Acute pancreatitis in patients with COVID-19 is more severe and lethal: a systematic review and meta-analysis.

BACKGROUND: Emerging evidence suggests an association between acute pancreatitis and COVID-19. Our objective is to conduct a systematic review and meta-analysis to evaluate whether COVID-19 affects the severity and outcomes associated with acute pancreatitis. METHODS: Cochrane guidelines and PRISMA statement were followed for this review. Digital dissertation bases were searched and all studies comparing the outcomes of acute pancreatitis amongst patients with and without COVID-19 were included. We compared the etiology, severity, length of hospital stay and mortality associated with acute pancreatitis in patients with and without COVID-19. RESULTS: Four observational studies with a total of 2,419 patients were included in the review. Presence of COVID-19 significantly increased the odds of mortality (OR 4.10, 95% CI 2.03-8.29) in patients with acute pancreatitis. These patients also had an increased incidence of severe pancreatitis (OR 3.51, 95% CI 1.19-10.32), necrotizing pancreatitis (OR 1.84, 95% CI 1.19-2.85) and a longer length of hospital stay (OR 2.88, 95% CI 1.50-5.52), compared to non-COVID patients. Patients with COVID-19 were more likely to have an unknown or idiopathic etiology of acute pancreatitis (OR 4.02, 95% CI 1.32-12.29), compared to non-COVID-19 patients. CONCLUSION: Current evidence suggests that COVID-19 adversely impacts the morbidity and mortality associated with acute pancreatitis. SARS-CoV-2 may be a causative agent for acute pancreatitis. Further population-based studies are needed to confirm or refute these findings.

A delay in colonoscopy after positive fecal tests leads to higher incidence of colorectal cancer: A systematic review and meta-analysis.

BACKGROUND AND AIM: A delay in performing colonoscopies after positive fecal tests in a screening program may risk neoplastic progression. Our objective is to conduct a systematic review and meta-analysis to evaluate the effects of timing of a colonoscopy after a positive fecal test on the detection of colorectal cancer. METHODS: Cochrane guidelines and PRISMA statement were followed for this review. Digital dissertation databases were searched from inception to June 1, 2020, and all studies reporting the detection rates of colorectal cancer on the basis of different time intervals between a positive fecal test and the post-test colonoscopy were included. We compared the detection rates of colorectal cancer (overall and advanced-stage) and advanced adenoma based on different time intervals. RESULTS: A total of 361 637 patients from six observational studies were included for the analysis. The odds of detecting any colorectal cancer (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.23-2.03, P < 0.001), advanced-stage colorectal cancer (OR 2.16, 95% CI 1.47-3.16, P < 0.001), or advanced adenomas (OR 1.17, 95% CI 1.06-1.28, P = 0.001) are significantly higher if the colonoscopies are performed after 6 months from a positive fecal test, compared with within 6 months. There was no significant difference in the detection rates based on a 1-month, a 2-month, or a 3-month cut-off. CONCLUSIONS: A delay of colonoscopies beyond 6 months after positive fecal tests is associated with a higher odds of detecting colorectal cancer. A timely follow up of patients with positive fecal tests is warranted.

MELD-Na Is More Strongly Associated with Risk of Infection and Outcomes Than Other Characteristics of Patients with Cirrhosis.

BACKGROUND AND AIMS: The nature and outcomes of infection among patients with cirrhosis in safety-net hospitals are not well described. We aimed to characterize the rate of and risk factors for infection, both present on admission and nosocomial, in this unique population. We hypothesized that infections would be associated with adverse outcomes such as short-term mortality. METHODS: We used descriptive statistics to characterize infections within a retrospective cohort characterized previously. We used multivariable logistic regression models to assess potential risk factors for infection and associations with key outcomes such as short-term mortality and length of stay. RESULTS: The study cohort of 1112 patients included 33% women with a mean age of 56 ± 10 years. Infections were common (20%), with respiratory and urinary tract infections the most frequent. We did not observe a difference in the incidence of infection on admission based on patient demographic factors such as race/ethnicity or estimated household income. Infections on admission were associated with greater short-term mortality (12% vs 4% in-hospital and 14% vs 7% 30-day), longer length of stay (6 vs 3 days), intensive care unit admission (28% vs 18%), and acute-on-chronic liver failure (10% vs 2%) (p < 0.01 for all). Nosocomial infections were relatively uncommon (4%), but more frequent among patients admitted to the intensive care unit. Antibiotic resistance was common (38%), but not associated with negative outcomes. CONCLUSION: We did not identify demographic risk factors for infection, but did confirm its morbid effect among patients with cirrhosis in safety-net hospitals.

