Is Blood Urea Concentration an Independent Predictor of Positive Endoscopic Findings in Presumed Upper Gastrointestinal Bleeding?

BACKGROUND: The test characteristics of blood urea concentration in the identification of upper gastrointestinal bleeding (UGIB) or high-risk endoscopic lesions have not been clearly determined. This study aimed to elucidate if urea independently correlates with the presence of positive endoscopic findings in cases of presumed UGIB and understand the diagnostic value of this parameter when assessing a patient with potential UGIB. METHODS: A retrospective cohort study was conducted at Hamilton Health Sciences hospitals examining patients who had upper endoscopy for presumed UGIB. Contingency tables were generated to determine the test characteristics of urea at different thresholds for prediction of UGIB. A crude OR was calculated for odds of bleeding being identified on endoscopy based on varying thresholds of urea, and adjusted ORs were calculated using logistic regression modelling. RESULTS: Variables significantly associated with detecting a source of GI bleeding at endoscopy included increase in urea (OR 1.06, 95% CI 1.01-1.09), male gender (OR 2.02, 95% CI 1.08-3.77), presence of melena (OR 2.37, 95% CI 1.06-5.33), and hematemesis (OR 3.88, 95% CI 1.70-8.83), when adjusted for other covariates. The odds of identifying UGIB at endoscopy in patients with urea ≥10 mmol/L was 3.73 (95% CI 1.90-7.31) times higher than for patients with urea <10 mmol/L. CONCLUSION: Urea level is an independent predictor of positive endoscopic findings in presumed UGIB, and urea ≥10 mmol/L may be a useful threshold to help guide clinicians towards clinically significant bleeding that could warrant early endoscopic evaluation.

Breast cancer learning health system: Patient information from a data and analytics platform characterizes care provided.

Purpose: In a learning health system (LHS), data gathered from clinical practice informs care and scientific investigation. To demonstrate how a novel data and analytics platform can enable an LHS at a regional cancer center by characterizing the care provided to breast cancer patients. Methods: Socioeconomic information, tumor characteristics, treatments and outcomes were extracted from the platform and combined to characterize the patient population and their clinical course. Oncologists were asked to identify examples where clinical practice guidelines (CPGs) or policy changes had varying impacts on practice. These constructs were evaluated by extracting the corresponding data. Results: Breast cancer patients (5768) seen at the Juravinski Cancer Centre between January 2014 and June 2022 were included. The average age was 62.5 years. The commonest histology was invasive ductal carcinoma (74.6%); 77% were estrogen receptor-positive and 15.5% were HER2 Neu positive. Breast-conserving surgery (BCS) occurred in 56%. For the 4294 patients who received systemic therapy, the initial indications were adjuvant (3096), neoadjuvant (828) and palliative (370). Metastases occurred in 531 patients and 495 patients died. Lowest-income patients had a higher mortality rate. For the adoption of CPGs, the uptake for adjuvant bisphosphonate was very low, 8% as predicted, compared to 64% for pertuzumab, a HER2 targeted agent and 40.2% for CD4/6 inhibitors in metastases. During COVID-19, the provincial cancer agency issued a policy to shorten the duration of radiation after BCS. There was a significant reduction in the average number of fractions to the breast by five fractions. Conclusion: Our platform characterized care and the clinical course of breast cancer patients. Practice changes in response to regulatory developments and policy changes were measured. Establishing a data platform is important for an LHS. The next step is for the data to feedback and change practice, that is, close the loop.

Early cholecystectomy and ERCP are associated with reduced readmissions for acute biliary pancreatitis: a nationwide, population-based study.

BACKGROUND: Cholecystectomy is recommended during hospitalizations for acute biliary pancreatitis (ABP). OBJECTIVE: We sought to assess the population-based effectiveness of index cholecystectomy by using nationwide data. DESIGN: Retrospective, cohort study. SETTING: All acute-care hospitals in Canada from 2007 to 2010. PATIENTS: This study involved patients admitted for ABP in the Canadian Institutes for Health Information hospital discharge database. INTERVENTION: Cholecystectomy and therapeutic ERCP during the index admission. MAIN OUTCOME MEASUREMENTS: Rate of hospital readmissions for ABP. RESULTS: Among 5646 patients with ABP, 32% underwent cholecystectomy and 22% ERCP during the index admissions. Patients admitted to hospitals in the highest quartile for cholecystectomy volume were more than 10-fold likely to undergo cholecystectomy during the index admission (adjusted odds ratio 11.0; 95% confidence interval [CI], 7.4-16.5). The 12-month readmission rate for ABP was lower with cholecystectomy (5.6% vs 14.0%; P < .0001) and therapeutic ERCP (5.1% vs 13.1%; P < .0001). After multivariate adjustment, lower readmission rates were independently associated with both cholecystectomy (adjusted hazard ratio [HR] 0.39; 95% CI, 0.32-0.48) and ERCP (adjusted HR 0.37; 95% CI, 0.29-0.50). After excluding early readmissions (within 28 days of discharge), the adjusted HR for cholecystectomy was 0.43 (95% CI, 0.34-0.57). The admitting hospital's cholecystectomy volume was inversely associated with 12-month readmission rates for ABP (quartile 1, 15.9%; quartile 2, 13.9%; quartile 3, 11.3%; quartile 4, 10.0%; P < .001). LIMITATIONS: The study was based on hospital administrative data. CONCLUSION: Cholecystectomy and ERCP during the index admission were associated with reduced readmission rates for ABP, providing population-based evidence to support consensus guidelines that recommend early biliary intervention.

