National report on healthcare utilization and mortality in patients with hepatitis A infection in the United States.

OBJECTIVES: Predictors of negative outcomes related to hepatitis A virus (HAV) need to be studied at a national level. STUDY DESIGN AND METHODS: A retrospective analysis using the Nationwide Inpatient Sample (2002-2013) and Nationwide Readmission Database (2010-2014) was performed to evaluate the outcomes of hospitalized patients with HAV. The Nationwide Inpatient Sample and the Nationwide Readmission Database included a varying number of states during the studied time and reflect the range of implementation dates of the HAV vaccines. Multivariable analyses were fit to determine predictors of outcomes. RESULTS: A total of 13,514 patients were admitted with HAV during the studied time. Thirty-day and 90-day readmission rates were 11.4% and 15%, respectively. Predictors of readmission, longer length of stay, and mortality included patients aged >60 years ([odds ratio [OR]: 1.02; 95% confidence interval [CI]: 1.001-1.03], [OR: 1.15; CI: 1.07-1.24], [OR: 4.06; 95% CI: 1.47-11.16], respectively), Medicare insurance ([OR:3.63; 95% CI: 2.18-6.03], [OR: 1.26; 95% CI: 1.17-1.37], [OR: 2.67; 95% CI: 1.18-6.04], respectively), and cirrhosis ([OR: 1.83; 95% CI: 1.05-3.21], [OR: 1.33; 95% CI: 1.20-1.47], [OR: 2.83; 95% CI: 1.14-7.05], respectively). Predictors of higher cost of admission included patients aged >60 years (OR: 1.32, 95% CI: 1.19-1.46), Hispanic (OR: 1.14; 95% CI: 1.05-1.24), Medicare insurance (OR: 1.22; 95% CI: 1.10-1.35), Medicaid insurance (OR: 1.10; 95% CI: 1.02-1.20), and cirrhosis (OR: 1.28; 95% CI: 1.11-1.46). CONCLUSIONS: Patients at increased healthcare utilization and mortality should be prioritized for HAV vaccination.

Universal prophylaxis or preemptive strategy for cytomegalovirus disease after liver transplantation: a systematic review and meta-analysis.

We systematically reviewed and meta-analyze the efficacy of universal prophylaxis (UP) and preemptive (PE) strategies (using ganciclovir or valganciclovir) in preventing cytomegalovirus (CMV) disease (CMD) among liver transplant recipients (LTRs). We performed an electronic search of MEDLINE, EMBASE and the Cochrane Database till December 2013. Studies that assessed UP or PE for preventing CMD in LTRs were included. The risk of bias was assessed using the Newcastle-Ottawa scale. The primary outcome was CMD, secondary outcomes being acute cellular rejection (ACR), graft loss (GL) and mortality. Due to the heterogeneity of comparative studies, an indirect comparison was performed. Pooled incidence rates with 95% confidence interval (CI) are calculated for each outcome using a random-effects model. Thirty-two studies involving 2456 LTRs were included. The majority of the studies were of low risk of bias. Irrespective of donor/recipient CMV sero-status, CMD was 10% with UP (95% CI: 6-14; I(2) = 87%; 16 studies, n = 1581) and 7% with PE (95% CI: 3-10; I(2) = 84%; 16 studies, n = 875) (mean difference 2.6; 95% CI: -3.25 to 8.45, p = 0.34). Likewise, ACR and mortality were similar with the two strategies. However, GL was significantly lower in the UP group, regardless of donor/recipient sero-status. In indirect comparison, the incidence of CMD, ACR and mortality in LTRs were similar with two strategies. Trials comparing the two strategies directly are needed.

Granulomatous gastritis: a diagnostic dilemma?

Granulomatous inflammation of the gastrointestinal tract is an uncommon entity; an aetiopathogenic diagnosis can be reached only by combining the morphological examination with clinical and laboratory investigations. We report two cases of granulomatous gastritis: a 27-year-old woman presenting with weight loss and a 55-year-old woman presenting with epigastric pain and vomiting. Upper oesophagastroduodenoscopy in these cases showed antral hyperaemia and histopathology showed non-caseating gastric granulomatous inflammation. Both the cases were extensively worked-up for possible tuberculosis (TB) as the patients lived in an endemic area, before starting steroids for the possibility of Crohn's disease (CD) . The first patient improved but the second patient had a flare of underlying undiagnosed TB. Granulomatous gastritis present a diagnostic challenge for treating physicians because of similar clinical, laboratory and endoscopical features between CD and intestinal TB.

Endoscopic retrograde cholangiopancreaticography with or without stenting in patients with pancreaticobiliary malignancy, prior to surgery.