Risk Factors, Management, and Outcomes of Pyogenic Liver Abscess in a US Safety Net Hospital.

BACKGROUND: The causes and management of pyogenic liver abscess (PLA) have undergone multiple changes over the past decades. It is a relatively rare disease in the USA, and its incidence rate in the USA is increasing. The last US community hospital experience of PLA was published in 2005. We performed a retrospective study of patients admitted with PLA to an urban safety net hospital. AIMS: To ascertain risk factors, management approaches, and outcomes of PLA. METHODS: Electronic medical record was queried for diagnosis codes related to PLA during the years 2009-2018. Clinical information was compiled in an electronic database which was later analyzed. Main study outcomes were in-hospital mortality, 30-day readmission rate, and intensive care utilization rate. RESULTS: A total of 77 patients with PLA were admitted in the study period. Most common risk factors were diabetes mellitus (23.4%), previous liver surgery (20.7%), and hepatic malignancy (16.9%). 89% of patients were treated with percutaneous drainage or aspiration, and surgical drainage was reserved for other with other indications for laparotomy. In-hospital mortality, 30-day readmission, and intensive care utilization rates were 2.6%, 7% and 22%, respectively. Median length of stay was 11 days (inter-quartile range 7). Rate of antimicrobial resistance in abscess fluid cultures was 40%; 13 cases of Klebsiella pneumoniae liver abscess were noted in our cohort, most of whom were Hispanic or Asian. CONCLUSIONS: PLA was principally managed by percutaneous drainage or aspiration with good outcomes. Further studies investigating the racial predilection of K. pneumoniae liver abscesses could reveal clues to its pathogenesis.

Revised Marshall Score: A New Approach to Stratifying the Severity of Acute Pancreatitis.

BACKGROUND: Modified Marshall Score is one of the severity scores for acute pancreatitis (AP) and is included in the Revised Atlanta Classification, but given its utilization of a set serum creatinine level (sCr), it may misclassify stable patients with chronic kidney disease (CKD) to a more severe class just due to their elevated sCr. AIMS: Our study aims to evaluate the role of CKD in AP and the possibility of utilizing acute kidney injury (AKI) into developing a new scoring system. METHODS: We retrospectively reviewed the electronic medical records of three hundred consecutive patients who were diagnosed with AP during hospitalization. Multiple demographic variables and clinical course indices were collected. Univariate logistic regression was then applied to predict mortality and ICU admission. Finally, receiver operating curve was utilized to compare original versus New Revised Marshall Score. RESULTS: Two hundred and eight-four (284) patients had a definitive diagnosis of AP. When comparing patients who had AKI on admission to those without AKI, the AKI group showed statistically significant higher mortality rate (5.6% vs. 1.1%, p = 0.04). Finally, we substituted the renal part of Marshall Score with our AKIN and we plotted the New "Revised" Marshall Score, which showed a higher AUROC compared to the original modified version (C-statistics 0.93 vs. 0.89, p < 0.05). CONCLUSION: We found that AKI predicts mortality and outperforms the use of a fixed sCr value alone. The use of our New Revised Marshall Score can accurately classify AP severity, avoiding misclassification of AP severity and providing better patient care.

Fluoxetine-induced Stevens-Johnson syndrome and liver injury.

