Risk factors for discharge against medical advice in patients with UGI bleeding or abdominal pain: a study of 170 discharges against medical advice among 11,996 emergency department visits.

AIM: The aim of this study was to identify rate of and risk factors for patients leaving against medical advice (AMA) from the emergency department (ED) with abdominal pain or upper gastrointestinal (GI) bleeding. METHODS: The National Hospital Ambulatory Medical Care Survey is a limited access dataset that includes ED visit data. All patients who left AMA between years 2007-2009 who had the diagnosis of upper GI bleeding or abdominal pain were studied. The following demographic factors were analyzed as potential risk factors for discharge AMA: patient age, sex, race/ethnicity, geographic location, annual income, type of insurance, urban versus rural status, prior ED visits, ED waiting time, and diagnosis of psychiatric illness. RESULTS: From 2007-2009, a total of 104,566 ED visits were analyzed, of which 1135 (1.1%) were ED visits of patients leaving AMA. Among those leaving AMA, 170 patients (1.4%) leaving AMA presented with upper GI bleeding or abdominal pain. Of nine analyzed parameters, only two parameters statistically significantly affected the rate of leaving AMA. First, patients aged 19-44 years were significantly more likely to leave AMA (P=0.001, odds ratio (OR)=1.67; 95%-CI: 1.21-2.32) whereas patient aged >65 years were less likely to leave AMA with upper GI bleeding or abdominal pain (P=0.01; OR=0.49; 95%-CI: 0.27-0.87). Second, patients with 1-5 prior ED visits were significantly more likely to leave AMA than other patients (P=0.009; OR=1.85; 95% CI: 1.15-2.97). Patients with psychiatric illness tended to have a greater risk of leaving AMA, with borderline statistical significance (P=0.04) Gender, race/ethnicity, geographic region, type of insurance, urban status, and waiting-time >60 minutes did not significantly affect AMA discharge rates. CONCLUSION: This study identifies risk factors for leaving AMA, including young age (19-44 years old), 1-5 prior ED visits within the prior 2 years, and psychiatric illness. Physicians may use these data to help design targeted strategies, based on the identified risk factors, to reduce AMA discharges.

Prognostic implications of recipient or donor hepatitis B seropositivity in thoracic transplantation: analysis of 426 hepatitis B surface antigen-positive recipients.

BACKGROUND: Prognostic data on survival of hepatitis B surface antigen-positive (HBsAg+) recipients and of hepatitis B core antibody-positive (HBcAb+) donors are limited in the thoracic transplantation (TT) cohort. Improved understanding of risks could potentially expand the recipient and donor pools. METHODS: Post-hoc analysis of limited-access dataset of the United Network for Organ Sharing database from January 2000-September 2010 was performed. Analyses were performed for all TT, including single and bilateral lung, orthotopic heart, and simultaneous heart-lung transplants. The primary analyzed outcome was overall survival. A Cox proportional multivariate hazards model was used to adjust for significant risk predictors. RESULTS: Of 24,817 patients included, 426 recipients were HBsAg+, of whom 106 (25%) died during a mean follow-up of 3.6 years. On multivariate analysis, recipient HBsAg+ (hazard ratio [HR] = 0.88, 95% confidence interval [CI]: 0.69-1.32; P = 0.80), and donor HBcAb+ (HR = 0.91, 95% CI: 0.68-1.22; P = 0.53) were not associated with increased overall mortality in the entire TT cohort, with similar results for each individual transplant cohort. Unadjusted survival analysis using Kaplan-Meier curves in individual transplant cohorts did not show significant differences between HBsAg+ and HBsAg- recipients. No statistically significant differences were found between causes of mortality in the 2 groups. CONCLUSION: HBsAg+ status of recipients or HBcAb+ status of donors does not significantly affect overall survival of TT recipients. These data add to the scant literature on this subject and could potentially increase the donor and recipient pools.

Liver transplantation of hepatitis B surface antigen positive donors to hepatitis B core antibody recipients: analysis of 27 patients.