BACKGROUND: Postoperative morbidity and mortality are high in patients undergoing pancreatico-duodenectomy for malignant pancreatico-biliary stricture. Different approaches have been tried to improve the outcomes, including pre-surgical biliary stenting with endoscopic retrograde cholangiopancreaticography (ERCP). OBJECTIVES: To assess the beneficial and harmful effects of biliary stenting via ERCP for pancreatico-biliary stricture confirmed or suspected to be malignant, prior to surgery. SEARCH STRATEGY: We identified trials through The Cochrane Hepato-Biliary Group Controlled Trials Register (October 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1950 to October 2006), EMBASE (1980 to October 2006), and Science Citation Index Expanded (1945 to October 2006). We also searched the references in the published papers and wrote to stent producers. SELECTION CRITERIA: Randomised trials comparing ERCP with biliary stenting versus ERCP without biliary stenting for pancreatico-biliary malignancy prior to surgery. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion and extracted data. The primary pre-surgical, post-surgical, and final outcome measures were mortality. The secondary outcomes were complications such as cholangitis, pancreatitis, bleeding, pancreatic fistula, intra-abdominal abscess, improvement in bilirubin, and quality of life. Dichotomous outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) based on fixed- and random-effect models. MAIN RESULTS: We identified two randomised trials with 125 patients undergoing pancreatico-duodenectomy; 62 patients underwent ERCP with biliary stenting and 63 had ERCP without biliary stenting prior to surgery. Pre-surgical mortality was not significantly affected by stenting (OR 3.14, 95% CI 0.12 to 79.26), while there were significantly more complications in the stented group (OR 43.75, 95% CI 2.51 to 761.8). Stenting had no significant effect on the post-surgical mortality (OR 0.75, 95% CI 0.25 to 2.24). However, post-surgical complications were significantly less in the stented group (OR 0.45, 95% CI 0.22 to 0.91). Overall mortality (OR 0.81, 95% CI 0.17 to 3.89) and complications (OR 0.50, 95% CI 0.01 to 23.68) were not significantly different in the two groups. AUTHORS' CONCLUSIONS: We could not find convincing evidence to support or refute endoscopic biliary stenting on the mortality in patients with pancreatico-biliary malignancy. Large randomised trials are needed to settle the question of pre-surgical biliary stenting.

Gastric variceal bleed in a patient without liver cirrhosis: an unusual cause of haematemesis.

Tumours of the pancreas presenting as haematemesis are rare entities, with scarce documentation in literature. We report a 50-year-old woman who presented with haematemesis secondary to gastric fundal variceal bleeding due to splenic vein occlusion by a large mucinous cystadenoma of the pancreas. We also review the literature pertaining to unusual pathologies presenting as haematemesis.

Pill-induced esophageal injury: endoscopic features and clinical outcomes.

BACKGROUND AND STUDY AIMS: Pill-induced esophageal injury is a common but under-reported problem. The purpose of this study was to explore the clinical and endoscopic features, and the outcome of pill-related esophageal injury. PATIENTS AND METHODS: Endoscopy records for the period from January 1997 to June 2003 were searched for reports of esophageal pathology. The records of patients with pill-induced esophageal injury were evaluated. RESULTS: A total of 92 patients with pill-induced esophageal injury were identified (33 men, 59 women; mean age 59, range 25-87). Common symptoms were odynophagia (n = 69, 75 %), chest pain (n = 55, 60 %), vomiting (n = 53, 58 %), dysphagia (n = 31, 33 %), and hematemesis (n = 14, 15 %). The endoscopic findings in the esophagus were: erythema in 76 patients (83 %), erosions in 53 patients (58 %), ulcers in 24 patients (26 %), seven of which were "kissing" ulcers, esophageal ulcer with bleeding in 17 patients (18 %), and esophageal strictures in seven patients (8 %). The causative pills were nonsteroidal anti-inflammatory drugs in 38 patients (41 %), tetracyclines in 20 patients (22 %), potassium chloride tablets in nine patients (10 %), alendronate in eight patients (9 %), and other drugs in 17 patients (18 %). Underlying diseases included diabetes in 60 patients (65 %), ischemic heart disease in 39 patients (42 %), and hypothyroidism in four patients (4 %). The mean hospital stay was 1.94 days; 14 patients (15 %) required injection of epinephrine 1 : 10,000 to control bleeding; and two patients died. CONCLUSIONS: Pill-induced injury may present as erosions, kissing ulcers, and multiple small areas of ulceration with bleeding, mainly in the middle third of the esophagus. Advanced age, female gender, diabetes, and ischemic heart disease were common associations. The majority of patients made an uneventful recovery.

Women need skills, income and family planning.

PIP: The myth in Pakistan is that women do not work outside the home but they do even though they tend not to be paid for it. They handle wheat and plant vegetables. They tend to and milk cattle. They handle manure used for fuel and fertilizer. They receive some money albeit small amounts for picking pesticide-laden cotton which puts them at risk. These work activities link them more closely with nature and natural resources than men. Yet modern harvest methods prevent women from gleaning fields for grain to sell to raise money for their family or for wheat stalks to use as fuel. This forces them to take wood from forests or shrubbery, thereby straining these limited resources. Other problems include population growth, male migration, landlessness, and insufficient health services. Society prefers sons. It considers women as childbearers and transitory persons. Females tend not to be educated, thus society does not value women. Social norms and infant mortality are associated with family size--the poorest women tend to have the highest fertility. More children serve as an economic safety valve. Many studies shatter the myth that women do not work. Policymakers and planners need to learn the results of these studies. The number of female-headed households rises. An increasing number of women must work to supplement their husband's income. To empower women, they need education and to acquire skills. Since they tend to be anemic, have an average of 9 births, and a life expectancy at birth for women of 55 years, they must also have access to health and family planning services. Nongovernmental organizations should help women to be more economically productive which allows them some economic independence. For example, in Gilgit, such an organization has trained women in tree planting, nursery rearing, vegetable growing, and caring for chickens.^ieng