Infliximab to Treat Refractory Inflammation After Pelvic Pouch Surgery for Ulcerative Colitis.

BACKGROUND: Inflammatory pouch complications refractory to first-line therapies remain problematic following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We evaluated infliximab efficacy and associations with therapeutic response. METHODS: Data from individuals who underwent colectomy and IPAA for UC (2000-2014) were reviewed. Patients with chronic refractory pouchitis (CP) and Crohn's disease (CD)-like outcomes treated with infliximab were included. Pre-treatment parameters and response at median 8 (initial) and 48 weeks (sustained) were measured. Complete response was defined as symptomatic and endoscopic resolution with modified Pouchitis Disease Activity Index (mPDAI) <5. Partial response included mPDAI improvement >2. Serum was analysed for Anti-Saccharomyces cerevisiae antibodies (ASCA), anti-OmpC, anti-CBir1 and perinuclear Anti-Neutrophil Cytoplasmic Antibodies (pANCA). RESULTS: One hundred and fifty-two patients with CP or a CD-like phenotype were identified. Forty-two were treated with infliximab (33% male; age 32.6±2.6 years, 28.5% CD-like). Post-induction response was achieved in 74% (48% complete) and sustained response in 62.6% (29.6% complete). Mean mPDAI and C-reactive protein declined from 8.5±0.3 to 2±3.4 (p < 0.002) and from 29.48±6.2 to 5.76±1.6mg/L (p < 0.001), respectively. Female gender, smoking and presence of anti-CBir1 were associated with infliximab use (p < 0.01) but not response. Pre-treatment mPDAI <10 (p < 0.01), resolution of rectal bleeding (p < 0.001 ) and week 8 endoscopic activity were associated with sustained response (p = 0.04; odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1-16.5]). More than 2 positive antimicrobial antibody titres were associated with non-response (p < 0.05), but did not retain significance in multivariate analysis (p = 0.197; OR 0.632; 95% CI 0.31-1.2). CONCLUSIONS: Infliximab can effectively treat inflammatory pouch complications. Pre-treatment mPDAI <10 and early endoscopy may identify responders.

The utility of screening for asymptomatic lower extremity deep venous thrombosis during inflammatory bowel disease flares: a pilot study.

BACKGROUND: Asymptomatic deep vein thrombosis (DVT) occurs in up to 11% of medical inpatients. The incidence of asymptomatic DVT among patients with inflammatory bowel disease (IBD) is unknown but may be even higher. D-dimer is effective for DVT screening, but its utility has not been studied in the IBD population. METHODS: Hospitalized and ambulatory patients with IBD during flares were recruited between 2009 and 2011. Those with clinical symptoms of venous thromboembolism or previous venous thromboembolism were excluded. We determined the prevalence of DVT among asymptomatic subjects using lower extremity Doppler ultrasound and assessed the performance characteristics of the D-dimer in this high-risk study population. RESULTS: We enrolled 101 hospitalized and 49 ambulatory patients with IBD during active flares. There were no cases of proximal DVT detected by lower extremity Doppler ultrasound. The 95% confidence interval (CI) for the rate of proximal DVT was 0% to 2%. D-dimer was elevated in 60% of subjects without DVT, occurring more frequently among hospitalized than ambulatory subjects [89% versus 65%, P = 0.01; adjusted odds ratio (aOR), 4.16, 95% CI, 1.58-10.9]. Other predictors of elevated D-dimer were incremental decade in age (aOR, 1.97; 95% CI, 1.24-3.14); ulcerative colitis versus Crohn's disease diagnosis (aOR, 3.38; 95% CI, 1.29-8.84); and every 10-unit increase in C-reactive protein (aOR, 1.33; 95% CI, 1.09-1.62). CONCLUSION: From this pilot study, there appears to be low prevalence of asymptomatic DVTs among patients with IBD during flares. The high prevalence of elevated D-dimer in DVT-negative patients limits its utility in IBD.