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Background and Aims: Cachexia is a metabolic syndrome defined by a loss of more than 5% of body weight in patients with chronic diseases. The goal of this study was to investigate the link between cirrhotic cachexia and hospital mortality and the 30-day risk of all-cause readmission. Methods: The study utilized Nationwide Readmission Database for the years 2016-2019 in which all patients older than 18 year old with a primary diagnosis of cirrhosis were included. We excluded patients with a concurrent diagnosis of Human Immunodeficiency Virus, chronic lung disease, end-stage renal disease, malignancy, heart failure, and certain neurological diseases. We compared baseline characteristics and outcomes between those who were cachectic and those who were not. Survey multivariate logistic regression was used to analyze the independent impact of cachexia on categorical outcomes. Results: The study cohort was 342,030 cases. Cachexia was identified in approximately 17% of the study population (58,509 discharges). The mean age was 56 years. Slightly more female patients noted in cachexia group (41% vs 38%). Inpatient mortality during index hospitalization were higher in patients with cirrhotic cachexia (6.7% vs 3%, P < .01). Inpatient mortality during first all-cause readmission within 30 days of index discharge was also higher in cachexia group (8.6% vs 6.5%, P < .01). Conclusion: Cachexia is an adverse prognosticator for inpatient outcomes in patients with cirrhosis. It is associated with greater readmission rates, inpatient mortality, and prolonged hospital admissions.
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Background: Combination therapy with thiopurines and anti-tumor necrosis factor (TNF) is superior to monotherapy in Crohn's disease (CD) and ulcerative colitis (UC). The optimal dose of thiopurines in combination therapy remains unclear. We investigated the impact of thiopurine dose in combination therapy on outcomes in inflammatory bowel disease (IBD). Methods: This was a single-center, retrospective study of patients with IBD treated with thiopurine and anti-TNF combination therapy between 1/2012 and 11/2020. A therapeutic dose of thiopurines was defined as ≥1 mg/kg for 6-mercaptopurine and ≥2 mg/kg for azathioprine. The primary outcome was anti-drug antibody (ADA) formation in patients on a therapeutic thiopurine dose vs. a lower thiopurine dose group. Secondary outcomes included steroid-free clinical remission, endoscopic healing (absence of ulcers/erosions in CD and Mayo endoscopic score ≤1 for UC), and normal serum C-reactive protein (CRP) in patients who were on combination therapy. Results: A total of 108 patients were included (median age 31.5 years; 58.3% male). A therapeutic dose of thiopurine was used in 19%. In the therapeutic thiopurine dose group, 23.8% developed ADA vs. 29.9% (P=0.58) in the lower dose group. No significant differences were noted between the therapeutic and lower dose thiopurine groups in terms of steroid-free clinical remission (57.1% vs. 60.9%, P=0.75), endoscopic healing (55% vs. 60%, P=0.69), and normal CRP (52.4% vs. 52.9%, P=0.27). Conclusion: In our cohort of patients with IBD on anti-TNF combination therapy, thiopurine dose was not associated with significant differences in anti-TNF immunogenicity and clinical outcomes.
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BACKGROUND: Aspirin is almost always used after coronary artery bypass graft (CABG) surgery; however, it is unclear what optimal dose should be prescribed. In this systematic review, we evaluated the effects of high versus low-dose aspirin in patients after CABG. METHODS: A comprehensive database search was conducted in several databases from date of inception until February 2018. There were no language restrictions. We included studies that compared different doses of aspirin in patients that had undergone CABG surgery. We included studies that evaluated patient-important outcomes (mortality, cardiovascular events, and gastrointestinal bleeding); and if not reported, we collected data on the surrogate outcome thromboxane B2 (TXB2). We collected relevant data and performed a meta-analysis. RESULTS: We identified 5903 references, and after two levels of screening by two independent reviewers, we included three randomized controlled trials in the meta-analysis with a total number of 122 participants. Mean age of trial participants was 65.63 years, and 88.68% were male. We planned to analyze all possible clinical outcomes, including mortality, recurrence, and hospitalization. However, no clinical outcomes are reported by the literature. The surrogate biochemical outcome of serum TXB2 was the only outcome reported by the eligible studies. High-dose aspirin (162-325mg once daily) achieved better suppression of TXB2 than low-dose aspirin (75-100mg once daily) (mean difference [MD], 2.00ng/mL, 95% confidence interval [CI]: 0.72-3.32; participants = 122; studies = 3; I2 = 0%). CONCLUSIONS: We found no clinical trials addressing any of the clinical outcomes of interest. High-dose aspirin was superior to low-dose aspirin in suppressing platelet function, a surrogate outcome. Trials evaluating clinical and patient-important outcomes are needed to better inform medical practice and fill this gap in clinical knowledge.
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Testicular cancer is the most common neoplasia in men between the ages of 15 to 44 years. Choriocarcinoma represents less than 2% of testicular tumors. It is usually characterized by an early hematogenous spread to the lungs and brain. Metastases to the gastrointestinal (GI) tract are extremely rare. Most metastatic lesions in the GI tract are seen in the small bowel. We present a 30-year-old African American male with a past medical history significant for stage III non-seminomatous germ cell testicular cancer. The patient was initially started on chemotherapy; however, he was not compliant with his treatment. One year following his diagnosis, he presented to the hospital with shortness of breath and chest pain. CT angiography of the chest was done and showed multiple masses scattered in all lung fields. The lesions were believed to be metastatic in nature. Laboratory testing showed a human chorionic gonadotropin beta level of 40,453 IU/L, LDH 258 IUnits/L, and alfa-fetoprotein 8.9 ng/mL. His hospital stay was complicated with melena and a drop in his hemoglobin from a baseline of 12 to 7 gm/dL. An esophagogastroduodenoscopy (EGD) showed three erythematous friable nodules in the gastric body. Biopsy results came back consistent with metastatic choriocarcinoma. The patient was offered salvage chemotherapy; however, he refused treatment and elected to proceed with suppurative measures. Testicular choriocarcinomas are the most aggressive and rapidly arising germ cell tumors. By the time they are diagnosed, large subsets of cases have already metastasized. Patients usually present with symptoms of hemorrhage in metastatic sites due to the high level of vascularization of those lesions. Gastrointestinal metastases from choriocarcinomas are very rare which account for 5% of all metastatic lesions with around 1% affecting the stomach. The presenting symptoms of stomach metastases are melena and/or hematemesis along with anemia. Although extremely rare, gastric metastases of choriocarcinoma should be kept in mind as part of the differential diagnosis for young patients with upper GI bleeding.
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Gastric cancer is the fifth most common malignancy worldwide and the fourth leading cause of cancer-related deaths. The diagnosis is usually made by direct visualization with supporting histopathology. However, patients with gastric bypass surgery pose a challenge in diagnosis due to the difficulty in the evaluation of the excluded stomach. We present two cases of gastric cancer in the excluded stomach after Roux-en-Y gastric bypass (RYGB) surgery was diagnosed using two different endoscopic approaches.