An Improved Assessment Method to Estimate (Poly)phenol Intake in Adults with Chronic Pancreatitis.

BACKGROUND: Insights into (poly)phenol exposure represent a modifiable factor that may modulate inflammation in chronic pancreatitis (CP), yet intake is poorly characterized and methods for assessment are underdeveloped. AIMS: The aims are to develop and test a method for estimating (poly)phenol intake from a 90-day food frequency questionnaire (FFQ) using the Phenol-Explorer database and determine associations with dietary patterns in CP patients versus controls via analysis of previously collected cross-sectional data. METHODS: Fifty-two CP patients and 48 controls were recruited from an ambulatory clinic at a large, academic institution. To assess the feasibility of the proposed methodology for estimating dietary (poly)phenol exposure, a retrospective analysis of FFQ data was completed. Mann-Whitney U tests were used to compare (poly)phenol intake by group; Spearman correlations and multivariable-adjusted log-linear associations were used to compare (poly)phenol intakes with dietary scores within the sample. RESULTS: Estimation of (poly)phenol intake from FFQs was feasible and produced estimates within a range of intake previously reported. Total (poly)phenol intake was significantly lower in CP vs controls (463 vs. 567mg/1000kcal; p = 0.041). In adjusted analyses, higher total (poly)phenol intake was associated with higher HEI-2015 (r = 0.34, p < 0.001), aMED (r = 0.22, p = 0.007), EDIH (r = 0.29, p < 0.001), and EDIP scores (r = 0.35, p < 0.001), representing higher overall diet quality and lower insulinemic and anti-inflammatory dietary potentials, respectively. CONCLUSIONS: Using enhanced methods to derive total (poly)phenol intake from an FFQ is feasible. Those with CP have lower total (poly)phenol intake and less favorable dietary pattern indices, thus supporting future tailored dietary intervention studies in this population.

An observational human laboratory assessment of nicotine delivery, vaping topography and subjective effects of usual brand electronic cigarette use among young adults.

AIMS: To measure nicotine delivery, vaping topography and subjective effects of current generations of disposable, cartridge-based and other types of electronic cigarettes (e-cigarettes) among young adults. DESIGN, SETTING, PARTICIPANTS: Observational, human laboratory assessment of e-cigarette use in Columbus, Ohio, USA (July 2020 to June 2021). Participants (n = 96, 60.4% female, age mean = 21.7 [standard deviation = 1.7] years, 82.4% white race) were identified via their participation in a cohort study or other convenience sampling and were 18 to 25 years old, vaped ≥4 days/week for ≥4 weeks and used other tobacco products for ≤5 days of past 30 days. Participants completed a pre-vaping questionnaire, vaped their usual brand of e-cigarette ad libitum for 30 min and completed a post-vaping questionnaire. MEASUREMENTS: Outcome variables included pre- and post-vaping measures of plasma nicotine (t = 0 and t = 30, respectively) and craving and withdrawal symptoms, as well as vaping topography (e.g. flow rate and inter-puff interval), pre-vaping expectancies and post-vaping product appeal. Variables used to characterize the sample included demographics, e-cigarette and other tobacco use history, e-cigarette dependence and e-cigarette device characteristics (e.g. device type, flavor and nicotine form). FINDINGS: Participants reported moderate nicotine dependence on average via the E-Cigarette Dependence Scale (mean = 6.9 [standard deviation = 4.0]). Following 30 min of ad libitum vaping, participants achieved substantial plasma nicotine boost (mean = 18.8 [standard deviation = 14.5] ng/mL), corresponding with statistically significant decreases in withdrawal symptoms measured via the Minnesota Nicotine Withdrawal Scale (pre-vaping mean = 9.0 [standard deviation = 5.1], post-vaping mean = 4.3 [standard deviation = 3.9]; P-value <0.0001). Pre-vaping, participants reported moderate vaping expectancies (e.g. mean = 2.5 [standard deviation = 1.0] on a scale from 0 to 4 for smell and taste expectancies); post-vaping, participants reported high satisfaction (mean = 4.6 [standard deviation = 1.2] on a scale from 1 to 7) and moderate reward (mean = 2.9 [standard deviation = 1.2]) and respiratory sensations (mean = 3.7 [standard deviation = 1.6]). Nearly half of participants (47.9%) used disposable e-cigarettes, and most used a mint/menthol or fruit flavored (99.0%) and nicotine salt (98.9%) e-liquid. CONCLUSIONS: Among young adults in the United States, the latest generations of e-cigarettes appear to deliver large quantities of nicotine (similar to cigarettes) and significantly relieve withdrawal symptoms, and they are appealing.