AIM: Shortage of donor livers is the major limiting factor for liver transplantation (LT). While livers from patients with past infection of Hepatitis-B (HBcAb+) are commonly used as donors, scant data exists on outcomes following transplantation of HBsAg+ donor livers. The impact of donor HBsAg positivity on recipient survival is currently analyzed. METHODS: Post hoc analysis of all adults undergoing LT from October 1987-September 2010 registered in United Network for Organ Sharing/Organ Procurement and Transplantation Network, a concurrent, limited access database of all American LT recipients. Only recipients who were HBcAb+ were analyzed. LTs with missing donor or recipient serologic parameters for Hepatitis-B were excluded. Significant predictors of survival were determined by univariate analysis. Cox proportional hazards model was used to determine independent risk predictors in the multivariate analysis. RESULTS: The population consisted of 13,329 LT recipients. The mean age of donors and recipients were 40±16 years and 52±9 years respectively. The mean follow-up was 3.7 years. Study population included 27 recipients transplanted with HBsAg+ grafts, of whom 7 (28%) died. Outcomes were adjusted for donor age, recipient age, donor gender, recipient gender, type of LT, MELD score, HCV status, previous LT, and cold ischemic time. On multivariate analysis, LT recipient outcomes were not significantly different for HBsAg+ donors versus donors without prior hepatitis B infection (HR: 1.14, 95% CI: 0.93-1.39, P=0.17). Kaplan-Meier curves revealed no significant survival difference between the two groups. CONCLUSION: These results suggest that donor HBsAg positivity did not affect overall survival of LT recipients. These findings could potentially expand the pool of liver donors.

Should a physician interpret a medical study improperly performed by a nurse or technician, such as capsule endoscopy performed on a wrong patient? A reasonable solution to a medicolegal dilemma.

Improper performance by a nurse of a medical study/procedure (e.g., video capsule endoscopy performed on a wrong patient) raises novel, previously unexplored questions regarding: 1) whether the study should subsequently be interpreted; 2) which physician should interpret the study; and 3) whether study interpretation requires another informed consent due to the extraordinary circumstances. Two such cases are reported. First, the Chief of Gastroenterology (GI) contacted the hospital ethics committee regarding procedure interpretation after the wrong patient underwent video capsule endoscopy by a nurse. The committee recommended to inform and apologize to the patient about the nursing error, to not charge for this study, and to interpret the study, likewise without charge, provided that a new informed consent was obtained that included discussion of the small potential patient benefit of study interpretation in this circumstance. These recommendations were followed. Study interpretation revealed a 3 mm wide characteristic angiodysplasia in the distal jejunum. Endoscopic therapy was not performed due to the small lesion size, and absence of gastrointestinal bleeding or significant anemia. Second, the Chief of GI was informed of an esophageal manometry performed for chronic dysphagia that had not been interpreted for 7 months due to its being performed by a nurse without any arrangement for a gastroenterologist to interpret the study. The referring gastroenterologist lacked training or privileges in esophageal manometry. The Chief of GI arranged for a motility expert to interpret the study. The study was read as technically inadequate because the nurse had been unable to intubate the stomach and the referring gastroenterologist had declined to assist in this difficult intubation. The motility expert noted that had he been involved earlier in the case he would have himself attempted gastric intubation. In conclusion, a reasonable approach to a medical study improperly performed by a nurse includes: 1) inform and apologize to the patient about the error; 2) obtain informed consent for study interpretation, and 3) interpret the study at no charge. Consultation with an institutional Ethics Committee is advisable. An interpreting physician should be identified at the time of scheduling a medical study. Although illustrated for GI studies, these recommendations pertain to studies performed by nurses or technicians in numerous medical fields, such as echocardiograms or pulmonary function tests.

Advice for a career in academic gastroenterology: from fellowship application through job selection and contract negotiations to research and promotion.

