we found that the trend of appendicectomy is linked to higher odds of CD, and tonsillectomy is more likely associated with increased odds for both CD and UC, with a risk of bias present.

Trends in Volume and Charges of Retinal Tear Patients in the Emergency Department.

PURPOSE: To characterize retinal tears (RTs) and calculate the economic burden of RTs that present to the emergency department (ED) in the US. METHODS: We used a large national ED database to retrospectively analyze RTs that presented to the ED from 2006 to 2019. Using extrapolation methods, national of the RT patient ED volume, demographics, comorbidities, disposition, inpatient (IP) charges, and ED charges were calculated. RESULTS: During the period between 2006 and 2019, 15841 ED encounters had RT listed as the primary diagnosis. The average annual RT ED encounters was 2,640 ± 856 and comprised an average of 6.4 × 10-5% of all ED visits annually. The number and ED percentage of RT encounters did not change during this time period (p = .22, p = .67, respectively). Most patients were males, Caucasian, paid with private insurance, and admitted to EDs in the Northeast. The most common comorbidities were hypertension (19%), a history of cataracts (15%), and diabetes (7.2%). During this time period, RTs charges added up to more than $79 million and $33 million in the ED and IP settings, respectively. Mean per-encounter ED and IP charges increased by 145% (p = .0008) and 86% (p = .0047), respectively. CONCLUSION: Despite the stable number of RT patients presenting to the ED, RTs place a significant economic burden to the healthcare system, which increases yearly. We recommend physicians and policy makers to work together to pass laws that could prevent the increasing healthcare charges.

Outcomes of COVID-19 amongst patients with ongoing use of inhaled corticosteroids - a systematic review & meta-analysis.

Background: WHO quoted the numbers for the Coronavirus disease 2019 (COVID-19) pandemic as of August 2021 were 200 million cases with over 4 million deaths globally. COVID-19 is associated with several respiratory pathologies. Inhaled corticosteroids (ICS) are used to improve lung function by reducing inflammation, edema, mucus secretion, and inhibiting various cytokine activities. However, there is limited data on the effect of ICS usage in patients with COVID-19. In this study, we aim to evaluate the association between the use of ICS and the outcomes in COVID-19 patients compared to standard COVID-19 treatment. Methods: We followed PRISMA guidelines and MOOSE protocol for conducting the systematic review and meta-analysis comparing ICS and standard COVID-19 therapy. A search on PubMed is conducted yielding 270 articles of which 6 manuscripts are finalized for inclusion in the study. Patients with COVID-19 are identified from the studies based on confirmed positive RT-PCR tests. Hospitalization, ICU admission, and mortality are selected as the outcomes of our study. Using RevMan 5.3, we performed random-effects models to estimate the pooled effect size (pooled odds ratio), 95% confidence interval (95% CI), and heterogeneity (I2). Forest plots are obtained and p <0.05 is considered statistically significant. Results: Our study involves the comparison of ICS vs Non-ICS for mortality (N= 207,842 vs 166,217), ICU hospitalization (N= 1,084 vs 9,425), and the risk of hospitalization (N= 1,273 vs 1,676).Of the six studies, five reported mortality. We found a higher mortality rate in patients with asthma (60.88%, 107/160) and chronic obstructive pulmonary disease (COPD) (68.46%, 382/558) among ICS users. The overall mortality is 7.49% (107/1428). We found that ICS use was associated with higher odds of mortality (OR=1.45 95%CI: 1.10-1.91; p=0.009, I2= 68%) amongst COVID-19 patients. In subgroup analysis, higher odds of mortality among COPD patients using ICS was noted [pooled OR: 1.52 (1.24-1.86); p<0.0001; I2=0%]. However, no significant association between ICS and mortality was observed among asthma patients. Conclusion: ICS is associated with increased mortality and risk for hospitalization in patients with COVID-19 as compared to standard non-steroid-based COVID-19 therapy. It is crucial for healthcare providers to carefully evaluate the potential risks and benefits of ICS usage in the context of COVID-19 management to optimize patient outcomes and safety.

Secondary Prevention of Cryptogenic Stroke and Outcomes Following Surgical Patent Foramen Ovale Closure Plus Medical Therapy vs. Medical Therapy Alone: An Umbrella Meta-Analysis of Eight Meta-Analyses Covering Seventeen Countries.