Examining the Predictive Utility of Behavioral Economic Demand Indices and Subjective Effects on the Actualized Reinforcing Value of Menthol Cigarettes and Potential Alternatives.

INTRODUCTION: Considering recent and proposed bans on menthol cigarettes, methods are needed to understand the substitutability of potential menthol cigarette alternatives (MCAs) for menthol cigarettes. This study examined the prospective relationship between behavioral economic demand indices and subjective effects of usual brand menthol cigarettes (UBMC) and preferred MCAs with subsequent performance on a laboratory-based concurrent-choice task comparing UBMC and MCAs. METHODS: Eighty participants who typically smoked menthol cigarettes completed this clinical laboratory study. After sampling each product, participants completed the cigarette purchase task (CPT) and modified cigarette evaluation questionnaire (mCEQ). Following 1 week of substituting their preferred MCA for their UBMC, participants completed a 90-minute concurrent-choice self-administration (SA) task comparing their UBMC and preferred MCA. Linear regression models explored associations between CPT demand indices and mCEQ subjective effects in the laboratory with subsequent response effort for UBMCs on the concurrent-choice task. RESULTS: Three demand indices for UBMC were positively associated with UBMC response effort: essential value (EV; p = .02), Omax (p = .02), and breakpoint (p = .04). Four CPT demand indices for the preferred MCA significantly corresponded with UBMC response effort: EV (p = .03), price associated with maximal expenditure (Pmax) (p = .04), maximal expenditure (Omax) (p = .03), and breakpoint (p = .03). Subjective effects captured by the mCEQ were not associated with response effort. CONCLUSIONS: Demand indices reflecting Persistence (ie, sensitivity to escalating price) predicted effort to obtain UBMC puffs on the concurrent-choice task. Among this sample, the CPT captured information on the relative reinforcing value (ie, addiction potential) of combustible tobacco products similar to the longer SA task. IMPLICATIONS: In an ever-changing product market, assessing the reinforcing efficacy of menthol cigarettes and putative substitutes quickly and with validity is an important methodological tool for understanding abuse liability. Results suggest that behavioral economic demand indices of CPT efficiently capture information on the relative reinforcing value of UBMC and plausible alternative tobacco products, similar to a 90-minute in-laboratory SA task.

Evaluating the effects of nicotine concentration on the appeal and nicotine delivery of oral nicotine pouches among rural and Appalachian adults who smoke cigarettes: A randomized cross-over study.

BACKGROUND AND AIMS: Oral nicotine pouches (ONPs) probably offer reduced harm compared with cigarettes, but independent data concerning their misuse liability are lacking. We compared nicotine delivery and craving relief from ONPs with different nicotine concentrations to cigarettes. DESIGN: This was a single-blind, three-visit (≥ 48-hour washout), randomized-cross-over study. Participants were encouraged to complete all study visits in less than 1 month. SETTING: The study took place in Rural/Appalachian Ohio. PARTICIPANTS: Participants comprised 30 adults who smoke cigarettes. Participants (meanage = 34.5) were 60% men and 90% White. INTERVENTION: Participants who were ≥ 12-hour tobacco-abstinent used: (1) a 3-mg nicotine concentration ONP, (2) a 6-mg nicotine concentration ONP and (3) usual brand cigarette in separate visits. ONPs (wintergreen Zyn) were used for 30 minutes; cigarettes were puffed every 30 sec for 5 minutes. MEASUREMENTS: Plasma nicotine and self-reported craving were assessed at t = 0, 5, 15, 30, 60 and 90 minutes. The primary outcome was plasma nicotine concentration at t = 30 minutes. A secondary outcome was craving relief at t = 5 minutes. FINDINGS: At t = 30, mean [95% confidence interval (CI)] plasma nicotine was 9.5 ng/ml (95% CI = 7.1, 11.9 ng/ml) for the 3 mg nicotine ONP, 17.5 ng/ml (95% CI = 13.7, 21.3) for the 6 mg nicotine ONP and 11.4 ng/ml (95% CI = 9.2, 13.6 ng/ml) for the cigarette. Mean plasma nicotine at t = 30 minutes differed between the 3- and 6-mg nicotine ONPs (P = 0.001) and between the 6-mg nicotine ONP and cigarette (P = 0.002). Mean (95% CI) craving at t = 5 minutes was lower for the cigarette (mean = 1.00, 95% CI = 0.61, 1.39) than either the 3 mg (mean = 2.25, 95% CI = 1.68, 2.82; P < 0.0001) or 6 mg nicotine (mean = 2.19, 95% CI = 1.60, 2.79; P < 0.0001) ONP. CONCLUSIONS: Among adult smokers, using 6-mg nicotine concentration oral nicotine pouches (ONPs) was associated with greater plasma nicotine delivery at 30 minutes than 3-mg ONPs or cigarettes, but neither ONP relieved craving symptoms at 5 minutes as strongly as a cigarette. Accelerating the speed of nicotine delivery in ONPs might increase their misuse liability relative to cigarettes.

