Association Between Portal Vein Thrombosis and Pouchitis in Patients with Ulcerative Colitis.

BACKGROUND: Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis. AIM: To evaluate the association between PVT and other demographic and clinical factors and pouchitis. METHODS: We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis. RESULTS: We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04-16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02-1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23-1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28-1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33-0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis. CONCLUSIONS: We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis.

Epidemiology and Diagnosis of Gastroparesis in the United States: A Population-based Study.

GOALS: We aimed to establish the epidemiological characteristics and documentation of diagnostic workup for gastroparesis (GP). BACKGROUND: No study has used a national database to evaluate the prevalence, demographics, and associated comorbid conditions of GP, and document rates of proper diagnosis. MATERIALS AND METHODS: This was a cross-sectional population-based study using the Explorys Platform to determine the prevalence of GP in a large and diverse population highly representative of the US population and to examine the diagnostic approach of GP. Data collected were individual characteristics from electronic medical records (EMRs) included age, ethnicity/race, sex, diagnostic report for esophagogastroduodenoscopy (EGD) and gastric emptying study (GES). RESULTS: A total of 43,827,910 medical records were surveyed (1999 to 2014), of which 69,950 had a diagnosis of GP, yielding an overall prevalence of 0.16%. We identified 249,930 EMRs with type 1 diabetes mellitus (T1DM), and 2,940,280 EMR's with type 2 diabetes mellitus (T2DM), of which 11,470 (4.59%) and 38,670 (1.31%) EMR's had concurrent GP, respectively. The remainder 19,810 EMRs with a diagnosis of GP were classified as having idiopathic GP. In all three subgroups, women and Caucasians had the highest prevalence of GP. The diagnosis of GP was confirmed by both GES and EGD in 9,950 of patients (14.22%). For patients with T1DM, T2DM, or idiopathic GP, GP was confirmed by both diagnostic tests in 16.8%, 14.0%, and 13.2%, respectively. CONCLUSIONS: Our estimated rates of prevalence of GP in T1DM and T2DM indicate that GP is not a common clinical complication in these populations. Majority of EMRs that indicated a diagnosis of GP did not include any documentation of definitive diagnostic testing (EGD and/or GES).

Awareness of academic use of smartphones and medical apps among medical students in a private medical college?

OBJECTIVE: To assess the awareness of medical apps and academic use of smartphones among medical students. METHODS: The questionnaire-based descriptive cross-sectional study was conducted in January 2015 and comprised medical students of the Rawal Institute of Health Sciences, Islamabad, Pakistan. The self-designed questionnaire was reviewed by a panel of expert for content reliability and validity. Questionnaires were distributed in the classrooms and were filled by the students anonymously. SPSS 16 was used for statistical analysis. RESULTS: Among the 569 medical students in the study, 545 (95.8%) had smartphones and 24(4.2%) were using simple cell phones. Overall, 226(41.46%) of the smart phone users were using some medical apps. Besides, 137(24.08%) were aware of the medical apps but were not using them. Also, 391(71.7%) students were not using any type of medical text eBooks through their phone, and only 154(28.3%) had relevant text eBooks in their phones. CONCLUSIONS: Medical college students were using smartphones mostly as a means of telecommunication rather than a gadget for improving medical knowledge.

Is chlorhexidine-gluconate superior than Povidone-Iodine in preventing surgical site infections? A multicenter study.

OBJECTIVE: To compare the efficacy of povidone-iodine and chlorhexidine gluconate scrubs in preventing surgical site infections. METHODS: The randomised controlled clinical trial was conducted from May 2012 to April 2013 in two public-sector hospitals of Pakistan; one each in Karachi and Islamabad. Patients undergoing clean or clean contaminated surgeries were included and were randomly assigned to one of the two groups: group I comprised patients whose skin was preoperatively disinfected using 10% povidone-iodine, and in group II by 2% chlorhexidine gluconate in 70% alcohol. A predesigned proforma was filled for all patients to record demographic data, diagnosis, surgical procedure and antibiotic used. Patients in both groups were followed up for one month postoperatively to monitor any signs of surgical site infections. SPSS 16 was used for statistical analysis. RESULTS: Of the 388 patients from the two hospitals, 220(57%) were in group I and 168(43%) were in group II. Surgical site infection was observed in 22(10%) cases in group I and 12(7.1%) in group II (p=0.324). Pseudomonas aeruginosa (23.5%) was the predominant pathogen associated with surgical site infections followed by Staphylococcus aureus (17.6%). CONCLUSIONS: Chlorhexidine gluconate was associated with lower infection rates compared to povidone-iodine; but it was not statistically significant.

