Prevalence and factors associated with inappropriate continuation of stress ulcer prophylaxis at discharge.

Stress ulcer prophylaxis is started in the critical care unit to decrease the risk of upper gastrointestinal ulcers in critically ill persons and to decrease mortality caused by stress ulcer complications. Unfortunately, the drugs are often continued after recovery through discharge, paving the way for unnecessary polypharmacy. STUDY DESIGN: We conducted a retrospective cross-sectional study including patients admitted to the adult critical care unit and started on the stress ulcer prophylaxis with a proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) with an aim to determine the prevalence of inappropriate continuation at discharge and associated factors. RESULT: 3200 people were initiated on stress ulcer prophylaxis, and the medication was continued in 1666 patients upon discharge. Indication for long-term use was not found in 744 of 1666, with a 44% prevalence of inappropriate continuation. A statistically significant association was found with the following risk factors: discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on a mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of stress ulcer prophylaxis drug used (H2 blocker vs PPI, p<0.001). CONCLUSION: The prevalence of inappropriate continuation was found to be higher than prior studies. Given the risk of unnecessary medication intake and the associated healthcare cost, a web-based quality improvement initiative is being considered.

Unveiling of Type B Lactic Acidosis From Systemic Lupus Erythematosus-Associated B-cell Lymphoma: A Fatal Oncology Emergency.

Type B lactic acidosis is a rare oncological emergency usually associated with leukemia and lymphoma but also with solid malignancies. It can often go unrecognized as a possible source of lactic acidosis, leading to a delay in treatment. We review a 56-year-old woman with systemic lupus erythematosus and generalized lymphadenopathy being evaluated for underlying malignancy who presented with dyspnea, fatigue, and hematemesis. The patient was hemodynamically unstable and had severe lactic acidosis, leukocytosis, electrolyte derangements, multiple organ damage, and worsening diffuse lymphadenopathy. She was initially treated for septic shock due to acalculous cholecystitis on imaging with antibiotics and a cholecystostomy. The latter was complicated by a liver laceration requiring explorative laparotomy and open cholecystectomy, during which an excisional biopsy of the omental lymph node was done and confirmed B-cell lymphoma with marked plasmacytic differentiation. Her lactic acidosis never fully cleared despite surgery, and the refractory nature of it despite appropriate treatment of septic shock confirmed the diagnosis of type B lactic acidosis from underlying B-cell lymphoma. Chemotherapy was deferred due to the acuity of the condition. She continued to deteriorate despite aggressive management and was transitioned to comfort measures only per family request, following which she passed away. Type B lactic acidosis should be suspected in oncology patients without clinical evidence of ischemia who are not responding to fluid resuscitation and appropriate treatment of septic shock. Prompt recognition and early initiation of antineoplastic agents should be considered, when possible, to prevent adverse outcomes.

Extraintestinal Clostridioides difficile Infection (CDI): A Recurrent Battle with Resilient Abdominal Wall Abscess.

Clostridioides (formerly Clostridium) difficile infection is a common and costly healthcare-associated infection. Extraintestinal C. difficile infection is rarely encountered, especially in isolation. We present a unique case of abdominal wall abscess presenting six months following gastrointestinal (GI) surgery. The patient was managed with computed tomography (CT) guided drainage of the abscess, placement of a drainage catheter, and aggressive broad-spectrum antibiotic treatment for a prolonged duration over multiple admissions. LEARNING POINTS: Risk factors for extraintestinal CDI include prior hospital stay, prolonged antibiotic therapy, proton pump inhibitor (PPI) use, relative state of immunodeficiency such as malnutrition and diabetes mellitus, previous abdominal surgery especially following perforation and leak of intestinal content.Presentation can be late following surgery with mesh repair (foreign body implantation) for intestinal perforation as they have high risk of colonisation, which later leads to infection.For extraintestinal CDI in the presence of a foreign body, removal is the desired course of action. But it is not always possible given the presence of comorbidities in this population, thus resulting in a prolonged course of antibiotics.

Clinical characteristics, predictors, and rates of hospitalized acute cholangitis patients in the United States.

Background: Acute cholangitis (AC) is a relatively uncommon condition, with a mortality rate of 50% without prompt treatment. Our study aimed to assess the impact of demographic and social factors on morbidity, mortality and healthcare utilization of patients with AC in the United States (US). Methods: We used data from the National Inpatient Sample (2016 and 2017). Our study population included all patients with a discharge diagnosis of AC, identified using the International Classification of Diseases, Tenth Revision (ICD-10) code K830. Results: A total of 18,649 patients were hospitalized with a diagnosis of AC, with rates higher among older persons. The incidence increased notably from 142.36 cases per million in 2016 to 144.3 in 2017. The majority (53%) of patients were on Medicare. Age >60 years was associated with greater mortality compared to 0-18 years (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.21-5.43). Hispanic race (OR 1.4, 95%CI 1.15-1.76) and Black race (OR 1.3, 95%CI 1.04-1.63) had an increased mortality compared to White race. Among the factors analyzed, age >60 (OR 3.72, 95%CI 2.93-4.70) and male sex (OR 0.91, 95%CI 0.86-0.98) were found to be significantly associated with endoscopic retrograde cholangiopancreatography (ERCP) during hospitalization. The total charge for hospitalizations in 2016 was $766 million, increasing to $825 million in 2017. Conclusions: The incidence of AC in the US increased slightly year over year. In patients presenting with AC, age and race were associated with mortality while age and sex were associated with the need for ERCP.

COVID-19 and acute pancreatitis: A systematic review.

We aimed to systematically review the relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and acute pancreatitis (AP). The global pandemic of coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 infection causes respiratory symptoms and notably also affects the gastrointestinal (GI) system. A systematic review of the available literature on the topic was performed with a search key using the terms "SARS COV 2," "Pancreatitis," "COVID-19" and synonyms. The search was conducted on 27 December 2020 using PubMed, EMBASE, CENTRAL, Web of Science, and Scopus. A meta-analysis was not conducted due to the low quality and poor comparability of the studies. We reviewed 66 studies that reported data on patients with polymerase chain reaction-confirmed SARS-CoV-2 infection and AP using the Atlanta Criteria. Our evaluation revealed a wide age range and diverse clinical presentation of COVID-19 with or without symptoms of AP, some of which preceded typical COVID-19 symptoms. We observed a myriad of complications and one study revealed that patients with both conditions were more likely to require mechanical ventilation and had longer lengths of hospital stay compared with patients with AP without COVID-19. Treatment for AP was mostly supportive, with varied therapies employed for COVID-19. Most cases were considered idiopathic and presumed to be SARS-CoV-2-induced as established etiological factors were not reported. AP should be considered in COVID-19 patients, especially in those exhibiting GI symptoms. Evidence to establish a causal relationship between SARS-CoV-2 infection and AP is currently lacking.