Early unplanned readmissions following same-admission cholecystectomy for acute biliary pancreatitis.

BACKGROUND: Same-admission cholecystectomy (CCY) is recommended for mild acute biliary pancreatitis (biliary-AP). However, there is a paucity of research investigating reasons for early (30-day) unplanned readmissions in patients who undergo CCY for biliary-AP. Hence, we sought to investigate this gap using a large population database. METHODS: Using the Nationwide Readmission Database (2010-2014), we identified all adults (age ≥ 18 years) with a principal diagnosis of biliary-AP who had undergone CCY during the index hospitalization. Multivariable logistic regression models were obtained to assess independent predictors for 30-day readmission. Principal diagnosis for all readmissions was collected to ascertain the indications for early readmission. RESULTS: During the study period, 118,224 patients underwent same-admission CCY for biliary-AP. Three-fourths of all patients underwent invasive cholangiography during the hospitalization (intraoperative cholangiogram (IOC) = 57,038, ERCP = 31,500). The rate of early (30-day) readmission was 7.25% (n = 8574). Exacerbation of prior medical conditions (42.2%), sequelae of biliary-AP (resolving and recurrent pancreatitis, pseudocysts) (27.6%), surgical site and other postoperative complications (16%), choledocholithiasis and/or bile leak (9.6%), and preventable hospital-acquired conditions (4.6%) accounted for early readmissions. On multivariable analysis, predictors for readmission included male sex (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.28), insurance type (Medicare insurance [OR 1.26, 95% CI 1.13-1.40]; Medicaid [OR 1.22, 95% CI 1.09-1.38]), outside-facility discharge (OR 1.35, 95% CI 1.16-1.57), severe AP (OR 1.35, 95% CI 1.21-1.50), and ≥ 3 Elixhauser comorbidities (OR 1.55, 95% CI 1.41-1.69). Performance of IOC (OR 0.90, 95% CI 0.82-0.97) and ERCP (OR 0.81, 95% CI 0.73-0.89) were associated with decreased risk of early readmission. CONCLUSION: In this study, using a national population database evaluating patients who underwent same-admission CCY after biliary-AP, we identified potentially modifiable risk factors and causes for early readmission as well as opportunities to improve clinical care.

National Trends of Hospitalizations in Cystic Fibrosis Highlight a Need for Pediatric to Adult Transition Clinics.

OBJECTIVES: We hypothesized that hospitalizations in cystic fibrosis (CF) would reflect the development of age-related comorbidities. METHODS: A retrospective analysis was performed using the Nationwide Inpatient Sample (2002-2017). Hospitalizations for which the principal diagnosis was CF were analyzed regarding age at discharge and presence of comorbidities. Trends were assessed for significance using the Cochran-Armitage test. RESULTS: The mean age of patients hospitalized for CF increased from 19.7 years in 2002 to 23.0 years in 2017 (P = 0.017). Several comorbidities are more than 10 times more prevalent among adults as compared with children, including congestive heart failure, substance abuse, and chronic kidney disease (P < 0.001). In addition, diabetes with chronic complications was more prevalent in adults than children (10.0% vs 3.9%; P < 0.001), as was hypertension (7.2% vs 1.3%; P < 0.001) and osteoporosis (10.2% vs 1.9%; P < 0.001). More than 65% of CF hospitalizations in 2017 were in individuals older than 18 years. CONCLUSIONS: Hospitalizations for adults with CF are increasing, and individuals with CF are developing age-related comorbidities. Providers equipped to manage the health care needs of adults need to be ready and able to care for this unique and growing patient population.