Efficacy and safety of subcutaneous lateral internal sphincterotomy for chronic anal fissure.

BACKGROUND: This study was undertaken to determine the efficacy and safety of subcutaneous lateral internal sphincterotomy (SLIS) for chronic anal fissure by assessing the relief of defecatory pain, duration of wound healing and associated complications such as bleeding, infection, and anal incontinence. METHODS: This descriptive case series was carried out at the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad from September 1, 2008 to February 28, 2009. RESULTS: Out of fifty patients 31 were males and 19 were females. The mean age was 30.04 ± 8.49 years. Defecatory pain and bleeding per rectum were the commonest symptoms, found among all patients. Symptomatic relief of pain following surgery was observed among all patients at 4th week while all fissures healed at 8th week. At 4th weeks follow-up visit none of the patients had flatus incontinence while at 8th weeks all patients had good faecal continence. Majority (76%) of the patients were managed as Day case or Extended day case surgeries. There was no in-hospital mortality in this case series. CONCLUSION: SLIS is a valuable surgical procedure for patients with chronic anal fissure. It is effective and safe, offers quick relief of defecatory pain, and promotes early fissure healing without being attended by any major complications. The initial transient incontinence of flatus and faeces improves spontaneously over few weeks period. Majority of the patients are manageable on day case or extended day case surgery basis.

Presentation and outcome of surgically managed liver trauma: experience at a tertiary care teaching hospital.

OBJECTIVE: To document and analyse the presentation and outcome of surgical management of liver trauma. METHODS: The study was a retrospective review of records of all surgeries carried out at the Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from January 2003 to December 2010. The study included all adult patients of either gender who presented with liver trauma and underwent operative management. Convenience sampling technique was employed. The study excluded patients who were managed conservatively. The data were collected through a proforma and analysed through SPSS 10. RESULTS: Out of 113 cases of liver trauma, 91 (80.5%) were males and 22 (19.4%) were females. The mean age was 34.8 +/- 9.7 years. Road traffic accidents were the leading cause (n = 75; 66.3%) of injuries. There were 37 (32.7%) patients with grade I injury; 41 (36.2%) with grade II injury; 29 (25.6%) with grade III injury; and 7 (6.1%) patients with grade IV injury. Besides, 62 (54.8%) patients had associated extra-hepatic injuries. Majority of the patients presented with haemodynamic compromise (n = 97; 85.8%). Perihepatic packing was the commonest operative procedure instituted (n = 43;38%). The in-hospital mortality was 9.7% (n = 11). CONCLUSION: Liver trauma constitutes an important cause of emergency hospitalisation, morbidity and in-hospital mortality in our population. It predominantly affects the younger males and road traffic accidents are the leading cause. Majority of the patients are successfully managed with perihepatic packing.

Clinical audit of the presentation and outcome of benign thyroid disorders in a tertiary care setting in Pakistan.

OBJECTIVE: To assess the clinical presentation and outcome of surgical management of benign thyroid disorders in a tertiary care set up in Pakistan. METHODS: The clinical audit was carried out at the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from September 2002 to December 2010. The data were recorded on a pre-designed proforma, which comprehensively encompassed the relevant variables and outcome measures. SPSS 10 was used for statistical analysis. RESULTS: Out of 527 patients, there were 474 (89.94%) females and 53 (10.05%) males. The overall age ranged 21-56 years, with a mean of 41.99 +/- 9.07 years. Symptoms due to local pressure effects of the goiter were the commonest presenting features found in 473 (89.75%) patients. The mean duration of thyroid disorder was 11.85 +/- 3.41 years. Hypothroidism was the commonest biochemical abnormality found in 117 (22.20%) patients, while hyperthyroidism was found in 63 (11.95%) patients. Multinodular goitre was the most frequent disorder found in 439 (83.30%) patients. Subtotal thyroidectomy constituted the commonest surgical procedure performed in 398 (75.52%) patients. Temporary hypocalcaemia was the most common post-operative complication observed in 93 (17.64%) patients. The mean hospital stay was 4.76 +/- 2.14 days. There was no in-hospital mortality. CONCLUSION: Benign thyroid disorders are prevalent in our population and commonly affect the younger females. Majority of the patients have a family history of thyroid disorders. Most of the patients present with several years history of the disease. Subtotal thyroidectomy is the most frequently offered surgical procedure, which is safe.

Predictors and Outcomes of Palliative Care Consultations for Patients With Liver Disease: Results of a Cohort Study of 75 Million Medical Records.