Background: Cryptogenic stroke (CS) is an exclusion diagnosis that accounts for 10-40% of all ischemic strokes. Patent foramen ovale (PFO) is found in 66% of patients with CS, while having a prevalence of 25-30% in the general population. The primary aim was to evaluate the risk of recurrent stroke following surgical PFO closure plus medical therapy vs. medical therapy alone amongst CS, an embolic stroke of undetermined source (ESUS), or transient ischemic attack (TIA). The secondary aim was to evaluate new-onset non-valvular atrial fibrillation, mortality, and major bleeding. Methods: We conducted an umbrella meta-analysis using PRISMA guidelines on English studies comparing surgical PFO closure plus medical therapy versus medical therapy alone for managing CS. We extracted data on interventions and outcomes and used random-effects models with generic inverse variance to calculate relative risks (RRs) with 95% confidence intervals for outcome calculations. Results: A comprehensive search yielded 54,729 articles on CS and 65,001 on surgical PFO closure, with 1,591 studies focusing on PFO closure and medical therapy for secondary CS, ESUS, or TIA prevention. After excluding non-meta-analyses, 52 eligible meta-analyses were identified, and eight studies were selected for outcome evaluation, excluding non-English, non-human, and studies before January 2019 as of August 31, 2021. Among a total of 41,880 patients, 14,942 received PFO closure + medical therapy, while 26,938 patients received medical therapy alone. Our umbrella meta-analysis showed that PFO closure plus medical therapy had a 64% lower risk of recurrent strokes than medical therapy alone (pooled RR: 0.36). PFO closure plus medical therapy was associated with 4.94 times higher risk of atrial fibrillation. There was no difference in the risk of death or bleeding between both groups. Conclusion: In patients with CS, PFO closure, in addition to medical therapy, reduces the risk of recurrence. More research is needed to assess the efficacy of early closure as well as specific risk profiles that would benefit from early intervention to reduce the burden of stroke.

Gastrointestinal Manifestations and Outcomes of COVID-19: A Comprehensive Systematic Review and Meta-analysis.

Introduction Pulmonary symptoms are the most prominent manifestations of Coronavirus disease 2019 (COVID-19). However, gastrointestinal (GI) symptoms have been reported widely as well. Literature describing the relation of these symptoms with outcomes of COVID-19 patients is limited in terms of sample size, geographic diversity, and the spectrum of GI symptoms included. We aim to evaluate the association of GI symptoms with outcomes of hospitalized COVID-19 patients. Methods A systematic review and meta-analysis of observational studies assessing GI symptoms and outcomes in COVID-19 patients were undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist. Details on outcomes included ICU vs. non-ICU admission, severe vs. non-severe disease, invasive mechanical ventilation (IMV) vs. no-IMV use, oxygen saturation <90% vs. >90%, in-hospital mortality vs. discharged alive and survivors. We obtained the odds ratio (OR), 95% confidence interval (95%CI), and forest plots. Sensitivity analysis was used to analyze publication bias and heterogeneity. Results In 35 studies with 7931 confirmed COVID-19 patients, we found that anorexia (pooled OR:2.05; 95%CI: 1.36-3.09, p=0.0006) and abdominal pain (OR 2.80; 95%CI: 1.41-5.54, p=0.003) were associated with a higher risk of poor outcomes and no such association was found for diarrhea (OR 1.04; 95%CI: 0.85-1.26, p=0.71), nausea (OR 0.73; 95%CI: 0.38-1.39, p=0.34) and vomiting (OR 1.24; 95%CI 0.86-1.79, p=0.25). Conclusion The meta-analysis concludes that anorexia and abdominal pain are associated with poor outcomes in hospitalized COVID-19 patients, while diarrhea, nausea, and vomiting have no association. Future research should focus on whether detecting GI invasion in conjunction with fecal polymerase chain reaction (PCR) testing can aid in the early triage of high-risk individuals and improve outcomes.

Effectiveness of Repetitive Transcranial Magnetic Stimulation in Depression, Schizophrenia, and Obsessive-Compulsive Disorder: An Umbrella Meta-Analysis.

Objective: To analyze the safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder, schizophrenia, and obsessive-compulsive disorder (OCD) via umbrella meta-analysis.Data Sources: Meta-analysis studies were searched in PubMed from inception to May 2021 using the keywords anxiety, depression, ADHD, schizophrenia, mood disorder, OCD, psychiatric disorders, GAD, bipolar disorders, ASD, PTSD, transcranial magnetic stimulation, transcranial, magnetic, stimulation. PRISMA guidelines were followed.Study Selection: Abstracts and full-length articles were reviewed for meta-analysis studies with data on the safety and efficacy of rTMS and sham and were collected for quantitative analysis. The full texts of all identified studies were independently screened and assessed to determine eligibility. Any disagreement was resolved through consensus.Data Extraction: The descriptive variables extracted included the author names, study year, sample size, studies included in the meta-analysis, study period, and type of intervention.Results: 28 meta-analyses were included; 13 were on treatment-resistant depression, 9 on schizophrenia, and 6 on OCD. In treatment-resistant depression, the rTMS group had higher odds of response compared to sham (odds ratio [OR] = 3.27; 95% CI, 2.76-3.87; P < .00001) and higher odds of remission (secondary outcome) (OR = 2.83; 95% CI, 2.33-3.45; P < .00001). rTMS was superior to sham in the reduction of negative symptoms of schizophrenia (mean difference [MD]: 0.47; 95% CI, 0.23-0.7; P < .0001). However, no significant difference was found between the effects of rTMS and sham on auditory hallucinations (MD: 0.24; 95% CI, 0.26-0.74; P = .35), which resulted in 94% heterogeneity. TMS was better than sham in reducing the severity of OCD symptoms (MD: 0.81; 95% CI, 0.53-1.10; P < .00001).Conclusions: The effectiveness of rTMS for symptom reduction in various psychiatric disorders is associated with differences in neuropathology, disease-specific target site, and frequency of rTMS.Prim Care Companion CNS Disord 2023;25(5):22r03423. Author affiliations are listed at the end of this article.