Acute and Severe Acute Pancreatitis and the Effect of Cannabis in States Before and After Legalization Compared With States Without Legalized Cannabis.

OBJECTIVES: Cannabis legalization has increased its use. The incidence of acute pancreatitis (AP) and severe acute pancreatitis (SAP) has also increased. In this study, data on pancreatitis were obtained from 2 states before and after cannabis legalization and compared with 2 states without legalized cannabis. METHODS: Data were extracted from State Inpatient Databases from the states of Colorado and Washington before recreational cannabis legalization (2011) and after legalization (2015). Arizona and Florida were used as the nonlegalized cannabis states. Multivariable logistic regression models were fit for AP and SAP to determine a trend difference between legalized and nonlegalized cannabis states. RESULTS: Cannabis use, AP, and SAP increased in all states. The increase in AP and SAP was not significantly different between the states that legalized cannabis use and those that did not. Legalized cannabis states had lower charges for AP and SAP and shorter length of hospitalizations. CONCLUSIONS: The trend of AP and SAP increased during the study period, but this was not correlated to cannabis use. Cannabis users had lower hospitalization costs and hospital stay. The effects of other confounders such as cannabis dose and delivery methods, alcohol, tobacco, and others need to be studied further as use increases.

Cannabis use may reduce healthcare utilization and improve hospital outcomes in patients with cirrhosis.

INTRODUCTION AND OBJECTIVES: Previous studies reveal conflicting data on the effect of cannabis use in patients with cirrhosis. This research evaluates the impact of cannabis on hepatic decompensation, health care utilization, and mortality in patients with cirrhosis. MATERIAL AND METHODS: A retrospective analysis of the State Inpatient Database (SID) was performed evaluating patients from Colorado and Washington in 2011 to represent pre-cannabis legalization and 2015 to represent post-cannabis legalization. Multivariable analysis was performed to study the impact of cannabis on the rate of admissions with hepatic decompensations, healthcare utilization, and mortality in patients with cirrhosis. RESULTS: Cannabis use was detected in 370 (2.1%) of 17,520 cirrhotics admitted in 2011 and in 1162 (5.3%) of 21,917 cirrhotics in 2015 (p-value <0.001). On multivariable analysis, cirrhotics utilizing cannabis after its legalization experienced a decreased rate of admissions related to hepatorenal syndrome (Odds Ratio (OR): 0.51; 95% Confidence Interval (CI): 0.34-0.78) and ascites (OR: 0.73; 95% CI: 0.63-0.84). Cirrhotics with an etiology of disease other than alcohol and hepatitis C had a higher risk of admission for hepatic encephalopathy if they utilized cannabis [OR: 1.57; 95% CI: 1.16-2.13]. Decreased length of stay (-1.15 days; 95% CI: -1.62, -0.68), total charges (-$15,852; 95% CI: -$21,009, -$10,694), and inpatient mortality (OR: 0.68; 95% CI: 0.51-0.91) were also observed in cirrhotics utilizing cannabis after legalization compared to cirrhotics not utilizing cannabis or utilizing cannabis prior to legalization. CONCLUSION: Cannabis use in patients with cirrhosis resulted in mixed outcomes regarding hospital admissions with hepatic decompensation. A trend towards decreased hospital utilization and mortality was noted in cannabis users after legalization. These observations need to be confirmed with a longitudinal randomized study.

Class III obesity rather than metabolic syndrome impacts clinical outcomes of acute pancreatitis: A propensity score weighted analysis.

OBJECTIVES: The incidence rates of acute pancreatitis (AP) and the prevalence of class III obesity, and metabolic syndrome (MetS) are increasing in the US. Since class III obesity was associated with adverse clinical outcomes of AP, we sought to understand if the presence of metabolic comorbidities collectively recognized, as MetS were associated with worse clinical outcomes and increased health-care utilization. METHODS: The Nationwide Readmissions Database (NRD) (2010-2014) was reviewed to identify all adult subjects with a principal discharge diagnosis of AP. Inpatient mortality, severe AP (SAP), and 30-day readmissions were the primary outcomes analyzed. Propensity score weighted analyses were used to compare AP subjects with and without MetS and were further stratified by class III obesity status. RESULTS: MetS was associated with 12.91% (139,165/1,078,183) of all admissions with AP. Propensity score weighted analyses showed that MetS was associated with an increased proportion of SAP (OR 1.21, 95% CI 1.17, 1.25), but decreased mortality (OR 0.62, 95% CI 0.54, 0.70) and 30-day readmissions (OR 0.86, 95% CI 0.83, 0.89). Propensity score weighted analyses also revealed that class III obesity was independently associated with increased mortality in AP subjects with (OR 1.92, 95% CI 1.41, 2.61) and without MetS (OR 1.55, 95% CI 1.26, 1.92), and increased SAP in subjects with and without MetS. CONCLUSIONS: Class III obesity appears to be the primary factor associated with adverse clinical outcomes in subjects with MetS admitted with AP. This has significant implications for patient management and future research targeting AP.

Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission.

BACKGROUND AND AIM: Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS: A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS: Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION: When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

A validated risk model for prediction of early readmission in patients with hepatic encephalopathy.

INTRODUCTION AND AIM: Hepatic encephalopathy (HE) is a common complication in cirrhotics and is associated with an increased healthcare burden. Our aim was to study independent predictors of 30-day readmission and develop a readmission risk model in patients with HE. Secondary aims included studying readmission rates, cost, and the impact of readmission on mortality. MATERIALS AND METHODS: We utilized the 2013 Nationwide Readmission Database (NRD) for hospitalized patients with HE. A risk assessment model based on index hospitalization variables for predicting 30-day readmission was developed using multivariate logistic regression and validated with the 2014 NRD. Patients were stratified into Low Risk and High Risk groups. Cox regression models were fit to identify predictors of calendar-year mortality. RESULTS: Of 24,473 cirrhosis patients hospitalized with HE, 32.4% were readmitted within 30 days. Predictors of readmission included presence of ascites (OR: 1.19; 95% CI: 1.06-1.33), receiving paracentesis (OR: 1.43; 95% CI: 1.26-1.62) and acute kidney injury (OR: 1.11; 95% CI: 1.00-1.22). Our validated model stratified patients into Low Risk and High Risk of 30-day readmissions (29% and 40%, respectively). The cost of the first readmission was higher than index admission in the 30-day readmission cohort ($14,198 vs. $10,386; p-value <0.001). Thirty-day readmission was the strongest predictor of calendar-year mortality (HR: 4.03; 95% CI: 3.49-4.65). CONCLUSIONS: Nearly one-third of patients with HE were readmitted within 30 days, and early readmission adversely impacted healthcare utilization and calendar-year mortality. With our proposed simple risk assessment model, patients at high risk for early readmissions can be identified to potentially avert poor outcomes.

Insurance status impacts treatment for hepatocellular carcinoma.

INTRODUCTION AND AIM: Previous studies have identified treatment disparities in the treatment of hepatocellular carcinoma (HCC) based on insurance status and provider. Recent studies have shown more Americans have healthcare insurance; therefore we aim to determine if treatment disparities based on insurance providers continue to exist. MATERIALS AND METHODS: A retrospective database analysis using the NIS was performed between 2010 and 2013 including adult patients with a primary diagnosis of HCC determined by ICD-9 codes. Multivariable logistic regressions were performed to analyze differences in treatment, mortality, features of decompensation, and metastatic disease based on the patient's primary payer. RESULTS: This study included 62,368 patients. Medicare represented 44% of the total patients followed by private insurance (27%), Medicaid (19%), and other payers (10%). Patients with Medicare, Medicaid, and other payer were less likely to undergo liver transplantation [(OR 0.63, 95% CI 0.47-0.84), (OR 0.23, 95% CI 0.15-0.33), (OR 0.26, 95% CI 0.15-0.45)] and surgical resection [(OR 0.74, 95% CI 0.63-0.87), (OR 0.40, 95% CI 0.32-0.51), (OR 0.42, 95% CI 0.32-0.54)] than patients with private insurance. Medicaid patients were less likely to undergo ablation then patients with private insurance (OR 0.52, 95% CI 0.40-0.68). Patients with other forms of insurance were less likely to undergo transarterial chemoembolization (TACE) compared to private insurance (OR 0.64, 95% CI 0.43-0.96). CONCLUSION: Insurance status impacts treatment for HCC. Patients with private insurance are more likely to undergo curative therapies of liver transplantation and surgical resection compared to patients with government funded insurance.