Background: Liver transplant is the only cure for cirrhosis. We studied the impact of palliative care on patient care by conducting a population-based cohort study. Methods: We queried the Explorys database (IBM, New York) database for a diagnosis of 'cirrhosis' followed by 'palliative care consultation' and collected demographic and clinical data. Results: We identified 316,970 patients with cirrhosis. Palliative care was consulted for 10.9% (n = 34,600) of patients. Patients aged >65 [OR 1.33 (1.30-1.36), P < .0001], men [OR 1.13 (1.11-1.16), P < .0001], a diagnosis of hepatocellular carcinoma (HCC) [OR 2.53 (2.45-2.60), P < .0001] were more likely to receive a palliative care consultation. Patients for whom palliative care were consulted were less likely to undergo surgical procedures [OR .49 (.47-.50)]. Conclusion: Only about 1 in 10 cirrhotics received a palliative care consultation. Older patients, males, and patients with a diagnosis of HCC are more likely to receive palliative care.

Centrally infiltrating renal masses on CT: differentiating intrarenal transitional cell carcinoma from centrally located renal cell carcinoma.

OBJECTIVE: The objective of our study was to retrospectively determine the accuracy of CT for differentiating intrarenal transitional cell carcinoma (TCC) from centrally located renal cell carcinoma (RCC) and to define the most discriminating diagnostic CT features. MATERIALS AND METHODS: CT studies of 98 pathologically proven central renal tumors (64 centrally located RCCs and 34 intrarenal TCCs) seen over 5 years at three university hospitals were reviewed by five specialty-trained radiologists who were blinded to the final diagnosis. Multiple CT features and global impression were graded on a 4-point score. The sensitivity and specificity of each feature and of global assessment were calculated and compared using receiver operating characteristic (ROC) analysis. Interobserver agreement (kappa values) was also calculated for each parameter. RESULTS: All five readers recognized intrarenal TCCs with a high diagnostic accuracy (sensitivity, 90%; specificity, 90%; area under ROC curve [AUC], 0.80-0.95 for global assessment) with moderate-to-excellent interobserver agreement (κ = 0.72-1). Six CT features were most diagnostically specific for identifying intrarenal TCCs: tumor centered within the collecting system; focal filling defect in the pelvicalyceal system; preserved renal shape; absence of cystic or necrotic change; homogeneous tumor enhancement; and tumor extension toward the ureteropelvic junction (sensitivity, 68-82%; specificity, 79-89%; AUC, 0.75-0.84). There was moderate-to-good agreement among the readers over all these features (κ = 0.44-0.69). CONCLUSION: Intrarenal TCC can be recognized with a high accuracy on CT; global impression showed the best diagnostic performance. A solid, homogeneously enhancing mass that is centered on the collecting system and extends toward the ureteropelvic junction combined with a focal pelvicalyceal filling defect and preserved renal outline is more likely to be an intrarenal TCC than a centrally located RCC.

Abdominal tuberculosis: epidemiologic profile and management experience of 233 cases.

OBJECTIVE: To document the epidemiologic profile and management outcome of patients with abdominal tuberculosis in a tertiary care setup. METHODS: This descriptive case series was conducted at the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, between January 2003 and December 2008. All adult patients of either gender who presented with abdominal tuberculosis and were managed at our hospital during the study period were included in the study on the basis of convenience sampling. Numerical data were expressed as mean +/- standard deviation, while categorical data were analysed using SPSS version 10. Chi square test was conducted to compare categorical variables. RESULTS: Of the 233 adult patients with abdominal tuberculosis who were part of the study, 110 (47.21%) were males and 123 (52.78%) females. The mean age was 28.21 +/- 5.75 years. Majority of our patients (80.68%) belonged to poor families. History of concomitant pulmonary tuberculosis was found in 23 (9.87%) patients. Family history of tuberculosis was found in 13 (5.57%) patients. Of the patients 157 (67.38%) presented with acute abdomen; strictures were the most common operative finding (n = 161; 69%); the patients needing hospitalisation were 204 (87.55%), with the mean hospital stay being 19.55 +/- 4.51 days. The in-hospital mortality was 5 (2.14%). CONCLUSION: Abdominal tuberculosis was found prevalent in the population and predominantly affected the younger lot belonging to the poor socioeconomic strata. Majority of the cases were of primary intestinal variety, and in a small proportion it was secondary to pulmonary tuberculosis. Majority of the patients presented with complications such as acute intestinal obstruction, intestinal perforation and peritonitis, necessitating emergency laparotomy.

Depression Before and After a Diagnosis of Pancreatic Cancer: Results From a National, Population-Based Study.