Prevalence and Outcomes of Depression, Obstructive Sleep Apnea, and Concurrent Anxiety (DOCA) in Stroke Survivors: Insights From a Nationwide Study.

BACKGROUND: Many individuals will also experience psychological side effects after a stroke episode, such as symptoms of depression, anxiety (generalized anxiety disorder (GAD)), and/or specific phobias, considerably decreasing their quality of life (QOL). OBJECTIVE: This study aimed to evaluate the prevalence of depression, obstructive sleep apnea (OSA), and concurrent anxiety (DOCA) and their outcomes (morbidity, disability (All Patient Refined Diagnosis Related Group (APRDRG) - loss of function), and discharge disposition) among acute ischemic stroke (AIS) hospitalizations. METHODS: A cross-sectional study used the National Inpatient Sample (NIS) from 2003-2017. Adults with hospitalizations with AIS were extracted, and DOCA was identified using ICD-9/10-CM codes. Weighted analysis using a chi-square test and mixed-effect multivariable survey logistic regression was used to assess the prevalence and role of DOCA in predicting outcomes. RESULTS: Out of 5,690,773 AIS hospitalizations, 2.7%, 3.1%, and 4.4% had depression, OSA, and GAD, respectively. In AIS patients, females had a higher prevalence of depression (3.4% vs. 2.3%) and GAD (5.9% vs. 3.0%) and a quality of life lower prevalence of OSA (2.2% vs 4.4%) in comparison to males (p<0.0001). Caucasians had a higher prevalence of depression, OSA, and GAD in comparison to others (African Americans/Hispanics/Asians/Native Americans). Depressed patients had a higher prevalence of morbidity (9% vs. 8% vs 5% vs. 7%), disability (46% vs. 46% vs. 35% vs. 37%), transfer to non-home (69% vs. 58% vs. 61% vs. 63%) in comparison with OSA, GAD, and non-DOCA patients, respectively (p<0.0001). Depression was associated with a 40% higher chance of severe disability (aOR 1.40; 95% CI 1.38-41), morbidity (1.36; 1.33-1.38), and discharge to non-home (1.54; 1.52-1.56). OSA and GAD had higher odds of non-home discharge amongst post-AIS hospitalizations. CONCLUSION: DOCA is associated with poor outcomes among post-AIS patients. Prompt recognition by screening and timely management of DOCA may mitigate the adverse outcomes.

Substance Use Disorders (SUDs) and Risk of Cardiovascular Disease (CVD) and Cerebrovascular Disease (CeVD): Analysis of the Nationwide Inpatient Sample (NIS) Database.

BACKGROUND:  Substance use continues to be on the rise in the United States and has been linked to new onset cardiovascular diseases (CVDs) and cerebrovascular disorders (CeVDs). We aimed to study the association between the types of substance use disorders (SUDs) with specific subtypes of CVDs and CeVDs among hospitalized patients using the National Inpatient Sample (NIS) Database. METHODS:  A retrospective study of the NIS database (2016-2017) using the ICD-10-CM codes was performed. The hospitalizations with a secondary diagnosis of SUDs were identified. Weighted univariate analysis using the Chi-square test and multivariate survey logistic regression analysis was performed to evaluate for the incidence, prevalence, and odds of association between vascular events and SUDs. RESULTS:  There were a total of 58,259,589 hospitalizations, out of which 21.42% had SUDs. SUDs were more common in the younger age group of 18-50, males, and the lower median household income group. We found a significant association of acute ischemic stroke (AIS) with amphetamine dependence (adjusted odds ratio, aOR 1.23, 95% confidence interval, CI 1.14-1.33), cocaine-related disorders (1.17, 1.12-1.23), and nicotine dependence (1.42, 1.40-1.43). There was a significant association between intracerebral hemorrhage with amphetamine dependence (2.58, 2.26-2.93), cocaine-related disorders (1.62, 1.46-1.79), and alcohol-related disorders (1.35, 1.01-1.82). The association of subarachnoid hemorrhage (SAH) was noted to be higher with amphetamine dependence (1.82, 1.48-2.24) and nicotine dependence (1.47, 1.39-1.55). The patients with nicotine dependence had greater odds of having a myocardial infarction (1.85, 1.83-1.87), those with cocaine-related disorders had higher odds of having angina pectoris (2.21, 1.86-2.62), and patients with alcohol-related disorders had higher odds of developing atrial fibrillation (1.14, 1.11-1.17) in comparison to non-SUDs. CONCLUSION:  Our study demonstrates the variability of CVD and CeVD in patients hospitalized for SUD. Findings from our study may help promote increased awareness and early management of these events. Further studies are needed to evaluate the specific effects of frequency and dose on the incidence and prevalence of CVD and CeVD in patients with SUD.