WHAT IS KNOWN AND OBJECTIVE: Drug-induced liver injuries (DILI) are overall rare and often associated with use of medications. Medications are also the most common aetiology of Stevens-Johnson syndrome (SJS), but SJS is seldom seen concomitantly with liver injury. Many common drugs can cause either one of these conditions; however, there are no reported cases of concomitant DILI and SJS secondary to fluoxetine. CASE SUMMARY: A 41-year-old female presented with a skin rash and abnormal liver function tests after the recent initiation of fluoxetine. Skin and liver biopsies showed features of SJS and DILI, respectively. Fluoxetine was stopped, following which there was improvement in her liver function tests and skin rash, without progression to fulminant hepatic failure. WHAT IS NEW AND CONCLUSION: Commonly used and safe pharmaceuticals such as fluoxetine have the potential for serious adverse events affecting the skin and liver.

Evaluation of the prognostic value of neutrophil to lymphocyte ratio in patients with hypertriglyceridemia-induced acute pancreatitis.

INTRODUCTION: Recent studies attribute promising prognostic values to various inflammatory biomarkers in acute pancreatitis, including the following: the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and red cell distribution width (RDW). We aimed to determine the performance of these biomarkers for detecting disease severity in patients with hypertriglyceridemia-induced acute pancreatitis (HTG-AP). METHODS: We retrospectively reviewed 110 patients with HTG-AP and compared the NLR, PLR, and RDW in different severity groups. We performed receiver-operating characteristic (ROC) analysis to identify the optimal cut-off value for NLR to predict severe AP. RESULTS: NLR was significantly higher in patients with severe AP than mild and moderately severe AP (14.6 vs. 6.9, p < 0.001), and higher with organ failure upon presentation (9.1 vs. 7.1, p = 0.026). After dichotomization by the optimal cut-off value of 10 as determined by the ROC curve, the high-NLR group had a significantly longer length of stay (9.1 vs. 6.6 days, p = 0.001), duration of nil per os (4.9 vs. 3.7 days, p = 0.007), and higher rates of complications, including systemic inflammatory response syndrome (81.5% vs. 44.6%, p = 0.001) and persistent acute kidney injury (25.9% vs. 3.6%, p < 0.001). High NLR independently predicted severe acute pancreatitis in multivariate analysis (Odds ratio 6.71, p = 0.019). CONCLUSION: NLR represents an inexpensive, readily available test with a promising value to predict disease severity in HTG-AP. Among the three inflammatory biomarkers, NLR has the highest discriminatory capacity for severe HTG-AP, with an optimal cut-off value of 10.

Characterization of ascites in cardiac cirrhosis: the value of ascitic fluid protein to screen for concurrent cardiac cirrhosis.

Abstracts Objectives: Cardiogenic ascites has been well described regarding its pathophysiology and fluid characteristics in prior literatures. However, ascites in patients with cardiac cirrhosis has not been characterized as a separate entity despite its unique pathophysiology and clinical aspects. This study aims to describe the fluid profile of ascites of cardiac cirrhosis and explore the utility of ascitic fluid protein (AFP) to predict concurrent cardiac cirrhosis. METHODS AND MATERIALS: We retrospectively selected and reviewed samples from the patients with cardiogenic ascites with and without concurrent cardiac cirrhosis. Epidemiologic characters, serum laboratory values, and fluid characteristics were directly compared between the groups. RESULTS: We analyzed 20 samples of ascitic fluid from the patients of cardiac cirrhosis and compared with 48 samples of non-cirrhotic cardiac ascites. The AFP was significantly lower in patients with cardiac cirrhosis (3.66g/dl) as compared to non-cirrhotic patients (4.31g/dl, p < .01); while there was no difference in serum-ascites albumin gradient (1.48g/dl vs. 1.47g/dl, p = .95). AFP equal to or less than 4.3g/dl predicted cirrhosis with a sensitivity of 95% and negative likelihood ratio of 0.10; the corresponding ROC curve of AFP has an AUC of 0.777, higher than AUC of other noninvasive prediction models. CONCLUSIONS: We presented the first fluid characterization of ascites in patients with cardiac cirrhosis. AFP was significantly lower than that from non-cirrhotic cardiac ascites, likely secondary to decreased serum protein level. AFP equal to or less than 4.3g/dl could be utilized to screen for concurrent cardiac cirrhosis with high sensitivity in patients with cardiogenic ascites without other predisposing factors for liver injury.