This study aims to describe a comprehensive strategy for success in academic gastroenterology by reporting common sense, but mostly previously unpublished, recommendations. The recommendation are based on expert opinion from personal experience mentoring 125 gastroenterology fellows and residents as a program director for nine years and from mentoring research while publishing more than 160 articles in peer-reviewed journals and editing 11 books during a 23-year academic career. Primary criteria for fellowship applicant selection include board scores, clinical performance, interview performance, clinical training, and research productivity. For optimal chances, select the subspecialty of gastroenterology early during residency, consult a mentor, and develop a well-planned strategy. Faculty advancement depends upon publications, grants, national recognition, interpersonal skills, and recommendations. Article categories from highest-to-lowest in prestige are original investigations, review articles, book chapters, case reports, and letters/abstracts. Articles are judged by the prestige of the journal of publication. Resubmit rejected articles to successively less prestigious journals until accepted for publication. Articles in journals without peer-review have negligible career impact. Grant support creates protected time. Institutional reputation is important in academics. Do not accept a job without a written contract. Have a lawyer review your contract. An outside offer strengthens a negotiating position. Be sociable and nonconfrontational at work. Network with colleagues. Seek a mentor. Meet your supervisor regularly for feedback. Never express anger at your boss or patients. Avoid litigation with employers. Sub-subspecialize to develop expertise in one area. Focus on this area in your research and clinical practice. In conclusion, a well-planned strategy can help you achieve a senior academic position early and efficiently.

Clinical presentation, diagnosis and management of autoimmune pancreatitis.

Autoimmune pancreatitis (AIP) is a relatively rare but clinically important form of chronic pancreatitis that has typical clinical, serologic, histologic, and radiologic findings. Patients frequently present with jaundice and cholestatic serum liver function tests. The serum IgG4 level is typically elevated with a lymphoplasmacytic infiltrate in affected tissue that stains by immunohistochemistry for IgG4-containing cells. Characteristic radiologic features include pancreatomegally and pancreatobiliary duct strictures. Extrapancreatic manifestations are increasingly being recognized. AIP typically rapidly responds to corticosteroid therapy and possibly other immunosuppressive medications. A missed diagnosis can result in unnecessary pancreatic surgery with unnecessary morbidity and mortality. Although significant progress in disease pathophysiology has occurred during the past decade, there is still much to learn regarding disease pathogenesis and management. With further research, the diagnostic algorithm, treatment strategy, follow-up protocol, and long-term prognosis should become better defined.

From colonic polyps to colon cancer: pathophysiology, clinical presentation, screening and colonoscopic therapy.

UNLABELLED: Colon cancer is the most common nondermatologic cancer in Italy and throughout Europe, with about 250,000 cases annually in Europe, about half of whom die. Yet, colon cancer is largely preventable through intensive, mass screening programs to remove premalignant colonic polyps. The persistently high incidence and mortality is largely due to ineffective implementation of established screening protocols due to patient fears about screening tests, physician under-referral for screening, and test costs. Colon cancer mostly arises from adenomas, recognized as colonic polyps, but may occasionally arise from the sessile serrated adenoma. Adenomatous polyposis coli (APC) gene mutation is the key molecular step in adenoma formation. Mismatch repair gene mutation is a less common alternative pathway. Progression from adenomas to colon cancer is a multistep process, involving mutations of the DCC, k-ras, and p53 genes; loss of heterozygosity in which cells loose one allele of some genes from chromosomal loss; and DNA methylation which can silence DNA expression. Numerous environmental factors can increase the risk of colon cancer, presumably by modulating these molecular pathways. While colon cancer in an advanced and incurable stage often produces clinical findings, premalignant adenomatous polyps and early, highly curable, colon cancer are often asymptomatic. This phenomenon renders adenomas or early cancers difficult to detect by clinical presentation and provides the rationale for mass screening of asymptomatic adults over 50 years old for early detection and prevention of colon cancer. Colonoscopy is the primary screening test. All polyps identified at colonoscopy are removed by colonoscopic polypectomy. Endoscopic mucosal resection is required for deeply penetrating noncancerous polyps. Colonoscopy is repeated every ten years if the index colonoscopy revealed no lesions, but is repeated more frequently if adenomatous polyps were identified at this colonoscopy due to an increased risk of subsequent polyps or colon cancer. Flexible sigmoidoscopy every few years with annual fecal occult blood testing is a significantly less sensitive screening protocol. Virtual colonoscopy is controversial as a screening test due to widely variable reported RESULTS: Computerized tomography is standardly used to preoperatively detect distant colon cancer metastases, while endosonography is being increasingly used for locoregional staging of rectal cancer. Stool genetic markers and videocapsule endoscopy are promising, but currently experimental, screening tests.

Acute gastrointestinal bleeding in the intensive care unit. The intensivist's perspective.

Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.

Gastrointestinal bleeding associated with myocardial infarction.

Gastrointestinal (GI) bleeding associated with myocardial infarcation (MI) often presents as a distinct syndrome that differs from either disease alone. MI is frequently overlooked in the setting of severe GI bleeding because the symptoms and signs of MI are frequently overshadowed by the severe bleeding. GI bleeding, particularly when massive, may precipitate MI from hypovolemia, hemodynamic compromise, and myocardial hypoperfusion. Esophagogastroduodenoscopy is safe in relatively clinically stable patients after MI and is indicated to evaluate significant upper GI bleeding.

Clinical scoring systems for determining the prognosis of gastrointestinal bleeding.

The prognosis of GI bleeding depends upon many factors. Patients should be evaluated carefully for risk factors. To avoid complications from GI bleeding, triage should be performed promptly after patient presentation. The history and physical examination should emphasize analysis of risk factors for severe GI bleeding and mortality. Factors that increase the morbidity and mortality include: age greater than 60 years; underlying comorbidity such as pulmonary diseases, liver diseases, renal diseases, encephalopathy, or cancer; physiologic stress from major surgery, trauma, or sepsis; coexisting disease in three organ systems; low hematocrit; melena or hematochezia; and prolonged prothrombin time. Hospitalized patients who require more than five units of packed erythrocytes transfusion or who develop hypotension or hypovolemic shock are more likely to need surgery. Patients with a high APACHE II score, the presence of esophageal varices, active bleeding, or other endoscopic stigmata of recent hemorrhage are more likely to rebleed and undergo surgery. The proliferation of multivariable prognostic scales, as described herein, provides ample evidence that the goal of developing a single comprehensive multivariable scale to accurately assess severity of disease and to determine prognosis of GI bleeding is still not achieved. Yet significant progress has occurred in this field, leading to the hope of developing a universally applicable multivariable scale.

Radiology in the diagnosis and therapy of gastrointestinal bleeding.

Major breakthroughs in catheter and guidewire design as well as improvements in angiographic x-ray equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. For chronic or recurrent GI bleeding, when endoscopy is unrevealing or equivocal, barium studies, CT scanning, nuclear medicine studies, and angiography can help determine the cause of bleeding. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is extremely helpful in managing GI bleeding, particularly in high-risk patients or patients presenting as diagnostic dilemmas.

Fifty landmark discoveries in gastroenterology during the past 50 years. A brief history of modern gastroenterology at the millennium: Part II. Gastrointestinal motility, nutrition, and diseases of the lower gastrointestinal tract, liver, and pancreas.

During the last half century, many outstanding discoveries have revolutionized the clinical practice and science of gastroenterology. Although the scientific results are widely disseminated, the discoverers have received inadequate recognition and the history of their discoveries is largely unstudied and unknown. At the millennium, a committee selected 50 landmark discoveries in gastroenterology during the past 50 years. A brief history of each landmark discovery is presented. Part I was presented in the previous issue of Gastroenterology Clinics of North America. Part II presents landmark discoveries in gastrointerintal (GI) motility, clinical trials, nutrition, and diseases of the lower GI tract, liver, biliary tree, and pancreas.

Diagnosis and treatment of nonsteroidal anti-inflammatory drug-associated upper gastrointestinal toxicity.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in the United States to treat pain and reduce inflammation from chronic inflammatory disorders such as rheumatoid arthritis and osteoarthritis. Approximately 40% of older Americans take NSAIDs. Chronic NSAID use carries a risk of peptic ulcer and other gastrointestinal disturbances. This article reviews the diagnosis of medication-induced ulcers based on clinical presentation, laboratory tests, and endoscopic findings to assist the clinician in early diagnosis and appropriate therapy. Risk factors for NSAID-induced ulcers include old age, poor medical status, prior ulcer, alcoholism, smoking, high NSAID dosage, prolonged NSAID use, and concomitant use of other drugs that are gastric irritants, such as alendronate, a bone resorption inhibitor prescribed for osteoporosis. Appropriate treatment options for patients with medication-induced ulcers include dosage reduction, medication substitution, medication withdrawal, antiulcer therapy, and discontinuation of other gastrotoxic drugs.