Epidemiology, Trends, Utilization Disparities, and Outcomes of Catheter Ablation and Its Association With Coronary Vasospasm Amongst Patients With Non-valvular Atrial Fibrillation: A Nationwide Burden of Last Decade.

BACKGROUND: Catheter ablation (CA) is an important curative treatment for non-valvular atrial fibrillation (NVAF), however, nationwide data on its utilization and disparities is limited. Coronary vasospasm is a rare, life-threatening, peri-operative complication of CA with limited literature in Caucasians. METHODS: We performed a retrospective study on adult hospitalizations in the USA from 2007 to 2017 by obtaining the data from National Inpatient Sample. The primary endpoints of our study were to identify the utilization rate of CA, disparities in utilization, and study the outcomes associated with CA. The secondary endpoints of the study were to identify the incidence of coronary vasospasm amongst patients who underwent CA, evaluate their association, and identify the predictors of coronary vasospasm. RESULTS: From 35,906,946 patients with NVAF, 343641 (0.96%) underwent CA. Its utilization decreased from 1% in 2007 to 0.71% in 2017. Patients who underwent CA, compared to those without CA, fared better in terms of hospital length of stay, mortality rate, disability rate, and discharge to the non-home facility. Patients in the 50-75 years age group, Native Americans, those with private insurance, and median household income of 76-100th percentile were associated with higher odds of CA utilization. Urban teaching hospitals and large-bedded hospitals performed more ablations, while the Mid-West region fared lower than the South, the West, and the Northeast. The prevalence of coronary vasospasm was higher amongst CA in comparison without CA, however, in regression analysis, no significant association was demonstrated between CA and coronary vasospasm. CONCLUSION: CA is an important treatment modality that is associated with improved clinical outcomes. Identification of factors associated with lower utilization of CA and its disparities will help to mitigate the burden associated with NVAF.

Prevalence of active and passive smoking among asthma and asthma-associated emergency admissions: a nationwide prevalence survey study.

Asthma affects 7% of children and 8% of adults in the United States. There is a paucity of studies examining the association between passive smoking and an increased risk of asthma exacerbations that led the authors to examine the association between various modes of smoking and rates of asthma exacerbations. A retrospective cross-sectional/case-control study was conducted using the National Health and Nutrition Examination Survey dataset (2013-2018). Out of 312,979 respondents, 35,758 (11.43%) had a history of asthma, 9083 (2.9%) had asthma attacks in the past year, and 4731 (1.51%) had asthma-related emergency room admissions in the past year. Prevalence of asthma-related emergency admissions were higher among active cigarette smoking (46.25 vs 35.46%), e-cigarette smoking (26.63 vs 16.07%), and passive smoking at home (37.53 vs 25.67%), workplace passive smoking (14.35 vs 12.11%), in bar (32.38 vs 26.16%), and car (26.21 vs 14.44%) (p < 0.0001). In multivariate regression analysis, we found regular cigarette smoking (OR 1.13, 95% confidence interval (CI) 1.009-1.260, p = 0.0252), e-cigarette (OR 2.13, 95% CI 1.92-2.36, p = 0.0043), cigar use (OR 1.21, 95% CI 1.1-1.33, p < 0.001), ultra-long cigarette length (OR 4.85, 95% CI 3.33-7.06, p < 0.0001), and passive smoking (OR 5.25, 95% CI 3.43-8.06, p < 0.0001) were associated with increased rates of asthma exacerbations over last 12 months. The study shows increased odds of asthma exacerbations among those using ultra-long cigarettes, e-cigarettes, and cigars. Consequently, passive inhalation from even a single smoker in the home, workplace, bars and cars is associated with worsening outcomes in asthma patients.

E-cigarette use and prevalence of lung diseases among the U.S. population: a NHANES survey.