Topical steroids in eosinophilic esophagitis: Systematic review and meta-analysis of placebo-controlled randomized clinical trials.

BACKGROUND AND AIMS: Eosinophilic esophagitis (EoE) is a clinicopathologic condition characterized by symptoms of esophageal dysfunction in the presence of eosinophil-predominant inflammation of esophageal mucosa. Topical steroids are recommended as first line pharmacologic therapy in EoE. We aimed to determine the efficacy of topical steroids in inducing histologic and clinical remission in children and adults with EoE. METHODS: We performed a systematic search of the MEDLINE, EMBASE, Scopus, and Cochrane library databases for studies investigating the efficacy of topical steroids in EoE. We collected data on the number of patients, dose and duration of therapy, complete and partial histological response, and clinical improvement. We performed meta-analysis of placebo-controlled randomized clinical trials using Review Manager version 5.2. We used funnel plots to evaluate for publication bias. RESULTS: Five studies that included 174 patients with EoE were included in the meta-analysis. Topical fluticasone was administered in three studies involving 114 patients, and topical budesonide in two studies involving 60 patients. Patients treated with topical steroids, as compared with placebo, had higher complete histological remission (odds ratio [OR] 20.81, 95% confidence interval [CI] 7.03, 61.63) and partial histological remission (OR 32.20, 95% CI 6.82, 152.04). There was a trend towards improvement in clinical symptoms with topical steroids as compared with placebo but it did not reach statistical significance (OR 2.72, 95 %CI 0.90, 8.23). CONCLUSIONS: Topical corticosteroids seem to be effective in inducing histological remission but may not have similar significant impact in improving clinical symptoms of EoE. Studies with large sample size are needed to uniformly validate symptom improvement in EoE.

Utility of Platelet Count for Predicting Cirrhosis in Alcoholic Liver Disease: Model for Identifying Cirrhosis in a US Population.

BACKGROUND: Thrombocytopenia has been shown to be the single most useful laboratory investigation for identifying subclinical cirrhosis of varying etiologies. However, alcohol per se can result in thrombocytopenia, and hence it is unclear whether platelet count can identify cirrhosis in patients who are alcoholic. OBJECTIVES: To characterize the utility of clinical predictors, especially platelet count, for identifying the presence of cirrhosis in alcoholics. To develop a simple, objective model for identifying cirrhosis in alcoholics. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 2,471 consecutive hospitalized patients with abnormal liver enzyme levels were screened, from which 272 patients with a history of recent and ongoing alcohol intake, negative diagnostic studies for alternative etiologies of chronic liver disease, and recent liver imaging with ultrasound or CT scan were included. MAIN MEASURES: Results of liver imaging and admission laboratory studies including liver enzymes, coagulation studies, and blood counts. KEY RESULTS: One hundred twenty-nine patients (47%) had cirrhosis based on imaging; 143 patients (53%) had no cirrhosis. A pre-sobriety platelet count (during ongoing alcohol intake) of less than 70*10(3) cells/mm(3) was effective for ruling in cirrhosis (positive likelihood ratio [LR] 6.8, 95% CI: 3.4, 14); platelet count greater than 200*10(3) was useful for ruling out cirrhosis in alcoholics (negative LR 0.18, 95% CI: 0.10, 0.35). Multivariate logistic regression analysis identified international normalized ratio (INR) (p < 0.01) and pre-sobriety platelet count (p < 0.01) as independent predictors of cirrhosis. A Model for identifying Cirrhosis in Alcoholic Liver Disease (MCALD) was developed using the INR and pre-sobriety platelet count; it had an area under the receiver operating characteristic curve of 0.89 and Hosmer-Lemeshow goodness of fit chi(2) (p value) of 8.9 (0.35) for predicting cirrhosis in alcoholics. A MCALD score > 5.5 corresponded to an increased likelihood of cirrhosis (LR: 6.5, 95% CI: 4.3, 11.0) and a MCALD score < 5.5 corresponded to decreased likelihood of cirrhosis in alcoholics (LR: 0.25, 95% CI: 0.19, 0.36). Sobriety platelet count (after alcohol abstinence) at a cutoff of 160*10(3) had positive LR of 7.9 (95% CI: 4.4, 14) and negative LR of 0.42 (95% CI: 0.34, 0.52) for predicting cirrhosis in alcoholics. CONCLUSIONS: A simple model of platelet count and INR has good diagnostic accuracy for identifying cirrhosis in alcoholics.