OBJECTIVES: The aim of this study was to evaluate depression in pancreatic cancer (PC) patients before and after a cancer diagnosis using a US-based healthcare database. We also sought to study the impact of treatment of depression in PC patients on all-cause mortality. METHODS: Pancreatic cancer patients with comorbid depression in Explorys (1999-2019) were compared with controls using odds ratios with 95% confidence intervals. Rates of depression diagnosed within 6 months, 1 year, and 3 years before and after a PC diagnosis were recorded. Patients who developed depression after a PC diagnosis were further categorized into those treated for depression using mental health professionals (MHPs), pharmacologic treatment, or both (2015-2019). RESULTS: Of the 62,450 PC patients, 10,220 (16.4%) were diagnosed with depression before PC and 8130 (13%) were diagnosed with depression after PC. Patients diagnosed with depression after PC had a significantly higher all-cause mortality than patients with PC alone (P < 0.0001). Involvement of MHP significantly improved all-cause mortality (P = 0.0041). CONCLUSIONS: Most post-PC depression is diagnosed in the first 6 months after a PC diagnosis. Although depression significantly increases PC mortality, integrating MHP in the care of PC patients with depression improves outcomes.

Risk of de-novo inflammatory bowel disease among obese patients treated with bariatric surgery or weight loss medications.

BACKGROUND: An association between bariatric surgery and development of de-novo inflammatory bowel disease (IBD) has been observed. AIM: To evaluate further the association among bariatric surgery, weight loss medications, obesity and new-onset IBD. METHODS: Using Explorys, a population-based Health Insurance Portability and Accountability Act compliant database, we estimated the prevalence of de-novo IBD among patients treated with bariatric surgery (Roux-en-Y gastrojejunostomy, laparoscopic sleeve gastrectomy or gastric banding) (n = 60 870) or weight loss medications (orlistat, phentermine/topiramate, lorcaserin, bupropion/naltrexone and liraglutide) (n = 193 790) compared with obese controls (n = 5 021 210), between 1999 and 2018. RESULTS: The prevalence of de-novo IBD was lower among obese patients exposed to bariatric surgery (7.72 per 1000 patients) or weight loss medications (7.22 per 1000 patients) compared with patients with persistent obesity not exposed to these interventions (11.66 per 1000 patients, P < 0.0001). The risk reduction for de-novo IBD was consistent across bariatric surgeries and weight loss medications with the exception of orlistat which was not associated with a reduction in risk for de-novo IBD compared with the persistent obese control cohort. CONCLUSION: Obese patients undergoing treatment with bariatric surgery or weight loss medications are at a lower risk for developing de-novo IBD compared with persistently obese controls not exposed to these interventions. These data suggest that obesity and ineffective management of obesity are risk factors for de-novo IBD. Further research is needed to confirm these observations and understand potential mechanisms.

Survival Trends for Resectable Pancreatic Cancer Using a Multidisciplinary Conference: the Impact of Post-operative Chemotherapy.

PURPOSE: Despite advances in various treatment modalities, surgical resection for pancreatic ductal adenocarcinoma (PDA) remains the only curative treatment. Data remains limited regarding survival rates for resectable PDA when managed by a multidisciplinary pancreas conference (MDPC). The aim of this study is to assess survival rates, identify significant predictors of mortality, and assess the benefits of adjuvant chemotherapy for resectable PDA following presentation at a MDPC. METHODS: All patients presented from April 2013 to August 2016 with resectable PDA were discussed at a MDPC at a tertiary care center and were followed prospectively until November 2017. Survival analysis was performed using Kaplan-Meier for age, tumor size, tumor differentiation, T-stage, lymph node status, and completion of adjuvant chemotherapy cycles. Independent predictors of survival were determined using multivariate Cox regression modeling. RESULTS: After MDPC consensus and exclusions, total of 64 patients underwent successful surgery. Amongst this cohort, 1-, 2-, and 3-year survival was 78.13%, 46.30%, and 27.27%, respectively. A total of 37 patients (58%) initiated and 16 patients (25%) finished chemotherapy following surgery. Log-rank analysis revealed that tumor size, age, surgical margins, lymph node status, and number of adjuvant chemotherapy cycles received significantly influenced post-operative survival. Tumor size (p < 0.001), lymph node status (p = 0.035), and number of adjuvant chemotherapy cycles (p = 0.041) remained significant after multivariate Cox regression model. CONCLUSIONS: Our results suggest that patients with PDA with tumor size > 50 mm and/or lymph node involvement have poor outcomes despite being surgically resectable. Successful completion of adjuvant chemotherapy has better survival outcomes as compared with incomplete or no adjuvant chemotherapy. The role of alternative management such as down-staging with neoadjuvant therapy should be considered.