Colonoscopy in Patients With Postmyocardial Infarction Gastrointestinal Bleeding: A Nationwide Analysis.

GOALS: The goal of this study was to evaluate outcomes of colonoscopy in the setting of post myocardial infarction (MI) gastrointestinal bleeding (GIB) in a large population-based data set. BACKGROUND: The literature to substantiate the proposed safety of colonoscopy following an acute MI is limited. STUDY: The Nationwide Inpatient Sample (2007 to 2013) was utilized to identify all adult patients (age, 18 y or above) hospitalized with a primary diagnosis of ST-elevation MI and receiving left heart catheterization (STEMI-C). The outcomes of patients with concomitant diagnosis of GIB receiving endoscopic intervention with esophagogastroduodenoscopy (EGD) or colonoscopy postcatheterization were compared with those who did not. Primary outcomes including mortality, length of stay, and hospital costs were evaluated with univariate and multivariate analysis. RESULTS: There were 131,752 patients with post-STEMI-C GIB (5.35% of all STEMI-C patients) and same admission colonoscopy was performed in 1599 patients (1.21%). Although the prevalence of post-STEMI-C GIB increased from 4.27% in 2007 to 5.87% in 2013 (P<0.001), patients receiving colonoscopy decreased from 1.42% to 1.09% (P<0.001) over the course of the study period. Multivariate analysis revealed that patients receiving no endoscopic intervention [odds ratio, 3.61; 95% confidence interval: 1.57, 8.31] or EGD alone (OR, 2.70; 95% confidence interval: 1.12, 6.49) have higher mortality compared with those receiving colonoscopy. CONCLUSIONS: Same admission colonoscopy performed for post-STEMI-C GIB was associated with lower mortality. However, despite increased incidence of GIB in these patients during the study period, a lower percentage of patients received colonoscopy. These results suggest that colonoscopy is safe but underutilized in this setting.

The magnitude and impact of tobacco marketing exposure in adolescents' day-to-day lives: An ecological momentary assessment (EMA) study.

PURPOSE: Research indicates that tobacco marketing contributes to higher pro-tobacco attitudes and behaviors among adolescents, but no studies have been able to assess the impact of real-world tobacco marketing exposures in real-time. The purpose of this study was to examine the magnitude and impact of tobacco marketing exposure on adolescents using ecological momentary assessment (EMA). Our primary hypotheses were that (1) youth would most frequently report tobacco marketing at the retail points-of-sale and (2) greater exposures to tobacco marketing would be associated with more favorable tobacco-related attitudes, use, and expectancies. METHODS: Participants were adolescent males from rural and urban Ohio (N = 176, ages 11-16). For ten days, these adolescents were prompted at two-three random times/day to complete a brief smartphone-based survey about their exposures and responses to tobacco-related advertising. RESULTS: Adolescents reported exposures to tobacco marketing an average of 1.9 times over the 10-day EMA period, with over 10% seeing a tobacco advertisement 5 or more times. Reports of marketing exposures occurred most frequently at the point-of-sale; exposures were higher among tobacco users and rural adolescents. Consistent with hypotheses, marketing exposure was related to more positive attitudes to the tobacco advertisements, more tobacco use, and higher expectancies to use in the future. CONCLUSIONS: Overall, these findings signal the magnitude of tobacco marketing exposures and their pernicious impact on youth. Findings underscore the importance of federal, state, and local-level tobacco regulatory policies to protect youth from the marketing that puts them at risk for a lifetime of nicotine addiction and tobacco-related diseases.

Impact of Presence of Children on Indoor Tobacco Restrictions in Households of Urban and Rural Adult Tobacco Users.

OBJECTIVES: Secondhand smoke exposure in children is changing as a result of new public policy and electronic nicotine products (e-cigarettes). We examined factors related to self-imposed indoor household tobacco restrictions, with emphasis on children in the household and associations with combustible and noncombustible product use. METHODS: A cross-sectional survey of urban and rural Ohio adult tobacco users classified participants as exclusive combustible users, smokeless tobacco (SLT) users, e-cigarette users, or dual users. They were further stratified according to combustible or noncombustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions. RESULTS: A total of 1210 tobacco users participated, including 25.7% with children living in the home. Half allowed combustible and two thirds allowed noncombustible tobacco use indoors. Urban location (odds ratio [OR] = 1.58), younger age (OR = 0.88 per 5 year), male sex (OR = 1.40), college education (OR = 1.40), household income of more than $15,000 (OR = 1.78), and being married (OR = 2.43) were associated with a higher likelihood of banning combustible products indoors. SLT (OR = 8.12) and e-cigarette (OR = 5.85) users were more likely to have indoor bans compared to combustible users. Children in the household (OR = 1.89), older age (OR = 1.12 per 5 years), and nonwhite race (OR = 1.68) were associated with a higher likelihood of banning noncombustible products indoors. Combustible (OR = 4.54) and e-cigarette (OR = 3.04) users were more likely than SLT users to have indoor bans. CONCLUSIONS: Indoor restrictions on tobacco use remain infrequent in homes with children and are associated with user type and socioeconomic factors. Public policy should target modifiable risk factors for in-home secondhand smoke exposure.