The primary aim of this study was to evaluate epidemiological characteristics and prevalence of lung disease among e-cigarettes users in the United States. A population-based, cross-sectional survey was performed using the National Health and Nutrition Examination Survey (NHANES) of 2015-2018. Adults using e-cigarettes (SMQ900), traditional smoking (SMQ020: > 100 cigarettes in lifetime or SMQ040: current cigarettes use), and dual smoking (e-cigarettes and traditional smoking) were identified and compared in their sociodemographic characteristics and prevalence of lung diseases (Asthma: MCQ010 and COPD: MCQ160O). We used the chi square test (categorical variables) and Mann-Whitney test and unpaired-student t test (continuous variables). p-value <0.05 was used as a reference. We excluded respondents <18 years and missing data on demographics and outcomes. Out of 178,157 respondents, 7745 (4.35%), 48,570 (27.26%), and 23,444 (13.16%) were e-cigarette smokers, traditional smokers, and dual smokers, respectively. Overall prevalence of asthma was 15.16% and COPD was 4.26%. E-cigarette smokers were younger in comparison to traditional smokers (median: 25 years vs 62 years; p < 0.0001). In females (49.34% vs 37.97%), Mexican (19.82% vs 13.35%), annual household income above $100,000 (23.97% vs 15.56%), prevalence of e-cigarette smoking was higher in comparison to traditional smoking (p < 0.0001). The prevalence of COPD was higher among dual smokers in comparison to e-cigarette and traditional smoking (10.14% vs 0.25% vs 8.11%; p < 0.0001). Prevalence of asthma was higher among dual and e-cigarette smokers in comparison with traditional smokers and non-smokers (22.44% vs 21.10% vs 14.46% vs 13.30%; p < 0.0001). Median age (Q1-Q3) was lower at which asthma (7 years (4-12) vs 25 years (8-50)) was diagnosed first among e-cigarettes smokers in comparison with traditional smokers. In a mixed effect multivariable logistic regression analysis, we found higher odds of asthma among e-cigarette users in comparison with non-smokers (Odds ratio (OR): 1.47; 95% Confidence Interval (CI): 1.21-1.78; p = 0.0001). Chronic Obstructive Pulmonary Disease (COPD) respondents were also associated with 11.28 higher odds of e-cigarette utilization (Oddsratio (OR): 11.28; 95% Confidence Interval (CI): 5.59-22.72; p < 0.0001). We conclude the higher prevalence of e-cigarette users is seen among the younger population, female, Mexican race, and annual income above $100,000 in comparison to traditional smokers. Chronic Obstructive Pulmonary Disease (COPD) and asthma were both more prevalent in dual smokers. As asthma was more prevalent and diagnosed at an early age in e-cigarette smokers, more prospective studies are needed to understand the effects of e-cigarette among the population at risk to mitigate the sudden rise in utilization and to create awareness.

Uncommon Presentation of Undiagnosed B-Cell Lymphoproliferative Disorder as Nodular Pulmonary Amyloidosis.

B-cell lymphoproliferative disorders are characterized by the accumulation of mature B lymphocytes in the bone marrow, lymphoid tissues, and/or peripheral blood. They can cause amyloid deposits in the lungs. In rare cases, lung nodules can be the first sign of this disorder. We present the case of an 89-year-old woman with stable shortness of breath and lung nodules on imaging. A positron emission tomography-computed tomography (PET-CT) scan showed the most intense hypermetabolic nodule in the patient's lung, which was 1.5 × 1.4 cm. A biopsy of this nodule showed amyloid material with trapped plasma cell infiltrate on microscopy. Congo red stain under polarizing microscopy showed apple-green birefringence, which is diagnostic for amyloidosis. Immunohistochemistry showed a mixture of kappa-positive and lambda-positive cells. B-cell gene rearrangement-clonal gene rearrangements were detected in the immunoglobulin heavy chain (IgH) gene and the kappa light chain (IGK). These findings suggest a B-cell lymphoproliferative disorder, such as a plasmacytoma or a marginal cell lymphoma with plasma cell differentiation. The patient was diagnosed with a B-cell lymphoproliferative disorder and pulmonary amyloidosis. Isolated amyloidosis in the lungs usually has a good prognosis, but it can be a sign of autoimmune diseases or B-cell lymphoproliferative disorders, as in this case. Early diagnosis of B-cell lymphoproliferative disorder can lead to successful treatment and prevents complications.

Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis.

PURPOSE: To examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization. METHODS: We applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant. MAIN FINDINGS: Medicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]). PRINCIPAL CONCLUSIONS: Likelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.

Within-Person Blood Pressure Variability During Hospitalization and Clinical Outcomes Following First-Ever Acute Ischemic Stroke.