Morning-only polyethylene glycol is noninferior but less preferred by hospitalized patients as compared with split-dose bowel preparation.

GOALS: To compare the efficacy and tolerability of morning-only polyethylene glycol (PEG) with split-dose preparation in hospitalized patients scheduled for colonoscopy. BACKGROUND: Morning-only colonoscopy preparation may improve efficiency by allowing patient preparation and colonoscopy to be performed on the same day. There are limited data comparing morning-only with split-dose preparation, and more studies are needed before morning-only preparation can be routinely recommended. STUDY: A single-center, prospective, endoscopist-blinded study was conducted, in which hospitalized patients scheduled to undergo diagnostic colonoscopy were randomly assigned to receive 4 L of PEG either on the morning of colonoscopy or as a split-dose (evening-morning). The primary endpoint was efficacy of bowel preparation measured by the Ottawa scale. Secondary endpoints were patient compliance and tolerance. RESULTS: A total of 120 hospitalized patients scheduled for diagnostic colonoscopy were randomized. The mean total Ottawa score was slightly superior for the morning-only arm, and the upper bound of 95% confidence interval (CI) for difference between arms was less than our prespecified noninferiority margin of 1.5 (difference=-0.23; 95% CI, -1.72 to 1.25). The percentage of patients with good bowel preparation was similar for all colonic segments. There was a trend toward more side effects among patients in the morning-only compared with the split-dose arm (71% vs. 54%; P=0.08). Compared with morning-only preparation, more patients in the split-dose arm were willing to undergo similar preparation for future colonoscopies (71% vs. 89%; P=0.02). CONCLUSIONS: Morning-only PEG is not inferior to split-dose preparation regarding bowel cleansing efficacy for colonoscopy in hospitalized patients. However, split-dose preparation was preferred by patients because of less side effects.

Plasma triglyceride levels may modulate hepatitis C viral replication.

BACKGROUND: Plasma and hepatic lipid abnormalities are frequent in hepatitis C infected individuals. METHODS: Plasma lipid and medical records profiles were prospectively obtained in 130 consecutive individuals seen by a single hepatologist in a university liver disease clinic. The relationships between viral load, genotype, plasma lipid fractions, HDL, LDL particle number and particle size were examined. RESULTS: Of 130 individuals studied, 74 had hepatitis C while 15 had NAFLD/NASH and 30 had alcohol related liver disease. The LDL particle number and LDL-C levels did not differ between those with and without hepatitis C although the number of small LDL particles was greater in those with hepatitis C infection. The HDL-C and total cholesterol levels were greater in those without hepatitis C than those with hepatitis C (P = 0.009). In contrast, the serum triglyceride level was greater in the hepatitis C viral group (P = 0.013). Importantly, the hepatitis C viral load regardless of the genotype correlated directly with the triglyceride and VLDL levels with r values of 0.73 and 0.84, respectively. CONCLUSIONS: There are: (1) important differences in lipid classes, number and the size of lipid particles exist between hepatitis C virus infected and noninfected liver disease groups, (2) the serum total triglyceride and the LDL levels correlate significantly with the hepatitis C viral load and, (3) Serum triglyceride level may play an important role in viral replication. These data further suggest that therapies directed at lowering plasma triglyceride levels may enhance the efficacy of current antiviral treatment regimens.