Old vs new: Risk factors predicting early onset colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of all cancer related deaths in the United States and Europe. Although the incidence has been decreasing for individuals' ≥ 50, it has been on the rise for individuals < 50. AIM: To identify potential risk factors for early-onset CRC. METHODS: A population-based cohort analysis using a national database, Explorys, screened all patients with an active electronic medical record from January 2012 to December 2016 with a diagnosis of CRC. Subgroups were stratified based on age (25 - 49 years vs ≥ 50 years). Demographics, comorbidities, and symptom profiles were recorded and compared between both age groups. Furthermore, the younger group was also compared with a control group consisting of individuals aged 25-49 years within the same timeframe without a diagnosis of CRC. Twenty-data points for CRC related factors were analyzed to identify potential risk factors specific to early-onset CRC. RESULTS: A total of 68860 patients were identified with CRC, of which 5710 (8.3%) were younger than 50 years old, with 4140 (73%) between 40-49 years of age. Multivariable analysis was reported using odds ratio (OR) with 95%CI and demonstrated that several factors were associated with an increased risk of CRC in the early-onset group versus the later-onset group. These factors included: African-American race (OR 1.18, 95%CI: 1.09-1.27, P < 0.001), presenting symptoms of abdominal pain (OR 1.82, 95%CI: 1.72-1.92, P <0.001), rectal pain (OR 1.50, 95%CI: 1.28-1.77, P < 0.001), altered bowel function (OR 1.12, 95%CI: 1.05-1.19, P = 0.0005), having a family history of any cancer (OR 1.78, 95%CI: 1.67-1.90, P < 0.001), gastrointestinal (GI) malignancy (OR 2.36, 95%CI: 2.18-2.55, P < 0.001), polyps (OR 1.41, 95%CI: 1.08-1.20, P < 0.001), and obesity (OR 1.14, 95%CI: 1.08-1.20, P < 0.001). Comparing the early-onset cohort versus the control group, factors that were associated with an increased risk of CRC were: male gender (OR 1.34, 95%CI: 1.27-1.41), P < 0.001), Caucasian (OR 1.48, 95%CI: 1.40-1.57, P < 0.001) and African-American race (OR 1.25, 95%CI: 1.17-1.35, P < 0.001), presenting symptoms of abdominal pain (OR 4.73, 95%CI: 4.49-4.98, P < 0.001), rectal pain (OR 7.48, 95%CI: 6.42-8.72, P < 0.001), altered bowel function (OR 5.51, 95%CI: 5.19-5.85, P < 0.001), rectal bleeding (OR 9.83, 95%CI: 9.12-10.6, P < 0.001), weight loss (OR 7.43, 95%CI: 6.77-8.15, P < 0.001), having a family history of cancer (OR 11.66, 95%CI: 10.97-12.39, P < 0.001), GI malignancy (OR 28.67, 95%CI: 26.64-30.86, P < 0.001), polyps (OR 8.15, 95%CI: 6.31-10.52, P < 0.001), tobacco use (OR 2.46, 95%CI: 2.33-2.59, P < 0.001), alcohol use (OR 1.71, 95%CI: 1.62-1.80, P < 0.001), presence of colitis (OR 4.10, 95%CI: 3.79-4.43, P < 0.001), and obesity (OR 2.88, 95%CI: 2.74-3.04, P < 0.001). CONCLUSION: Pending further investigation, these potential risk factors should lower the threshold of suspicion for early CRC and potentially be used to optimize guidelines for early screening.

Fluoroscopy Dose and Time Characteristics During Endoscopic Retrograde Cholangiopancreatography (ERCP).

Radiation exposure during endoscopic retrograde cholangiopancreatography is known, however, data in relation to radiation usage is unclear. We evaluate radiation exposure using fluoroscopy dose (FD) and time (FT). A prospective analysis of 197 patients undergoing endoscopic retrograde cholangiopancreatography was completed. Univariate and multivariate analyses were performed to determine characteristics associated with higher FD and FT. The mean FT was 307 seconds; the mean FD was 16.5 centigray. On univariate and multivariate analysis, indication of common bile duct stricture and pancreatic stricture, interventions including dilation and the use of plastic stents placement, procedures that were moderately or very difficult, and procedures that used magnification and high-resolution images were associated with higher FD± and longer FT. Indications of common bile duct stricture and pancreatic stricture as well as interventions of dilation, plastic stents placement, and procedures that are moderately or very difficult, involve high-resolution image leading to a higher radiation exposure. Special care should be considered in these settings.