Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis.

BACKGROUND: Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort. METHOD: We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality. RESULTS: Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table 1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65-1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table 2). Table 1 Baseline demographics of the cohort Characteristics Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value N = 1,267,744 N = 728,953 (57.5%) N = 538,781 (42.5%) Age  Mean years (Mean ± SD) 64.8 ± 12.6 58.6 ± 9.5 < 0.001 Gender < 0.001  Male 59.1% 52.3%  Female 40.9% 47.7% *Missing-475 Age groups < 0.001  18-44 3.7% 14.3%  45-64 48% 52.9%  65-84 32.2% 28.7%  ≥ 85 16.1% 4.1% Race < 0.001  Caucasians 67.4% 61.9%  African Americans 9.6% 16.8%  Others 23% 21.3% *Missing-10 Insurance type < 0.001  Medicare 40.9% 36.3%  Medicaid 17.2% 24.3%  Private 31.8% 27.9%  Other 9.9% 11.4% *Missing-75 Active smoking 32.7% 37.9% 0.005 Biliary Stone 36.2% 16.7% < 0.001 Admission Type < 0.001  Emergent 93.7% 94.3%  Elective 6.3% 5.7% *Missing-2880 Hospital ownership/control < 0.001  Rural 7.8% 10%  Urban nonteaching 26.3% 26.6%  Urban teaching 65.9% 63.4% Table 2 Outcomes Outcomes Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value In-hospital mortality *Missing-920 4.3% 2.5% < .0001 1.72(1.65-1.80) < .0001 Length of stay, days (Median,IQR) 6(3-8) 4(2-6) < .0001 Total hospitalization cost, $ (Median,IQR) 14,412(8843-20,216) 10,193(6840-13,842) < .0001 In-Hospital Complications  ARDS 0.4% 0.3% 0.08  Ventilator dependence respiratory failure 0.23% 0.29% 0.25  Septicemia 15.2% 9.6% < .0001  Septic Shock 6.1% 2.9% < .0001  AKI 24.8% 14.9% < .0001 Disposition < .0001  Discharge to home 58.9% 74.9%  Transfer other: includes  Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility 17.1% 8.6%  Home health care 11.5% 8.1%  Against medical advice (AMA) 1.6% 3.4% *Missing-920 CONCLUSION: Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.

The Rolling Stone: Bouveret Syndrome Requiring Open Gastrotomy After Failing Electrohydraulic Lithotripsy.

Bouveret syndrome (BS) is an extremely rare form of gallstone ileus where a stone travels through a biliary-enteric fistula and causes gastric outlet obstruction. A 92-year-old male presented with gastric outlet obstruction secondary to an impacted gallstone in the duodenal bulb seen on imaging. Endoscopic therapy failed twice due to the immense gallstone size, and an open gastrotomy was required to remove the stone. The procedure was successful; however, the patient, unfortunately, passed away days after the operation due to other hospital illnesses. BS should be considered in patients with advanced age and significant comorbidities presenting with gastric outlet obstruction.

Endoscopic Mucosal Resection of Pancreatic Rest Presenting as a Sub-epithelial Nodule in the Gastric Antrum.

Pancreatic rest/ectopic pancreas is a rare condition. An 82-year-old male presented with abdominal pain and was found to have an antral nodule on esophagogastroduodenoscopy (EGD). An endoscopic ultrasound (EUS) was done and the nodule was resected. Histology showed ectopic pancreatic tissue with pancreatic intraepithelial neoplasia, PanIN-1 (low-grade dysplasia). This case highlights the importance of considering pancreatic rest as a differential in patients who present with a gastric sub-epithelial lesion and the associated finding of PanIN-1 highlights the importance of resecting such heterogeneous appearing lesions given the potential risk of progressing to pancreatic ductal adenocarcinoma (PDA).

Effect of Using Personal Protective Equipment during the COVID-19 Pandemic on the Quality Indicators of Screening Colonoscopies.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) has affected many facets of the practice of medicine including screening colonoscopies. AIMS: Our study looks to observe if there has been an effect on the quality of colonoscopies, as indicated by quality measures such as the cecal intubation rate (CIR), cecal intubation time (CIT), scope withdrawal time (SWT), and adenoma detection rate (ADR) with the adoption of standard COVID-19 precautions. METHODS: We conducted a retrospective chart review to analyze the effects of the COVID-19 pandemic on screening colonoscopies. The study utilized data on CIR, CIT, SWT, and ADR from outpatient, nonemergent procedures conducted at 3 endoscopy suites of St. Luke's University Health Network. All inpatient and emergent procedures were excluded. RESULTS: Our study demonstrated that the total number of screening colonoscopies was decreased between 2019 and 2020 (318 in 2019 vs. 157 in 2020, p = 0.005). CIT (320 ± 105 seconds in 2019 vs. 392 ± 107 seconds in 2020, p = 0.001) and SWT (706 ± 232 seconds in 2019 vs. 830 ± 241 seconds in 2020, p = 0.001) were increased while CIR (98.2% in 2019 vs. 96.6% in 2020, p = 0.04) was decreased between 2019 and 2020 likely due to PPE introduction. ADR was similar between the two groups (38.23 (12.50-66.66) in 2019 vs. 38.18 (16.66-66.00) in 2020, p = 0.8). CONCLUSION: Our study showed that quality indices for screening colonoscopies like CIR, CIT, and SWT were negatively impacted during the COVID-19 time period. ADR, however, was similar. Thus, the efficiency of the procedures was affected by the use of PPE but it did not affect the colonoscopy's clinical benefit.

A case of H3N2 complicated by acute kidney injury secondary to rhabdomyolysis.

H3N2 was first detected in July 2011 in the USA. It is responsible for sporadic cases of influenza and localised outbreaks and has not yet taken over on an epidemic or pandemic scale. An 84-year-old man presented with a dry cough, fever and myalgia for 3 days. On examination, he had a pulse of 98 bpm and blood pressure of 124/88 mm Hg. The patient was tachypnoeic, SpO2 was 90%. Auscultation revealed bilateral diffuse wheeze and crackles. He had generalised muscle tenderness on examination. On admission, creatinine was 1.9 mg/dL and CK(creatine kinase) was 44 000 U/L. Chest X-ray was suggestive of ARDS (acute respiratory distress syndrome). Throat swab was positive for H3N2. The patient was given intravenous fluids, oral sodium bicarbonate, oxygen and oseltamivir tablet. In view of ARDS, he was given intravenous methylprednisolone and bronchodilators for bronchospasm. The patient improved symptomatically; vitals and lab reports were normal at the time of discharge.