The role of travel distance and price promotions in tobacco product purchase quantity.

INTRODUCTION: Rural Americans are particularly vulnerable to tobacco price reducing promotions are known to be directed to and used by vulnerable populations. Tobacco purchasing decisions, such as unit quantity purchased, may vary by rurality, by price promotion use, and possibly by the interaction between the two. Purchase decisions are likely to affect tobacco use behavior. Therefore, explanation of variation in tobacco purchase quantity by factors associated with rural vulnerability and factors that fall under the regulatory scope of the Tobacco Control Act (TCA) of 2009 could be of value to regulatory proposals intended to equitably benefit public health. METHODS: Our sample included 54 combustible tobacco users (298 purchase events) and 27 smokeless tobacco users (112 purchase events), who were asked to report all tobacco purchases on a smartphone application. We used an ecological momentary assessment methodology to collect data about tobacco users' purchasing patterns, including products, quantity purchased, and use of price promotions. A parent cohort study provided relevant data for home-outlet distance calculation and covariates. Our analysis examined associations between our outcome-purchase quantity per purchase event-and distance from participant's home to the nearest outlet, whether a price reducing promotion was used, and the interaction of these two factors. RESULTS: Combustible users showed an increased cigarette pack purchase quantity if they lived further from an outlet and used a price promotion (i.e., an interaction effect; RR = 1.70, 95% CI [1.11, 2.62]). Smokeless users purchased more units of snuff when they used price promotions (RR = 1.81, 95% CI [1.02, 3.20]). CONCLUSIONS: Regulatory action that imposes restrictions on the availability or use of price promotions could alter the purchasing behavior of rural Americans in such a way that makes it easier to reduce tobacco use or quit. Such action would also restrict flexibility in the price of tobacco products, which is known as a powerful tobacco control lever.

Acute Pancreatitis Admission Trends: A National Estimate through the Kids' Inpatient Database.

OBJECTIVES: To evaluate national health care use and costs for pediatric acute pancreatitis. STUDY DESIGN: The Kids' Inpatient Database for 2006, 2009, and 2012 was queried for patients with a principal diagnosis of acute pancreatitis. Cases were grouped by age: preschool (<5 years of age), school age (5-14 years of age), and adolescents (>14 years of age). RESULTS: A total of 27 983 discharges for acute pancreatitis were found. The number of admissions increased with age: young n = 1279, middle n = 8012, and older n = 18 692. Duration of stay was highest in preschool children (median, 3.47 days; IQR, 2.01-7.35), compared with school age (median, 3.22 days; IQR, 1.81-5.63) and adolescents (median, 2.87 days; IQR, 1.61-4.81; P < .001). The median cost of hospitalization varied with age: $6726 for preschoolers, $5400 for school-aged children, and $5889 for adolescents (P < .001). Acute pancreatitis-associated diagnoses varied by age. The presence of gallstone pancreatitis, alcohol, and hypertriglyceridemia was more common among older children compared with younger children (P < .001). There was an increasing trend in acute pancreatitis, chronic pancreatitis, and obesity for the 2 older age groups (P < .001). CONCLUSION: Admission of children for acute pancreatitis constitutes a significant healthcare burden, with a rising number of admissions with age. However, the cost and duration of stay per admission are highest in young children.

Geographical differences exist in high-value care delivery for inpatient management of cirrhosis: Cost conscious care in cirrhosis.