BACKGROUND: Uncertainty remains over the relationship between blood pressure (BP) variability (BPV), measured in hospital settings, and clinical outcomes following acute ischemic stroke (AIS). We examined the association between within-person systolic blood pressure (SBP) variability (SBPV) during hospitalization and readmission-free survival, all-cause readmission, or all-cause mortality 1 year after AIS. METHODS: In a cohort of 862 consecutive patients (age [mean ± SD] 75 ± 15 years, 55% women) with AIS (2005-2018, follow-up through 2019), we measured SBPV as quartiles of standard deviations (SD) and coefficient of variation (CV) from a median of 16 SBP readings obtained throughout hospitalization. RESULTS: In the cumulative cohort, the measured SD and CV of SBP in mmHg were 16 ± 6 and 10 ± 5, respectively. The hazard ratios (HR) for readmission-free survival between the highest vs. lowest quartiles were 1.44 (95% confidence interval [CI] 1.04-1.81) for SD and 1.29 (95% CI 0.94-1.78) for CV after adjustment for demographics and comorbidities. Similarly, incident readmission or mortality remained consistent between the highest vs. lowest quartiles of SD and CV (readmission: HR 1.29 [95% CI 0.90-1.78] for SD, HR 1.29 [95% CI 0.94-1.78] for CV; mortality: HR 1.15 [95% CI 0.71-1.87] for SD, HR 0.86 [95% CI 0.55-1.36] for CV). CONCULSIONS: In patients with first AIS, SBPV measured as quartiles of SD or CV based on multiple readings throughout hospitalization has no independent prognostic implications for the readmission-free survival, readmission, or mortality. This underscores the importance of overall patient care rather than a specific focus on BP parameters during hospitalization for AIS.

Past and Present of Point-of-Care Ultrasound (PoCUS): A Narrative Review.

This article aims to conduct a literature review to gain insight into point-of-care ultrasound (PoCUS). PoCUS is a rapid, accurate, non-invasive, and radiation-free imaging modality that can be used in stable and unstable patients. PoCUS can be performed parallel to physical examination, resuscitation, and stabilization; repeated exams in critical patients are essential for improving sensitivity. The review highlights how PoCUS, which was initially used to detect free intraperitoneal fluid in trauma patients, has developed into a life-saving diagnostic tool that could be utilized by treating physicians during various stages of diagnosis, resuscitation, operation, and postoperative critical care when managing sick patients. The review also notes the barriers to the widespread uptake of PoCUS in general internal medicine and the recent commercial availability of "pocket" or handheld probes that have made PoCUS more readily available. This review concludes that adopting a focused binary decision-making approach can maximize PoCUS's value in many clinical settings, including emergency departments, intensive care units, and operation theatres. Overall, the review emphasizes the importance of awareness of common indications, limitations, and strengths of this evolving and promising technology to determine its future trajectory: Providing comprehensive PoCUS training within internal medicine curriculums and supporting trainers to do so.

Depression in Childhood Asthma vs. Adult-Onset Asthma: A Cross-Sectional Study from the National Health and Nutrition Examination Survey (NHANES).

Background: asthma, a chronic respiratory disease caused by inflammation and narrowing of the small airways in the lungs, is the most common chronic childhood disease. Prevalence of childhood asthma in the United States is 5.8%. In boys, prevalence is 5.7% and it is 6% in girls. Asthma is associated with other comorbidities such as major depressive disorder and anxiety disorder. This study explores the association between asthma and depression. Methods: we conducted a retrospective cross-sectional study using NHANES data from 2013 to 2018. Asthma and childhood onset asthma were assessed using questionnaires MCQ010 and MCQ025, respectively. Sociodemographic variables were summarized, and univariate analysis was performed to determine the association between asthma and major depressive disorder and its individual symptoms. Results: there were 402,167 participants from 2013−2018 in our study: no asthma in 84.70%; asthma in 15.30%. Childhood onset asthma (COA) included 10.51% and adult-onset asthma (AOA) included 4.79%. Median age of COA is 5 years and AOA is 41 years. Among the asthma groups, most AOA were females (67.77%, p < 0.0001), most COA were males (52.16%, p < 0.0001), and ethnicity was predominantly White in AOA (42.39%, p < 0001) and in COA (35.24%, p < 0.0001). AOA mostly had annual household income from $0−24,999 (35.91%, p < 0.0001), while COA mostly had annual household income from $25,000−64,999 (36.66%, p < 0.0001). There was a significantly higher prevalence of MDD in COA (38.90%) and AOA (47.30%) compared to NOA (31.91%). Frequency of symptoms related to MDD were found to have a significantly higher prevalence and severity in the asthma groups compared to no asthma, and slightly greater and more severe in AOA than in COA. Symptoms include having little interest in doing things (COA 18.38% vs. AOA 22.50% vs. NOA 15.44%), feeling down, depressed, or hopeless (COA 20.05% vs. AOA 22.77% vs. NOA 15.85%), having trouble sleeping or sleeping too much (COA 27.38% vs. AOA 23.15% vs. NOA 22.24%), feeling tired or having little energy (COA 39.17% vs. AOA 34.24% vs. NOA 33.97%), having poor appetite or overeating (COA 19.88% vs. AOA 20.02% vs. NOA 15.11%), feeling bad about yourself (COA 13.90% vs. AOA 13.79% vs. NOA 10.78%), having trouble concentrating on things (COA 12.34% vs. AOA 14.41% vs. NOA 10.06%), moving or speaking slowly or too fast (COA 8.59% vs. AOA 9.72% vs. NOA 6.09%), thinking you would be better off dead (COA 3.12% vs. AOA 4.38% vs. NOA 1.95%) and having the difficulties these problems have caused (COA 21.66% vs. AOA 26.73% vs. NOA 19.34%, p < 0.0001). Conclusion: MDD and related symptoms were significantly higher and more severe in participants with asthma compared to no asthma. Between adult-onset asthma compared to childhood onset asthma, adult-onset asthma had slightly greater and more severe MDD and related symptoms compared to childhood onset asthma.