Current concepts and management approaches in nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of liver dysfunction worldwide. NAFLD may progress to nonalcoholic steatohepatitis (NASH) and in turn cirrhosis. Importantly, hepatic cancer can occur in NASH in the absence of cirrhosis. The cardinal histologic feature of NAFLD is the presence of an excessive accumulation of triacylglycerols and diacylglycerols in hepatocytes. The presence of obesity and insulin resistance lead to an increased hepatic-free fatty acid (FFA) flux creating an environment appropriate for the development of NAFLD. The generation of toxic reactive oxygen species with the production of hepatic injury and inflammation as a consequence of FFA oxidation will ultimately lead to the initiation and progression of fibrosis. Lifestyle modifications specifically weight loss, physical exercise, and cognitive behavior therapy have been recommended as treatments for NASH. Dietary fructose is an independent risk factor for the development of NAFLD. Pioglitazone can be used to treat biopsy-proven NASH; however, its safety risks should be considered carefully. Greater consumption for coffee, independent of its caffeine component, has been associated with a significant reduced risk of advanced fibrosis in NASH. Additional data are needed before recommending bariatric surgery as an established option for the specific treatment of NASH.

Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Background: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP. Methods: A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression. Results: A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05). Conclusion: Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.

Newcastle disease virus LaSota strain kills human pancreatic cancer cells in vitro with high selectivity.

CONTEXT: Pancreatic cancer is highly resistant to treatment. Previously, we showed that Newcastle disease virus (NDV) strain 73-T was highly cytotoxic to a range of tumor types in vitro and in vivo but the effects of NDV on pancreatic tumors are unknown. We determined the cytotoxicity of the lentogenic LaSota strain of NDV (NDV-LS) toward 7 different human pancreatic tumor cell lines and 4 normal human cell lines (keratinocytes, fibroblasts, pancreatic ductal cells, and vascular endothelial cells). METHODS: Cytotoxicity assays used serially diluted NDV incubated for 96 hours post-infection. Cells were fixed, stained, and minimum cytotoxic plaque forming unit (PFU) doses were determined (n = 10-24/cell line). RESULTS: Normal cells were killed only by high doses of NDV-LS. The cytotoxic doses for pancreatic ductal cells, fibroblasts, and vascular endothelial cells were 729, 626, and 1,217 plaque forming units, respectively. In contrast, most pancreatic cancer cells were killed by much lower doses. The doses for PL45, Panc 10.05, PANC-1, BxPC3, SU.86.86, Capan-1 and CFPAC-1 were 0.15, 0.41, 0.43, 0.55, 1.30, 17.1 and 153 plaque forming units, respectively. CONCLUSIONS: Most pancreatic tumor cells were more than 700 times more sensitive to NDV-LS killing than normal cells. Such avirulent, lentogenic NDV strains may have therapeutic potential in the treatment of pancreatic cancers.

Two avirulent, lentogenic strains of Newcastle disease virus are cytotoxic for some human pancreatic tumor lines in vitro.

CONTEXT: Pancreatic cancer is the fourth leading cause of cancer death in the U.S. Highly infectious Newcastle disease virus (NDV) strains are known to be very cytotoxic for an array of human tumor cell types in vitro and in vivo but the effects of these and avirulent NDV strains on pancreatic neoplasms are little known. OBJECTIVE: Here, the direct cytolytic effects of the avirulent Hitchner-B1 (B1) and Ulster (U) NDV strains on 7 human pancreatic tumor cell lines and 4 normal human cell lines were studied. METHODS: Cytotoxicity assays used serially diluted NDV to determine minimum cytotoxic plaque forming unit (PFU) doses. RESULTS: For NDV-B1, normal human cells were killed only by relatively high doses (range: 471-3,724 PFU) whereas NDV-U killed these cells at low PFU (range: 0.32-1.60 PFU). Most pancreatic cancer cell types were killed by much lower NDV-B1 doses (range: 0.40-2.60 PFU) while NDV-U killed Capan-1 and SU.86.86 cultures at very low doses (0.00041 PFU and 0.0034 PFU, respectively). CONCLUSIONS: On average, 1,555 times more NDV-B1 was needed to kill normal cells than most pancreatic tumor cells and 558 times more NDV-U to kill the two most sensitive pancreatic cancer lines. These innately-targeted lentogenic viruses may have meaningful potential in treating pancreatic cancer.