BACKGROUND AND AIMS: The United States spends more money per person on health care than any other country in the world. Patients with cirrhosis are at an increased risk of health-care utilization. The aim of this study is to evaluate differences in health-care utilization based on the region of treatment during the inpatient management of patients with cirrhosis. METHOD: A retrospective database analysis using the Nationwide Inpatient Sample was performed, including adult patients with a primary diagnosis of cirrhosis determined by ICD-9 codes. Univariate and multivariate analyses were performed to analyze liver decompensation, mortality, length of stay, and total charges in different regions across the United States. RESULTS: A total of 75 280 patients with cirrhosis who received treatment in nine different regions across the United States were included. Rates of liver decompensation were significantly decreased in the Pacific region compared to the New England region (OR: 0.69, 95% CI: 0.51-0.94). Length of stay was significantly different between regions; however, the means only varied by half a day and were of minimal clinical significance. Inpatient mortality rates were not significantly different between regions. Total charges for inpatient management between regions were significantly different, with the Pacific region having the highest total hospital charges with a mean of $82 731. CONCLUSIONS: Health-care utilization during the inpatient management of cirrhosis varies based on the region. The charges for treatment were the highest in the West despite no impact on mortality, minimal improvement in length of stay, and fewer features of decompensation on admission.

Hospital-Acquired Conditions Are Associated with Worse Outcomes in Crohn's Disease-Related Hospitalizations.

BACKGROUND: Crohn's disease (CD) is a chronically relapsing condition that frequently requires hospitalization. In 2008, the Centers for Medicare and Medicaid Services selected ten conditions that were deemed healthcare-acquired conditions (HACs). Costs related to HACs are not reimbursed as they are considered to be preventable. AIM: To determine the prevalence and impact of HACs on hospital outcomes of hospitalized CD patients. METHODS: This was a cross-sectional study using data from the Nationwide Inpatient Sample between 2007 and 2011 with an extended time frame between 2002 and 2013 to specifically evaluate the prevalence of HACs. CD-related hospitalizations and HACs were identified using International Classification of Diseases, Ninth revision, Clinical modification codes. The trend of HACs between 2002 and 2013 was assessed using a Cochran-Armitage test. Primary outcomes, including hospital mortality, length of stay, and hospital charges, were analyzed using univariate and multivariate analyses. RESULTS: The prevalence of HACs initially increased between 2002 and 2008, remained stable between 2008 and 2011, than significantly decreased from 2011 to 2013. CD patients with HACs had higher hospital mortality, prolonged LOS, and higher hospital charges compared to patients without HACs. CONCLUSIONS: The prevalence of HACs among hospitalized CD patients initially increased from 2002 to 2008; however, rates began to decrease between 2011 and 2013. In addition, HACs were associated with worse healthcare outcomes in hospitalized CD patients.

Trends and outcomes of transarterial chemoembolization in hepatocellular carcinoma: a national survey.

BACKGROUND: Transarterial chemoembolization (TACE) is a palliative procedure frequently used in patients with advanced hepatocellular carcinoma (HCC). We examined the national inpatient trends of TACE and related outcomes in the United States over the last decade. METHODS: We utilized the National Inpatient Sample (2002 to 2012) and performed trend analyses of TACE for HCC in all adult patients (age >18 years). Multivariate analyses for the outcomes of in-hospital "procedure-related complications" (PRCs) and "post-procedure complications" (PPCs) were performed. We also compared early (2002 to 2006) and late (2007 to 2012) eras by multivariate analyses to identify predictors of complications, healthcare resource utilization and mortality. RESULTS: Overall, 19058 patients underwent TACE for HCC where PRCs and PPCs were seen in 24.2% and 17.6% of patients, respectively. The overall trends in the use of TACE (P<0.001) and associated PRCs (P=0.006) were observed to be increasing. There was less mortality [adjusted Odds ratio (aOR): 0.58; 95% CI: 0.41, 0.82], reduced length of hospital stay (-1.87 days; 95% CI: -2.77, -0.97) and increased hospital charges ($19232; 95% CI: 11013, 27451) in the late era. Additionally, there was increased mortality (aOR: 4.07; 95% CI: 2.96, 5.59), PRCs (aOR: 3.21; 95% CI: 2.56, 4.02), and PPCs (aOR: 2.70; 95% CI: 2.11, 3.46) among patients with coagulopathy. CONCLUSIONS: There is an increasing trend of TACE utilization in HCC. However, the outcomes are worse in patients with coagulopathy. Although PRCs have increased, mortality has decreased in recent years. These findings should be considered during TACE evaluation in patients with HCC.