Prevalence of Cerebrovascular Accidents Among the US Population With Substance Use Disorders: A Nationwide Study.

Introduction Globally, stroke is one of the top ten causes of death. The incidence of stroke in patients aged 44 years and younger was noted to have risen over the past three decades. This rise in stroke diagnosis among young adults could be attributed to multiple reasons, including the rising prevalence of comorbidities like diabetes, hypertension, substance use disorders (SUDs), etc. Aim & objectives This study's primary aim was to evaluate the prevalence of stroke in the US population and the prevalence of SUDs amongst patients with a prior history of stroke. The secondary aim was to evaluate the association between Stroke and SUDs. Methods Our population was obtained from the National Health and Nutrition Examination Survey (NHANES) between the years 2013 to 2018. We identified respondents diagnosed with stroke using the questionnaire and the history of various SUDs amongst this population. The data were analyzed using SAS software (Version 9.4). We performed univariate analysis using the chi-square and Mann-Whitney test, and a p-value of <0.05 was considered statistically significant. Results Two hundred sixty-four thousand seven hundred forty (264,740) respondents were included in this study, and 10435 (3.94%) respondents were noted to have a history of stroke. The population subset with a stroke diagnosis was older (68 years vs. 51 years). Higher prevalence was noted among the female sex (52.14% females vs. 47.86% males), Non-Hispanic white ethnicity, followed by Non-Hispanic black & then other Hispanics (47.56% vs.25.47% vs. 7.82%), and those belonging to a lower annual household income of $0-$25,000 and $25,000-$65,000 ( 46.61% vs. 35.93% ). (p<0.0001). After adjusting for socio-demographics and coexisting comorbidities, e-cigarette [OR: 2.03; 95% CI: 2.03-2.03], cocaine [OR: 1.54; 95%CI:1.54-1.54], heroin [OR: 1.83; 95%CI: 1.83-1.83], marijuana or hashish [OR: 1.01; 95% CI: 1.01-1.01], were observed to have an association with higher odds of stroke than the population without a history of using these illicit drugs.  Conclusion Among respondents with a history of stroke, the use of cocaine was most prevalent, followed by marijuana/hashish, heroin, e-cigarettes, and injecting illegal drugs. The odds of having a stroke were two times higher in the population using an e-cigarette and higher among those using heroin, cocaine, and marijuana/ hashish. The Government should plan policy changes to treat SUDs in the USA, which could help reduce the stroke burden. Recall that bias and geographic variations in response rate by participants of the study were the limitations of our survey-based study.

Long-Term Neurological Sequelae Among Severe COVID-19 Patients: A Systematic Review and Meta-Analysis.

Few studies have thoroughly evaluated the neuro-invasive effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which may contribute to a wide range of sequelae from mild long-term effects like headaches and fatigue to severe events like stroke and arrhythmias. Our study aimed to evaluate the long-term neurological effects of coronavirus disease 2019 (COVID-19) among patients discharged from the hospital. In this systematic review and meta-analysis, we assessed the long-term neurocognitive effects of COVID-19. Post-COVID-19 neurological sequelae were defined as persistent symptoms of headache, fatigue, myalgia, anosmia, dysgeusia, sleep disturbance, issues with concentration, post-traumatic stress disorder (PTSD), suicidality, and depression long after the acute phase of COVID-19. Data from observational studies describing post-COVID-19 neurocognitive sequelae and severity of COVID-19 from September 1, 2019, to the present were extracted following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol with a consensus of three independent reviewers. A systematic review was performed for qualitative evaluation and a meta-analysis was performed for quantitative analysis by calculating log odds of COVID-19 neurocognitive sequelae. The odds ratio (OR) and 95% confidence interval (CI) were obtained and forest plots were created using random effects models.  We found seven studies, out of which three were used for quantitative synthesis of evidence. Of the 3,304 post-COVID-19 patients identified, 50.27% were male with a mean age of 56 years; 20.20% had post-COVID-19 symptoms more than two weeks after the acute phase of infection. Among persistence symptoms, neurocognitive symptoms like headache (27.8%), fatigue (26.7%), myalgia (23.14%), anosmia (22.8%), dysgeusia (12.1%), sleep disturbance (63.1%), confusion (32.6%), difficulty to concentrate (22%), and psychiatric symptoms like PTSD (31%), feeling depressed (20%), and suicidality (2%) had a higher prevalence. In meta-analysis, COVID-19 patients with severe symptoms had higher odds of headache (pooled OR: 4.53; 95% CI: 2.37-8.65; p<0.00001; I2: 0%) and myalgia (pooled OR: 3.36; 95% CI: 2.71-4.17; p<0.00001; I2: 0%). Anosmia, fatigue, and dysgeusia had higher but non-significant odds following COVID-19. Although we had sufficient data for headache and fatigue to identify higher rates and associations following COVID-19, we could not establish relationships with other post-COVID-19 neurocognitive séqueles. Long-term follow-up may mitigate the neurocognitive effects among COVID-19 patients as these symptoms are also associated with a poor quality of life.

