Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study.

BACKGROUND: Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. METHODS: We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors. RESULTS: Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01). CONCLUSION: We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.

A Case of Unresolved and Worsening Retroperitoneal Abscess.

Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset. Herein, we present a case of retroperitoneal abscess secondary to a perforation that occurred during an ERCP. A 54-year-old female patient was admitted to an outside hospital with gallstone pancreatitis and underwent ERCP with sphincterotomy followed by laparoscopic cholecystectomy. An abdominal CT scan was performed at the outside hospital 10 days later for worsening abdominal pain which showed multiple loculated pockets in the right upper and lower quadrant. Her condition improved after IV antibiotics and percutaneous drainage. Her symptoms recurred a month later and she presented to our hospital. Repeat abdominal CT scan at our hospital revealed recurrence of her abscesses. Multiple drains were placed and the abscess cavity was washed out without much improvement. EGD revealed a small mucosal defect in the distal portion of the duodenal bulb which was closed successfully using an over-the-scope clip. Repeat CT scan after 8 weeks from the endoscopic closure showed near complete resolution of the abscess. ERCP-associated perforation is a rare complication and can be challenging to diagnose and treat; prompt recognition is mandatory for favorable prognosis. Our patient was managed successfully via nonsurgical approach.

Association between serum vitamin D levels and gastric cancer: A retrospective chart analysis.

AIM: To determine whether there is an increased risk of gastric adenocarcinoma associated with vitamin D deficiency (VDd). METHODS: A retrospective case control study was performed of all patients diagnosed with gastric adenocarcinoma between 2005 and 2015. After we excluded the patients without a documented vitamin D level, 49 patients were included in our study. RESULTS: The average age of patients with gastric adenocarcinoma and documented vitamin D level was 64 years old (95%CI: 27-86) and average vitamin D level was 20.8 mg/dL (95%CI: 4-44). Compared to a matched control group, the prevalence of VDd/insufficiency in patients with gastric adenocarcinoma was significantly higher than normal vitamin D levels (83.7% vs 16.3%). Forty-one patients (83.7%) with adenocarcinoma showed VDd/insufficiency compared to 18 (37%) patients with normal vitamin D level without gastric cancer (OR: 8.8, 95%CI: 5-22, P value < 0.0001). The average age of males with gastric adenocarcinoma diagnosis was 60 years old vs 68 years old for females (P = 0.01). Stage II gastric adenocarcinoma was the most prevalent in our study (37%). CONCLUSION: We reported a positive relationship between VDd and gastric adenocarcinoma, that is to say, patients with decreased VDd levels have an increased propensity for gastric adenocarcinoma.

ASGE guidelines result in cost-saving in the management of choledocholithiasis.

BACKGROUND: The goal of this study was to determine whether utilization of the ASGE guidelines for the evaluation of bile duct stones (BDS) would result in fewer imaging studies and in turn lead to a lower healthcare expenditure. METHODS: This was a retrospective study set in an urban Teaching Hospital. Patients undergoing evaluation for BDS and who had their gallbladders in situ were included in the study. Data with regard to age, sex, clinical history, pain level, vital signs and laboratory studies as well as diagnostic tests performed were extracted from the hospital's electronic medical record. The ASGE guidelines were applied retrospectively to each patient in the study group and the group was divided into two cohorts: one that followed the ASGE guidelines and one which did not. Patients in the two cohorts were further stratified into high-, intermediate-, and low-risk categories. RESULTS: Thirty-eight patients met the criteria and were included in the study. Of the 38 patients, 22 were managed as per the ASGE guidelines and 16 were not. Twenty-seven patients were categorized as high-risk (14 following the correct algorithm, 13 not) and 11 as intermediate-risk (8 following, 3 not). There were no low-risk patients. Twelve of the 27 patients in the high-risk group had stones (56%) while 6 of 11 (55%) had stones in the intermediate-risk group. Fourteen computed tomography scans and 12 magnetic resonance cholangiopancreatographies were deemed inappropriate resulting in unnecessary increased expenditure of $ 22,236. CONCLUSION: The application of ASGE guidelines can minimize redundant investigations and effect cost saving but need to be refined to produce a better yield.

Factors predicting early discharge and mortality in post-percutaneous endoscopic gastrostomy patients.

BACKGROUND: The aim of our study was to ascertain factors that favor early discharge and predict mortality in post-percutaneous endoscopic gastrostomy (PEG) patients. METHODS: Successive patients who underwent successful PEG placement during a 10-year period in a single New York City hospital were included in the study. Data was retrospectively extracted from hospital electronic medical records. RESULTS: Two hundred and eighty-four patients underwent successful PEG placement. Forty-six patients (16%) were discharged within 3 days of PEG placement (early discharge). Two hundred and thirty six patients (84%) remained in hospital from 4 to 244 days (median 13.5) after PEG insertion (late discharge). Twenty-six (9%) patients died in-house after PEG placement. A serum albumin level <2.2 g/dL (P=0.007) and presence of 2 or more co-morbidities (P=0.019) were predictors of late discharge. A dementia indication was twice as likely to result in an early discharge compared to a stroke indication (OR 2.39; 95% CI 1.07-5.36; P=0.033). Female sex, positive urine cultures and low serum albumin levels were independent predictors of in-house mortality. CONCLUSION: Clinical and laboratory markers may predict post-PEG mortality as well as early patient discharge.

Treatment of gastroparesis: an update.

Gastroparesis is a chronic disorder of gastric motility that is characterized by delayed emptying of either solids or liquids from the stomach in the absence of any mechanical obstruction. Nausea, vomiting, early satiety and bloating are some of the manifestations of gastroparesis. Idiopathic, diabetes mellitus and postsurgical states account for the majority of cases. Gastroparesis is a difficult condition to treat. Prokinetic drugs like metoclopramide and erythromycin form the mainstay of therapy but are less than ideal. Some patients may benefit from endoscopic botolinium toxin injection. Gastric electrical stimulation, though promising, is not ready for prime time yet.

Do corporate chains affect quality of care in nursing homes? The role of corporate standardization.

BACKGROUND: Chain-owned nursing homes have become the predominant type of provider in the United States, but little is known about their management structures. Prior research has found that chain ownership has significant effects on health outcomes, but why that is the case is not well understood. PURPOSE: This study examines the effects of corporate-mandated standardization and corporate-sponsored training in administrative and clinical processes on the total number of deficiencies reported for a facility and on the percentage of residents with pressure ulcers for chain-owned facilities in Michigan and North Carolina. METHODOLOGY: Data on the corporate practices of standardization and training were collected in a mail survey of facility administrators in Michigan in 2001 and North Carolina in 2002. We received responses from 117 of 239 chain-owned facilities in Michigan and 86 of 270 in North Carolina. Survey responses were merged with facility characteristics taken from the On-line Survey, Certification, and Report System. Seemingly unrelated regression was used to estimate the effects of standardization on the count of health deficiencies and percentage of residents with pressure ulcers simultaneously. FINDINGS: Health deficiencies, but not pressure ulcers, were lower in facilities of chains with greater overall corporate standardization. More detailed analysis revealed that standardization of facilities' physical plant lowered both deficiencies and pressure ulcers and standardization of clinical activities lowered pressure ulcers (but not deficiencies). In contrast, standardization of administrative practices increased pressure ulcers (but not deficiencies). PRACTICE IMPLICATIONS: Corporate standardization of resident-centered activities such as clinical guidelines and common facility layouts may contribute to superior resident care, whereas primary reliance on administrative standardization may interfere with residents' needs. Chains need to balance administrative efficiency with the local needs of individual chain-owned facilities and their residents.