The Cook Score: A Novel Assessment for the Prediction of Liver-Associated Clinical Events in a Diverse Population.

BACKGROUND AND AIMS: Transient elastography (TE) provides accurate quantification of liver fibrosis. Its usefulness could be significantly amplified in terms of predicting liver-associated clinical events (LACE). Our aim was to create a model that accurately predicts LACE by combining the information provided by TE with other variables in patients with chronic liver disease (CLD). METHODS: We retrospectively reviewed the electronic medical records of patients who underwent liver elastography, at John H. Stroger Hospital in Cook County, Chicago, IL. The incidences of LACE were documented including decompensation of CLD, new hepatocellular carcinoma, and liver-associated mortality. Significant predicting factors were identified through a forward stepwise Cox regression model. We used the beta-coefficients of these risk factors to construct the Cook Score for prediction of LACE. Receiver-operating characteristic (ROC) curves were plotted for Cook Score to evaluate its efficiency in prediction, in comparison with MELD-Na Score and FIB-4 Score. RESULTS: A total of 3097 patients underwent liver elastography at our institution. Eighty-eight LACE were identified. Age (hazard ratio (HR) 1.04, p = 0.002), aspartate aminotransferase to alanine aminotransferase ratio (HR 2.61, p < 0.001), platelet count (HR 0.98, p < 0.001), international normalized ration (INR) (HR 17.80, p < 0.001), and liver stiffness measurement (HR1.04, p < 0.001) were identified as significant predictors. The Cook Score was constructed with two optimal cut-off points to stratify patients into low-, intermediate-, and high-risk groups for LACE. The Cook Score proved superior than MELD-Na Score and FIB4 Score in predicting LACE with an area under curve of 0.828. CONCLUSION: This novel score based on a large robust sample would provide accurate prediction of prognosis in patients with chronic liver disease and guide individualized surveillance strategy once validated with future studies.

Predictors of poor bowel preparations and colonoscopy cancellations in inpatient colonoscopies, a single center retrospective study.

BACKGROUND: An adequate bowel preparation prior to colonoscopy is a major quality-limiting factor that determines both the diagnostic and therapeutic yield of a colonoscopy. Colonoscopy is considered the gold standard for colon cancer screening and it is the primary approach to the workup of hematochezia, diarrhea and iron deficiency anemia (IDA). Several modifiable factors of bowel prep adequacy have been identified, that account for around 25% of inadequate bowel preparations in outpatient colonoscopies. However, the literature is sparse when examining the factors associated with inadequate preparations and procedure cancellations in an inpatient hospital setting. We aim to identify factors that affect bowel preparation adequacy and procedure cancellations among diagnostic colonoscopies performed during hospitalization. METHODS: We retrospectively reviewed the electronic medical records of 1,500 consecutive patients who had a diagnostic colonoscopy as an inpatient at a tertiary level hospital over a 2-year period. All patients were administered a clear liquid diet the day prior to the colonoscopy. Patients were then instructed to drink 4 L of polyethylene glycol (PEG, Golytely) between 5 am to 9 am on the day of the procedure. The clinical course of each case was followed to identify quality of preparations, cancelled procedures and the reasons for cancellations. We applied univariate and multivariate logistic regression analysis to identify variables to predict cancellation and poor preparation. RESULTS: A total of 1,029 patients were included in the study. 194 (18.8%) patients had colonoscopy cancellations and 268 (26.0%) had poor bowel preparations. Multivariate analysis revealed these factors to be associated with colonoscopy cancellations: education at the graduate school level [odds ratio (OR) =1.93, P=0.04], Hispanic ethnicity (OR =0.47, P<0.01), hemoglobin level <10 g/dL (OR =1.41, P=0.05) and if the colonoscopy was done for other indications (OR =0.53, P=0.04). Factors associated with poor bowel preparation on multivariate analysis, were dementia (OR =2.44, P=0.02), gastroparesis (OR =3.97, P=0.01) and inpatient opioids use (OR =1.69, P=0.04). CONCLUSIONS: The rate of colonoscopy cancellations and poor bowel preparations in inpatient colonoscopies were high, and we were able to identify predictors of inadequate colon preparation and procedure cancellations. Exploring more individualized colon preparation regimens based on personal risk factors could reduce the number of inadequate and cancelled colonoscopies in an inpatient setting.