Carpal Tunnel Syndrome: Pathophysiology and Comprehensive Guidelines for Clinical Evaluation and Treatment.

In carpal tunnel syndrome (CTS), the median nerve is compressed at the level of the carpal tunnel in the wrist. This entrapment manifests as unpleasant symptoms, such as burning, tingling, or numbness in the palm that extends to the fingers. As the disease progresses, afflicted individuals also report decreased grip strength accompanied by hand weakness and restricted movement. The first half of this review elaborates on CTS pathology by providing readers with a comprehensive understanding of the etiology, relevant anatomy, and disease mechanism. CTS is considered the most common entrapment neuropathy, affecting around 3-6% of the adult population. Further, CTS prevalence has seen a dramatic increase in the last few decades paralleling the growth of everyday technology usage. Despite how common it is to have CTS, it can be quite challenging for physicians to make a definite diagnosis due to differentials that present with overlapping symptoms. Even more difficult can be deciding on a course of treatment that is the most effective and considerate of patient needs. Thus arises the need for clear clinical direction, and hence we end with a discussion around such guidelines that serve as a starting point toward effective diagnoses and patient treatment.

Epidemiology, Burden, and Association of Substance Abuse Amongst Patients With Cardiovascular Disorders: National Cross-Sectional Survey Study.

BACKGROUND: Substance use disorders (SUDs) are considered to be a major risk factor for cardiovascular disorders (CVDs). In 2019, as per the National Drug Use and Health Survey (NSDUH), 20.4 million American adults suffered from a substance use disorder. The main purpose of this study is to determine the prevalence of several SUDs (cigarette smoking, cigar, smokeless tobacco, marijuana, cocaine/heroin/methamphetamine, and injectable illegal drug) amongst patients diagnosed with various CVDs (angina pectoris, myocardial infarction, and coronary heart disease). METHODS: This is a retrospective cross-sectional study carried out using the National Health and Nutrition Examination Survey (NHANES) database from 2013 to 2018, and respondents with CVDs were recognized using questionnaires. Different SUDs (active history) were identified amongst the adult population with a history of CVDs and without CVDs. Univariate analysis was performed using chi-square and unpaired t-test/Mann-Whitney test to identify characteristics of respondents with CVDs and mix effect multivariable logistic regression models were generated to find the prevalence of SUDs amongst the CVD population. Datasets were analyzed using Statistical Analysis System (SAS) software, and the p-value of < 0.05 was considered statistically significant. RESULTS: Of the 263465 respondents, 7.90% respondents were diagnosed with CVDs and were noted to be in older age group (median age: 69 years). CVDs were more prevalent amongst 66-years and above (19.36% vs. 45-64 years: 6.81% vs. 18-44 years: 1.17%), male (10.40% vs. female: 5.66%), Non-Hispanic White race (10.92%), and lower annual household income population (<$25000 vs. >$100,000:12.21% vs. 4.01%) (p<0.0001). When compared with respondents without a history of CVDs, respondents with a history of CVDs were noted to be more prevalent with a concurrent diagnosis of hypertension (85.98% vs. 79.53%), hypercholesterolemia (68.78% vs. 34.54%), diabetes (37.86% vs. 12.70%), stroke (17.4% vs. 2.71%), and congestive heart failure (28.80% vs. 1.31%) (p<0.0001). History of CVDs were more prevalent amongst the respondents using marijuana (overall 53.14%; CVD vs. no-CVD 65.42% vs. 52.81%; p<0.0001), cigarette smoking (60.47% vs. 40.41%; p<0.0001), cigar-smoking (47.05% vs. 35.58%; p<0.0001), methamphetamine/cocaine/heroin (23.82% vs. 16.71%; p<0.0001), smokeless tobacco use (18.53% vs. 14.59%; p<0.0001), and injectable illegal drug use (4.67% vs. 2.43%; p<0.0001). Additionally, prevalence of history of CVDs was almost double in respondents using cigarettes without filters (2.28% vs. 1.10%; p<0.0001) when compared with respondents using cigarettes with filters. CONCLUSION: Respondents who used marijuana or hashish, injectable illegal drugs, and e-cigars were at elevated risk for cardiovascular disorders. Providing situational awareness and offering a good support system can be a strategy to prevent the development of cardiovascular disorders among substance users.