Acute pancreatitis as a rare initial manifestation of Wegener's granulomatosis. A case based review of literature.

CONTEXT: Vasculitis is a known cause of pancreatitis and other gastrointestinal symptoms; however, most of these patients have medium vessel vasculitis like polyarteritis nodosa and often there are other associated conditions like hepatitis B or clinical manifestations that suggest the diagnosis. Wegener's granulomatosis is predominantly a reno-pulmonary disorder, rarely having gastrointestinal manifestations. CASE REPORT: We report a case of Wegener's granulomatosis initially presenting as acute pancreatitis and then rapidly progressing to severe multi-organ involvement over the next few months. DISCUSSION: Pancreatic association as an initial presentation of Wegener's granulomatosis is limited to only a few reports. This extremely rare initial presentation makes the diagnostic process challenging. Two different pancreatic manifestations have been reported: as a pancreatic mass mimicking a tumor or as acute pancreatitis. The patients who presented as pancreatic head masses underwent extensive surgical procedures before the diagnosis was established. Acute pancreatitis as the initial presentation is usually associated with an aggressive course of the vasculitis and often results in a fatal outcome. CONCLUSIONS: This case illustrates Wegener's granulomatosis as a rare cause of acute pancreatitis. It emphasizes the need for thorough continued systemic clinical evaluation of patients when the etiology is not readily evident. Also, since most patients with pancreatitis due to Wegener's granulomatosis rapidly progress to severe multiorgan involvement, knowledge of a broad differential of potential etiologies and a low index of suspicion is required for timely diagnosis and treatment.

Prophylactic Antibiotics Do Not Prevent Infectious Complications of Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts: A Systematic Review and Meta-Analysis.

ABSTRACT: Despite limited evidence, endoscopic societies recommend routine use of antibiotic prophylaxis for endoscopic ultrasound fine-needle aspiration of pancreatic cystic lesions. Recent studies suggest lack of benefit in this setting. Our objective is to conduct a systematic review and meta-analysis to assess the efficacy of antibiotics in prevention of infectious complications after ultrasound fine-needle aspiration of pancreatic cystic lesions. A bibliographic search of digital dissertation databases was performed from inception until March 2020. Randomized controlled trials, cohort, and case-control studies that compared prophylactic antibiotics with placebo or no therapy were included in the analysis. The primary outcome was the development of cyst infections. Secondary outcomes were incidence of fever; procedural complications such as bile leak, pancreatitis, or bleeding; and medication-related adverse events. Six studies with a total of 1683 patients were included. The overall incidence of cyst infections was 0.53%. For the primary outcome, there was no significant difference between the 2 groups (odds ratio, 0.54; 95% confidence interval, 0.16-1.82; P = 0.32). No significant difference was noted regarding other complications like fever, pancreatitis, or bile leak. In conclusion, the rate of infectious complications is very low, and antibiotic prophylaxis does not seem to confer any additional benefit in their prevention.